In 1995, physicians in the Netherlands received 9700 explicit requests for euthanasia or physician assisted suicide, of which 37% were granted and carried out.1 Among the remaining requests, about half were refused by the physician; in the rest of the cases either the patient died before a decision had been reached or the physician's promise of help could be effected, or the patient withdrew the request.2 Knowledge of specific characteristics of refused and granted requests for euthanasia or physician assisted suicide may give insight into physicians' decision making and into the role of criteria for prudent practice. We therefore compared the characteristics of refused and granted requests.
Subjects, methods, and results
In 1995 and 1996, 405 Dutch physicians, randomly sampled nationwide and stratified by specialty and region, were interviewed by over 30 specifically trained and experienced physicians using a structured questionnaire. The response rate was 89%. Euthanasia was defined as the administration of drugs with the explicit intention of ending the patient's life, at the patient's explicit request. Assisted suicide was defined as the prescribing or supplying of drugs with the explicit intention of enabling the patient to end his or her own life. All physicians were asked to describe their most recent case of a granted request (134 physicians had had such a case) and their most recent case of a refused request (148 physicians had had such a case).
Patients whose requests were refused, compared with patients whose requests were granted, were more often female and aged over 80; were less likely to have cancer; were more likely to have depression as a predominant complaint; were more likely to have a remaining life span of over six months; were less likely to have made a highly explicit request; were less likely to be competent; were less likely to be suffering utterly “hopelessly and unbearably,” and were more likely to have access to alternatives for treatment (table).
In both the refused and the granted requests “avoiding loss of dignity” (42% (95% confidence interval 31.6% to 52.4%) and 56% (46.3% to 66.2%) respectively) and “unbearable or hopeless suffering” (39% (29.0% to 48.8%) and 74% (64.9% to 82.6%)) were most often mentioned as the patient's reason for requesting euthanasia or physican assisted suicide. Only two reasons were mentioned more often in refused requests than in granted requests: “weariness of life” (40% (29.8% to 50.5%) and 18% (10.2% to 25.5%) respectively) and “not wanting to become a burden on the family” (23% (14% to 32.3%) v 13% (5.8% to 19.2%)). The most often mentioned reasons given by physicians for refusing the request were “suffering was not unbearable” (35%); “still alternatives for treatment” (32%); “the patient was depressed or had psychiatric symptoms” (31%); and “the request was not well considered” (19%) (data not shown).
Comment
Requests for euthanasia and physician assisted suicide that are refused have several characteristics not shared by granted requests. The criteria for prudent practice, which are supposed to guide physicians in their decision making, are more often met in granted requests than in refused requests. In particular, the availability of alternatives for treatment and the incompetence and depression of the patient seem to play an important part in refusals. The findings seem to show that, compared with patients whose requests are granted, patients whose requests are refused have more mental health problems and are less likely to be clearly in the terminal phase. Studies in the United States have shown that patients with depression are more inclined than patients without depression to request physician assisted suicide.3,4 Whether this is the case in the Netherlands is not known.
Table.
Characteristics of most recent cases of refused and granted requests for euthanasia or physician assisted suicide. Values are weighted, rounded percentages (95% confidence intervals), extrapolated to all physicians in the Netherlands*
| Refused requests (n=148) | Granted requests (n=134) | |
|---|---|---|
| Patient's characteristics | ||
| Female | 53 (43.4 to 63.2) | 40 (30.5 to 50.2) |
| Age (years): | ||
| 0-49 | 13 (7.4 to 20.4) | 21 (12.6 to 29.1) |
| 50-64 | 18 (9.8 to 25.1) | 28 (18.7 to 36.7) |
| 65-79 | 45 (34.3 to 55.3) | 43 (32.8 to 52.6) |
| ⩾80 | 24 (14.8 to 33.0) | 9 (3.1 to 14.5) |
| Diagnosis: | ||
| Cancer | 43 (32.2 to 52.9) | 86 (78.4 to 92.6) |
| Cardiovascular disease | 6† | 2† |
| Disease of the nervous system | 16 (9.4 to 22.0) | 5† |
| Disease of the respiratory system | 10 (2.8 to 16.2) | 2† |
| Psychiatric disorders | 13 (5.8 to 21.9) | 0 |
| Other | 13 (6.5 to 19.8) | 7 (0.2 to 13.0) |
| Depression was a predominant complaint | 39 (28.9 to 49.7) | 3 (0.2 to 5.0) |
| Shortening of life: | ||
| >6 months | 41 (30.7 to 51.4) | 5 (0.4 to 8.6) |
| 1-6 months | 24 (14.9 to 33.2) | 22 (14.2 to 30.1) |
| 1-4 weeks | 15 (7.8 to 22.8) | 45 (34.7 to 54.6) |
| <1 week | 16 (8.2 to 24.6) | 18 (10.0 to 25.6) |
| <24 hours | 2† | 8 (2.5 to 14.4) |
| No shortening of life | 1† | 2† |
| Requirements for prudent practice | ||
| Patient's request: | ||
| Highly explicit | 75 (66.2 to 83.9) | 97† |
| Fairly explicit | 25 (16.1 to 33.8) | 3† |
| Patient's request entirely voluntary | 80 (72.0 to 88.1) | 98† |
| Patient was competent | 62 (51.5 to 72.3) | 100† |
| Unbearable suffering: | ||
| Utterly | 11 (4.6 to 18.3) | 58 (48.0 to 67.7) |
| To a high degree | 19 (10.9 to 26.8) | 25 (16.3 to 33.4) |
| To a lower degree | 70 (60.2 to 79.3) | 17 (9.7 to 25.0) |
| Hopeless suffering: | ||
| Utterly | 29 (19.3 to 38.2) | 81 (72.3 to 88.6) |
| To a high degree | 23 (13.9 to 31.8) | 14 (6.8 to 21.3) |
| To a lower degree | 48 (37.8 to 59.0) | 5† |
| Alternatives for treatment available | 50 (39.8 to 60.9) | 17 (10.0 to 24.2) |
| Written will | 35 (24.4 to 44.8) | 70 (60.4 to 80.4) |
| Consultation of another physician took place | 16 (8.0 to 23.9) | 79 (71.7 to 88.0) |
To extrapolate our findings to all physicians in the Netherlands, we calculated weights based on the percentage of the different types of physician represented in the sample and on the 13% of inpatient deaths that were attended by physicians of specialties not included in our sample; 95% confidence intervals were computed through direct standardisation using the normal approximation to the binomial distribution.
Confidence intervals cannot be calculated.
Footnotes
Funding: The study was supported by a grant from the Dutch Ministry of Justice and Health, Welfare, and Sports.
Competing interests: None declared.
References
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