BIOETYKA / WPROWADZENIE

BIOETYKA / WPROWADZENIE - Przeglądy aktów prawnych

Annual Report 2012 – Regional euthanasia review committees

Written directive not a prerequisite s. 12

The Act requires the physician to be satisfied that the patient has made a voluntary and well-considered request. The request for termination of life is almost always made during a conversation between the physician and the patient, and hence is made orally. Contrary to popular belief, the Act does not require an advance directive or living will to be drawn up. On the other hand, even if the patient is capable of expressing his wishes, a written directive can help eliminate any uncertainty and confirm the oral request. Although in practice the existence of such a directive makes it easier to subsequently assess the case, the committees wish to emphasise that it is not the intention that people be put under unnecessary pressure to draw up such a directive in difficult circumstances, in some cases only shortly before they die.

Dementia s.18

As indicated in the section on voluntary and well-considered requests, requests for euthanasia made by patients suffering from dementia should normally be treated with great caution. The question of decisional competence has already been discussed.

Another key issue is whether dementia patients can be said to be suffering unbearably. What makes their suffering unbearable is often their perception of the deterioration that is already taking place in their personality, functions and skills, coupled with the realisation that this will only worsen and eventually lead to utter dependence and total loss of self. Being aware of their disease and its consequences may cause patients great and immediate suffering. A realistic assessment of how the illness is likely to progress may also lead to case will determine whether the doctor is satisfied that the patient’s suffering is unbearable. In the case of dementia, there is a close connection between both aspects, i.e. assessing whether the request is voluntary and well-considered and assessing whether suffering is unbearable with no prospect of improvement.

Mental illness or disorder s. 19

It has already been emphasised elsewhere in this report that a wish to die expressed by a patient suffering from a mental illness or disorder requires the attending physician to exercise particular caution. Apart from the question of decisional competence and whether the patient can be deemed capable of making a voluntary, well-considered request, a key question is whether the suffering considered unbearable by the patient is without prospect of improvement.

Coma and reduced consciousness (non-comatose) s.20

Suffering assumes a conscious state. Since a patient in a coma is in a state of complete unconsciousness, he cannot be said to be suffering. In this situation, euthanasia cannot be performed. One exception can be made to this principle: unlike in cases where coma has occurred spontaneously as the result of illness or complications associated with illness, euthanasia may be justified in the case of medically induced coma, resulting from the administration of medication to alleviate pain and symptoms and therefore in principle reversible. In this case, it is considered inhuman to wake the patient simply so that he can confirm that he is again, or still, suffering unbearably.

If a patient is in a state of reduced consciousness (but not in a coma) – either spontaneously or as a result of medication to reduce pain or symptoms – the physician may, in the light of the patient’s responses, reach the conclusion that the patient is indeed suffering unbearably. The Glasgow Coma Scale can be a valuable tool to assess the level of consciousness or depth of coma (and therefore the possibility of suffering).

Guideline on euthanasia for patients in a state of reduced consciousness s. 21

The KNMG Guideline ‘Euthanasia for patients in a state of reduced consciousness’ deal specifically with the situation where, after the attending physician has consulted an independent physician and is ready to carry out euthanasia, the patient – spontaneously or unintentionally, as a result of medication to reduce pain or dyspnea – falls into a state of reduced consciousness. According to the Guideline, the physician may proceed with the euthanasia if the patient is still suffering unbearably. This is determined using the Glasgow Coma Scale (GCS). The Guideline also allows the physician to proceed if the patient unintentionally falls into a coma resulting from the administration of medication to alleviate pain or dyspnea. While such a coma is in principle reversible, it is not necessary to wake the patient simply so that he can confirm that he is again, or still, suffering unbearably. In

these situations set out in the Guideline, the physician may proceed with the euthanasia without again consulting an independent physician. Although the patient is no longer able to express his wishes immediately prior to euthanasia an advance directive is not required. the patient is indeed suffering unbearably. The Glasgow Coma Scale can be a valuable tool to assess the level of consciousness or depth of coma (and therefore the possibility of suffering).