1998 OPEN FORUM Abstracts
Euthanasia in Clinical Medicine -- The Dutch Experience
Charles G. Durbin, Jr., M.D.
Physician's granting patients' requests for an "easy death" has occurred in the Netherlands for decades. This practice, a form of active euthanasia, remains a criminal offense but one which is rarely (never) prosecuted. From a large survey of Dutch physicians, euthanasia was identified as the cause of death in as many as 1.8% of total Dutch deaths in 1990. Despite being "illegal", Dutch law prescribes the procedure for reporting euthanasia. The patient's physician must submit a report of the death to the local coroner who notifies the local prosecutor. The report documents the patient's medical history and the patient's expressed request to end his life. The report must include evidence that the request was carefully considered, usually this means that it was repeated over a period of time. Sometimes patients are unable to explicitly request euthanasia to the doctor but family members who know the patient well may relay his request. In addition, a second physician must consult on the case and agree with the decision. Finally by law, the report must contain the means taken to end the life. If these conditions are met, there is essentially no risk of criminal prosecution.
Interestingly, there is nothing in the police procedure that requires that the patient be terminally ill. Patients with chronic but not necessarily terminal disease have been afforded euthanasia. Euthanasia is considered a private decision between the patient and his physician. Most often this method of death occurs at the patient's home in the presence of family and friends. Most often the general practitioner administers the lethal medications. Occasionally, critically ill patients are allowed to receive euthanasia.
Mrs. Van H was a 76 year old woman with rheumatic valvular heart disease. She had undergone mitral commissurotomy twice in the past 30 years. She presented with severe aortic stenosis, regurgitation, mitral regurgitation and severe congestive heart failure. She was clinically depressed and unable to carry out normal daily living activities during the previous 18 months. She reluctantly agreed to a double valve replacement, mostly to appease her children. Following surgery she was unable to be weaned from mechanical ventilation and repeatedly requested "a peaceful death". After negotiation with her surgeon and intensivist it was agreed that if she could not be liberated from mechanical ventilation in the following two weeks, she would receive euthanasia. Her family was also part of the discussion. At the end of two weeks she was still on high levels of ventilatory support and with her family at her side; sedation, analgesia, muscle paralysis and potassium chloride was administered and she died peacefully. Prior to this, she thanked her physicians for their care and said "good bye" to her family and friends.
The acceptance of euthanasia by the Dutch people and physicians has provoked strong reactions in other parts of the world including the United States. This practice makes only a minor contribution to death in the Netherlands and interestingly, other end of life decisions in terminally ill patients are poorly handled by the Dutch. Many patients not making explicit requests for euthanasia prior to becoming incapable of deciding remain on life support inappropriately. Characteristics of Dutch society, medical systems, and legal and personal rights will be illuminated in this presentation and lessons for the United States discussed.
The 44th International Respiratory Congress Abstracts-On-Disk®, November 7 - 10, 1998, Atlanta, Georgia.