Physician assisted dying (PAD) remains a hotly debated and controversial issue, but this practice is now legal, to varying degrees, in several countries and in several states in America.
A new report from the Netherlands, which in 2002 became the first country to allow PAD and euthanasia, shows that the rates for these practices are rising.
The report was published as a letter to the editor on August 3 in the New England Journal of Medicine. The researchers explain that in the Netherlands, PAD or euthanasia is “allowed only for patients who are ‘suffering unbearably’ without any prospect of relief.” The process involves a physician administering a lethal medication at the explicit request of a patient.
The researchers report results from a survey conducted in 2015, which found that 4.5% of deaths resulted from euthanasia. This is an almost twofold increase from the 2010 rate of 2.8%.
The use of continuous deep sedation until death has steadily risen during the past decade, from 8.2% in 2005, to 12.3% in 2010, to 18.3% in 2015.
Ending of life without an explicit patient request was slightly higher than in 2010 (0.3% in 2015 vs 0.2% in 2010), but was lower than in previous years (0.4% in 2005 and 0.7% in 2001).
Lead author Agnes van der Heide, MD, PhD, who is professor of decision making and care at the end of life at Erasmus Medical Center, Rotterdam, the Netherlands, emphasized that this is not as ominous as it may sound.
“The cases where physicians responded that they ended life without an explicit patient request to do so are clearly outside the legal framework for assistance in dying,” she told Medscape Medical News. “However, these cases typically represent a gray area between assistance in dying on the one hand and comfort on the other.”
These cases are often labeled “palliative sedation,” Dr van der Heide noted.
“They often use morphine in these cases and estimate the amount of time by which life shortened, and it is generally negligible or less than 24 hours,” she said. “The family sometimes gives their consent to acts in this category, but not always.”
Details of the Findings
For the 2015 survey, a total of 9351 questionnaires were mailed to physicians, and 7277 were returned (response rate, 78%). The study was conducted with complete anonymity for both physicians and patients.
The findings showed that some type of end-of-life decision was made in 4379 cases, with the majority of patients (n = 2469) undergoing “intensified alleviation of symptoms.” This is defined by the authors as “measures to alleviate pain or other symptoms” that are “intensified while taking into account the possible hastening of death. This practice may or may not involve prior discussion with or a nonexplicit wish of the patient or their relatives” and it “mostly concerns administration of opioids to patients who are in the last hours or days of life.”
A total of 1288 patients received “continuous deep sedation,” which, the authors note, overlapped with other end-of-life measures in 11% of cases. A total of 1041 patients refused to continue life-prolonging measures. Among the remaining patients, 829 underwent euthanasia; 22 underwent physician-assisted suicide; and 18 patients underwent “ending of life without an explicit patient request.”
General practitioners are primarily responsible for end-of-life decisions (93% of cases in 2015).
The percentage of patients older than 80 years was higher in 2015 than in 1990 (35% vs 22%), as was the percentage of those for whom estimated life expectancy was longer than a month (27% vs 16%).
The vast majority of patients (92%) who received physician assistance in dying had a serious somatic disease. Past studies have indicated that cancer patients are those most likely to request and receive euthanasia in the Netherlands.
In addition, 14% had a variety of health problems related to old age, and a small minority had early-stage dementia (3%) or psychiatric problems (3%).
Broader Scope Than in the US
The scope of the legalization in the Netherlands is wider than that in the United States.
Oregon became the first state to enact a physician aid in dying law, known as the Death With Dignity Act (DWD), in 1997. Since the passage of the law in 1997, 1545 people have received prescriptions under the DWD in Oregon, and as of the end of 2016, 991 patients had died from ingesting the lethal medications.
Although the percentages of patients requesting these services has risen during the past 20 years, studies have found no evidence of misuse. The majority of patients had cancer, and the most common reasons for choosing to end their lives were related to quality of life, autonomy, and dignity.
The laws in the United States are more restrictive and do not permit euthanasia. They require that the lethal medication that physicians prescribe be administered orally by patients on their own, and the life expectancy of the patients must be 6 months or less.
In the Netherlands, the scope is much broader ― the law permits euthanasia, and does not explicitly state that a patient must be terminally ill.
According to the 2002 law passed in the Netherlands,
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The physician must be satisfied that the patient’s request is voluntary and well considered.
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The physician must be satisfied that the patient’s suffering is unbearable and without prospect of improvement.
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The physician must have informed the patient about the patient’s situation and prognosis.
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The physician must have come to the conclusion, together with the patient, that there is no reasonable alternative in the patient’s situation.
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The physician must consult at least one other independent physician, who must see the patient and give a written opinion on whether statutory criteria for due care have been fulfilled.
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The physician must have exercised due medical care and attention in terminating the patient’s life or assisting in the patient’s suicide.
The Dutch researchers say that, as in the United States, there are no indications in the Netherlands that the law is not being closely followed or that it is being misused.
“All reported cases of assistance in dying are reviewed by one of five review committees,” said Dr van der Heide. “It is extremely rare that these committees come to the conclusion that the legal criteria were not met.
“Thus,” she added, “we can conclude that physicians adhere to the criteria in the large majority of cases.”
Assisted Dying Prior to Legalization?
The 2015 survey from the Netherlands is similar to surveys conducted in 1990, 1995, 2001, 2005, and 2010, the researchers note. These surveys have allowed researchers to monitor end-of-life decision making both before and after enactment of the 2002 law.
In the Netherlands, physicians are asked to fill out a questionnaire every 5 years, yielding a nationwide stratified sample of recently deceased patients. Since 1990, physicians have reported on end-of-life decisions. Assisted dying only became legal in 2002, although results indicate that physicians were practicing various forms of assisted dying prior to that.
Dr van der Heide explained that since the 1970s, Dutch physicians have been encouraged both by medical and judicial authorities to be open about their practices.
“This was supported by the development of criteria of due care in several court cases and policy statements,” she said. “From a strictly legal point of view, assistance in dying was a criminal activity prior to enforcement of the law, but there was societal consensus that there should be room for physicians to engage in this practice if they were transparent and adhered to specific criteria.”
This transparency has contributed to the high response rate in these studies. “Validity checks on the outcomes in previous years suggested that the frequencies found were very reliable and that underreporting is unlikely or very limited,” Dr van der Heide affirmed.
Dr van der Heide and her coauthors received grants from the Netherlands Organization for Health Research and Development during the conduct of the study.
N Engl J Med. 2017;377:492-494.
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