Papers

Refused and granted requests for euthanasia and assisted suicide in the Netherlands: interview study with structured questionnaire

Ilinka Haverkate, psychologist ^a, Bregje D Onwuteaka-Philipsen, researcher ^b, Agnes van der Heide, epidemiologist ^c, Piet J Kostense, statistician ^d, Gerrit van der Wal, professor ^b, Paul J van der Maas, professor ^c. 

^a Institute for Research in Extramural Medicine, Vrije Universiteit Amsterdam, van der Boechorststraat 7, 1081 BT Amsterdam, Netherlands, ^b Department of Social Medicine, Institute for Research in Extramural Medicine, Vrije Universiteit Amsterdam, ^c Department of Public Health, Erasmus University Rotterdam, PO Box 1738, 3000 DK Rotterdam, Netherlands, ^d Department of Epidemiology and Biostatistics, Institute for Research in Extramural Medicine, Vrije Universiteit Amsterdam

Correspondence to: I Haverkate I.Haverkate.gpnh{at}med.vu.nl

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

Top Subjects, methods, and results Comment References

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

Top Subjects, methods, and results Comment References

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.

	Acknowledgments

   Contributors: GvdW and PJvdM initiated the research. All authors contributed to the development of the study. IH and BDO-P coordinated the interviews. IH carried out data analyses and wrote the paper. BDO-P helped with data analyses and edited the paper. PJK gave statistical advice and calculated the 95% confidence intervals. All authors participated in interpreting the data and in writing and editing the paper.

	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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1.	Van der Maas PJ, van der Wal G, Haverkate I, de Graaff CLM, Kester JGC, Onwuteaka-Philipsen BD, et al. Euthanasia, physician-assisted suicide, and other medical practices involving the end of life in the Netherlands, 1990-1995. N Engl J Med 1996; 335: 1699-1705[Abstract/Free Full Text].
2.	Van der Wal PJ, van der Maas PJ. Euthanasia and other medical decisions concerning the end of life. In: Practice and notification procedure. SDU Publishers: The Hague, 1996. [In Dutch.]
3.	Breitbart W, Rosenfeld BD, Passik SD. Interest in physician-assisted suicide among ambulatory HIV-infected patients. Am J Psychiatry 1996; 153: 238-242[Abstract/Free Full Text].
4.	Emanuel EJ, Fairclough DL, Daniels ER, Clarridge BR. Euthanasia and physician-assisted suicide: attitudes and experiences of oncology patients, oncologists, and the public. Lancet 1996; 347: 1805-1810[CrossRef][Medline].

(Accepted 14 April 2000)