1. Dutch euthanasia… an easy death? For whom? Philip Esterhuizen RN, BA(Cur) MScN, PhD

2. Philosophy of care ‘Care delivery’ can only be referred to if the needs of the individual patient are taken into account when providing care and professional treatment.

3. Definition Euthanasia is a deliberate life-ending activity undertaken by someone other than the person involved at their request. ‘Deliberate action of ending life’ ‘by a person, other that the person involved’ ‘at their request’

4. What euthanasia is not…  Non-commencement or stopping of treatment because the patient refuses treatment.  Non-commencement or stopping of treatment because (further) medical treatment would be futile.  Alleviation of suffering by administering prescribed pain medication.  Ending life without request.

5. Per year:  140.000 deaths  30.000 discussions about PAD  9.000 explicit requests  3800 die with physician assistance »3520 euthanasia (2,5% of all deaths) »280 assisted suicide (0,2% of all deaths) »3000 diagnoses of cancer Physician assisted dying in the Netherlands

6. Cohort study on physician assisted dying in Utrecht  198 patients with terminal cancer (life expectancy < 3 months)  140 agreed and could complete questionnaire  Median age: 60 years  59% discussed euthanasia (age: no difference)  21% requested euthanasia (age: no difference)  14% died with physician assistance (age: no difference)

7. Predictors for requesting physician assisted dying Univariate (p<0,1)  Pain  Insomnia  Depressed mood  Religion Multivariate  Pain (odds ratio 1,37)  Religion (odds ratio 0,21)

8. Depression and physician assisted dying  Patients with depressed mood: 23%, 44% requested euthanasia  Patients without depressed mood: 77%, 15% requested euthanasia  Patients with request: 50% with depressed mood (HADS score> 20 points) 8% major depression (DSM IV)

9. Grief in family and friends of patients dying Mean score (95% CI) Euthanasia (n=189) Natural death (n=315) Inventory of traumatic grief (ITG)39* (38-41)45 (43-47) Impact of event scale (IES) (posttraumatic stress reaction) 13* (11-15)18 (16-19) Symptom check list (SCL-90) (psychiatric symptomatology) 116 (111-120)121 (118-125) * significant

10. Euthanasia and assisted suicide…  Is punishable by Dutch Law  An exception is… -A doctor, -Provides euthanasia on request of the patient, -Adheres to the guidelines and demands of care, -Reports to the coroner in accordance to the Law.

11. Guidelines and demands (1)  The doctor must be convinced that the patient’s request is enduring, voluntary and well-considered.  The doctor must be convinced that the patient’s suffering is hopeless and unbearable.  The doctor must have informed the patient about their situation and the prognosis.

12. Guidelines and demands (2)  The doctor and patient have reached the conclusion that there is no other reasonable solution for the situation.  The doctor has consulted at least one other independent doctor who has seen the patient and provided a written report regarding adherence to the guidelines.  The doctor has carried out the euthanasia or assisted suicide with care.

13. Advance directives  Sixteen en older,  An advance directive written prior to the patient being unable to communicate,  Has same status as verbal request.  Advance directives have no specific template and are not bound to a limited time frame.

14. Minors:  A patient 16 and older, who is able to reasonably access their situation, can request euthanasia if the parents or guardian have been involved in the decision-making.  A patient between 12 -16, who is able to reasonably access their situation, can request euthanasia if the parents or guardian have consented.

15. Procedure (1)  Well documented written report is essential and the prescribed forms must be filled out.  Report must be made to the coroner.  Coroner presents report to regional commission for examination – regional commission consists of an odd number of representatives including a lawyer, a doctor and an expert in ethics.

16. Procedure (2)  Commission can request further information from the doctor or any of the team involved in the activity.  The doctor is provided with the commission’s judgement within six weeks of submitting the report and can be, if necessary, extended by another six weeks.  If necessary, or requested, the commission will provide the doctor with further explanation on the findings.

17. Procedure (3)  If the commission finds that the doctor has not adhered to the guidelines and demands, a report is filed with the Attorney General and the Regional Inspector of Health. The doctor is informed of this.  The Public Prosecutor can, based on the report, call for an investigation and commence with criminal prosecution.  All parties are legally obliged to provide any information requested to further the investigation.

18. Procedure (4)  The Regional Inspector of Health can put the case to the Regional Disciplinary Tribunal.  The Regional Disciplinary Tribunal examines whether any acts or omissions have contravened the acceptable standard of care demanded of the health care professional by the Individual Health Care Professions Act.

19. In euthanasia… The patient has the right to request, but no obligation to receive. And… Medical staff have an obligation to listen, advise and refer on moral grounds, but the right to refuse,

20. Approach to schooling on moral decision-making Principle-based ethics  The value of life  Goodness/no harm  Justice  Truth telling  Autonomy  Beneficence Care-based ethics  Moral attention  Sympathetic understanding  Relationship awareness  Accommodation  Response

21. Evaluation of schooling Participant satisfaction Questionnaire Semi-structured interviews

22. Results from the questionnaires Assertiveness Current and adequate knowledge Discussion techniques Morally challenging situations o Organizational o Multi-disciplinary interaction o Direct patient care

23. Results from the semi-structured interviews Positive influence within the nursing team Increased knowledge of jurisprudence Improved communication Increased knowledge and application of ethics of caring / principle-based ethics

24. The hospital should do the patient no harm

25. Contact information Philip Esterhuizen p.esterhuizen@hva.nl