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Euthanasia endorsed in Dutch patient with dementia

Tony Sheldon , Utrecht

A doctor in the Netherlands has not been prosecuted for helping an elderly patient with vascular dementia to die. The psychiatric patient was considered to have been competent to request assisted suicide and the procedure was judged to be medically and legally sound.

The facts were reported in a rare case history in a Dutch medical journal (Nederlands Tijdschrift Voor Geneeskunde 1999;143:17). Dutch law states that doctors can avoid prosecution for assisted suicide only if their patient has persistently made an informed and voluntary request and is suffering unbearably and hopelessly. The patient in this case was considered "ill enough not to want to go on anymore, but... not so demented that he could not decide." A complex protocolthe first of its kind in the Netherlandswas set up by the hospital involved, the Twents Psychiatric Hospital, to consider the patient's request.

The case involved a 71 year old man who for four years had had a psycho-organic disorder, diagnosed as cerebral atrophy and multiple brain infarction. Magnetic resonance imaging confirmed that his condition was deteriorating. He asked his doctor to help him to die because he did not want to have to cope with further decline.

The patient's case was assessed by the hospital's chief psychiatrist, a committee of independent professionals, and an external consultant psychiatrist. Four months after assessment the patient died at home after drinking a high dose solution of barbiturate given to him by his doctor. The public prosecutor approved the procedure after consultation with the national forum of procurators general.

The case has raised fears that it brings euthanasia for demented elderly patients a step closer. The Alzheimer's Foundation in the Netherlands warned: "Dementia itself could never be a reason for assisted suicide because the patient is incapable of making an informed request."

The doctor involved in the case defended her actions, writing in the journal that she opposes euthanasia and assisted suicide for patients who are unable to express their will, and she agrees that most patients with dementia cannot. In this case, however, her patient was lucid at all times and completely able to understand the consequences of his request.

Medical director of the Royal Dutch Medical Association, Rob Dillmann, said that if a patient was in the early stages of dementia but still clearly competent and with an untreatable progressive neurological disease then there was the possibility of appropriate physician assisted suicide.