Pressure in dealing with requests for euthanasia or assisted suicide. Experiences of general practitioners

Marike E de Boer, Marja F I A Depla, Marjolein den Breejen, Pauline Slottje, Bregje D Onwuteaka-Philipsen, Cees M P M Hertogh

Abstract

Journal of Medical EthicsThe majority of Dutch physicians feel pressure when dealing with a request for euthanasia or physician-assisted suicide (EAS). This study aimed to explore the content of this pressure as experienced by general practitioners (GP). We conducted semistructured in-depth interviews with 15 Dutch GPs, focusing on actual cases. The interviews were transcribed and analysed with use of the framework method. Six categories of pressure GPs experienced in dealing with EAS requests were revealed: (1) emotional blackmail, (2) control and direction by others, (3) doubts about fulfilling the criteria, (4) counterpressure by patient’s relatives, (5) time pressure around referred patients and (6) organisational pressure. We conclude that the pressure can be attributable to the patient–physician relationship and/or the relationship between the physician and the patient’s relative(s), the inherent complexity of the decision itself and the circumstances under which the decision has to be made. To prevent physicians to cross their personal boundaries in dealing with EAS request all these different sources of pressure will have to be taken into account.


de Boer ME, Depla MFIA, den Breejen M, Slottje P, Onwuteaka-Philipsen BD, Hertogh CMPM.  Pressure in dealing with requests for euthanasia or assisted suicide. Experiences of general practitioners. J Med Ethics. 2019 Jul;45(7):425-429. doi: 10.1136/medethics-2018-105120. Epub 2019 May 15.

Can physicians conceive of performing euthanasia in case of psychiatric disease, dementia or being tired of living?

J Med Ethics doi:10.1136/medethics-2014-102150

Eva Elizabeth Bolt, Marianne C Snijdewind, Dick L Willems, Agnes van der Heide, Bregje D Onwuteaka-Philipsen

Abstract

Background Euthanasia and physician-assisted suicide (EAS) in patients with psychiatric disease, dementia or patients who are tired of living (without severe morbidity) is highly controversial. Although such cases can fall under the Dutch Euthanasia Act, Dutch physicians seem reluctant to perform EAS, and it is not clear whether or not physicians reject the possibility of EAS in these cases.

Aim To determine whether physicians can conceive of granting requests for EAS in patients with cancer, another physical disease, psychiatric disease, dementia or patients who are tired of living, and to evaluate whether physician characteristics are associated with conceivability. A cross-sectional study (survey) was conducted among 2269 Dutch general practitioners, elderly care physicians and clinical specialists.

Results The response rate was 64% (n=1456). Most physicians found it conceivable that they would grant a request for EAS in a patient with cancer or another physical disease (85% and 82%). Less than half of the physicians found this conceivable in patients with psychiatric disease (34%), early-stage dementia (40%), advanced dementia (29–33%) or tired of living (27%). General practitioners were most likely to find it conceivable that they would perform EAS.

Conclusions This study shows that a minority of Dutch physicians find it conceivable that they would grant a request for EAS from a patient with psychiatric disease, dementia or a patient who is tired of living. For physicians who find EAS inconceivable in these cases, legal arguments and personal moral objections both probably play a role.

[Full text]

Clinical Problems with the Performance of Euthanasia and Physician-Assisted Suicide in the Netherlands

N Engl J Med 2000; 342:551-556 February 24, 2000 DOI:10.1056/NEJM200002243420805

Johanna H. Groenewoud, M.D., Agnes van der Heide, M.D., Ph.D., Bregje D. Onwuteaka-Philipsen, Ph.D., Dick L. Willems, M.D., Ph.D., Paul J. van der Maas, M.D., Ph.D., and Gerrit van der Wal, M.D., Ph.D.

Background and Methods

The characteristics and frequency of clinical problems with the performance of euthanasia and physician-assisted suicide are uncertain. We analyzed data from two studies of euthanasia and physician-assisted suicide in the Netherlands (one conducted in 1990 and 1991 and the other in 1995 and 1996), with a total of 649 cases. We categorized clinical problems as technical problems, such as difficulty inserting an intravenous line; complications, such as myoclonus or vomiting; or problems with completion, such as a longer-than-expected interval between the administration of medications and death.

Results

In 114 cases, the physician’s intention was to provide assistance with suicide, and in 535, the intention was to perform euthanasia. Problems of any type were more frequent in cases of assisted suicide than in cases of euthanasia. Complications occurred in 7 percent of cases of assisted suicide, and problems with completion (a longer-than-expected time to death, failure to induce coma, or induction of coma followed by awakening of the patient) occurred in 16 percent of the cases; complications and problems with completion occurred in 3 percent and 6 percent of cases of euthanasia, respectively. The physician decided to administer a lethal medication in 21 of the cases of assisted suicide (18 percent), which thus became cases of euthanasia. The reasons for this decision included problems with completion (in 12 cases) and the inability of the patient to take all the medications (in 5).

Conclusions

There may be clinical problems with the performance of euthanasia and physician-assisted suicide. In the Netherlands, physicians who intend to provide assistance with suicide sometimes end up administering a lethal medication themselves because of the patient’s inability to take the medication or because of problems with the completion of physician-assisted suicide. [Full text]