The last wish of a patient with end stage chronic obstructive pulmonary disease

Explicit request of the patient

The attending doctor must be satisfied that the patient has made a voluntary and carefully considered request. Our patient had discussed euthanasia years ago with her treating chest physician and her general practitioner. Since then, she repeatedly said she wished to die if her life was unbearable with no chance of improvement. Two weeks before her death, she asked explicitly for euthanasia. Her request was not made under pressure from or influence by other people, such as her family or friends. She expressed her wish in the presence of her partner, mother, sisters, and daughters, who respected her wish. She completed a living will in which she declared that she wished to die of euthanasia because her suffering was no longer bearable. A week after her explicit request she saw a psychiatrist to exclude the possibility that her wish to die was a symptom of a depressive disorder. The psychiatrist declared that she had no symptoms of a psychiatric disease that could have influenced her wish for euthanasia. Moreover, the psychiatrist declared that her request was voluntary and well considered.

In the 13 days between her request and her death she discussed her wish to die, the possibilities for end of life care, and the things that were important in her life with her doctor almost every day.

Suffering and no prospect of improvement

The attending doctor must be satisfied that the patient’s suffering is unbearable, and that no prospect of improvement exists. Our patient clearly had no chance of improving, and her suffering was unbearable. The main reason for this was her progressive decline in daily functioning and increasing dependency on care givers and loved ones. She needed help with almost all tasks of daily living. She had dyspnoea at minimal exercise and sometimes even at rest. Since she had a stroke in 2000, she had neuropathic pain in the left side of her body, which was hard to treat effectively. For several months she also had thoracic pain.

An informed patient

The attending doctor must have informed the patient about his or her situation and prospects. In the nursing home our patient talked with her doctor about her disease and its expected trajectory, which would probably be characterised by a further decline and punctuated by acute deteriorations in health status and daily functioning. She fully understood the nature of her condition, her prospects, and the possibilities for treatment.

No reasonable alternative

The attending doctor must have concluded, along with the patient, that no reasonable alternative exists in the light of the patient’s situation. The main reason for our patient’s wish for euthanasia was her progressive decline in daily functioning and increasing dependency on care givers and loved ones. There was no possibility that her daily functioning would improve.

Her lung function had deteriorated over the past few years. A year before she expressed her wish for euthanasia, her forced expiratory volume in the first second was only 26% of predicted values. Her chronic obstructive pulmonary disease was optimally treated according to the current international guidelines—she received long term oxygen therapy and non-invasive positive pressure ventilation. She had participated in seven comprehensive inpatient pulmonary rehabilitation programmes. In 2000, she had lung volume reduction surgery. She had recently deteriorated, despite an intensive patient tailored interdisciplinary management programme. Lung transplantation was not possible because she smoked.

She also mentioned that dyspnoea and pain contributed to her suffering. In the days after her request for euthanasia, her dosage of opioids was increased until the pain and dyspnoea were optimally treated. However, her wish for euthanasia became stronger every day. The optimal management of pain and dyspnoea did not improve her physical functioning and did not reduce her dependency. In the days before her death, her physical functioning declined quickly so that leaving her bed became harder every day.

Independent opinion

The attending doctor must have consulted at least one other independent doctor, who must have seen the patient and given a written opinion on the due care criteria, as mentioned above. Twelve days after our patient’s request for euthanasia, she was visited by an independent doctor—a general practitioner trained in performing consultation for euthanasia. He assessed the four due care criteria explained above and reported that these criteria were met.

Medical care at termination

The attending physician must terminate the patient’s life with due medical care and attention. After the independent doctor’s visit, the euthanasia was planned for the next day. Once the plans were made our patient seemed to be quiet and peaceful. She said she had finished everything she wanted to do and that she had completely accepted her situation. On the day of her death, her family was with her to say goodbye. In the presence of her mother, sisters, daughters, and partner, she died quickly and quietly after intravenous infusion of a barbiturate to induce a coma, followed by a neuromuscular relaxant, as per protocol.

Outcome

After the patient died the attending doctor completed a report and notified the municipal pathologist of this instance of death from non-natural causes. The pathologist viewed the patient. He informed the public prosecutor, who gave consent for burial. The pathologist then sent his own report, the attending doctor’s report, the independent doctor’s report, and the patient’s living will to the regional review committee. This committee—a legal expert, a medical doctor, and an expert on ethics—used these documents to assess whether euthanasia had been carried out in accordance with the due care criteria.

Three weeks after euthanasia was carried out, the review committee informed the attending doctor that she had met the statutory due care criteria for euthanasia and would not be prosecuted. A few weeks later the doctor discussed the patient’s life course, her disease, and her death with her family and loved ones, who were grateful that her last wish had been honoured.