Dutch doctors to receive more clarity over use of advance euthanasia directives for patients with dementia

BMJ 2013; 346 doi: (Published 30 May 2013) Cite this as: BMJ 2013;346:f3545
  1. Tony Sheldon
  1. 1Utrecht

Senior figures in Dutch medicine and politics are set to decide whether advanced euthanasia directives can, in practice, replace verbal requests if patients with dementia are no longer able to express their wishes.

Doctors in the Netherlands have expressed “difficulties” with this “grey area,” arguing that some communication is essential if they are to understand properly their patients’ suffering and wishes.

But eminent figures in medical ethics argue that doctors are placing themselves above the 2002 euthanasia law. This law states that doctors can act on an earlier advanced directive once a patient becomes incompetent.

A public debate has raged on this subject since the Dutch Medical Association, in its response to the government’s latest research assessing euthanasia policy, proposed adapting the law. It suggested that the legally required second medical opinion must not only see but also communicate with the patient.

Former health minister Els Borst, who piloted the euthanasia law through parliament, has since argued: “A professional body cannot choose its own interpretation of the law.” Heleen Dupuis, emeritus professor in medical ethics at Leiden University and member of the Dutch upper chamber of parliament, acknowledged the difficulties for doctors of advanced directives, but believed that the association seemed reluctant to find a solution. “I think physicians should have started the debate by proposing solutions [and] not trying to forbid it,” she said.

The association argues that it is not seeking to sabotage the law, but wants clarity for doctors and patients over how the existing law is applied. The association’s policy director Lode Wigersma explained that there was a “difference of opinion” with the euthanasia review committees, to which all cases are reported, over whether an advanced directive can replace the verbal confirmation of a euthanasia request. He said: “As a doctor you must understand what the patient really wants. Communication is essential if you are to be convinced as a doctor of the seriousness of the suffering at that moment.”

Before accepting a euthanasia request, doctors in the Netherlands must be convinced that their patient is suffering hopelessly and unbearably. The acceptance of requests from patients in the early stages of dementia has recently increased. In 2010 requests for euthanasia were accepted from 25 patients with dementia. This number almost doubled to 49 in 2011. A case has also been documented of a woman in an advanced stage of dementia, who had made an advanced directive and whose longstanding general practitioner agreed to euthanasia.1 The euthanasia review committees ( accepted that the degree of communication through limited verbal responses and body language was sufficient.

A joint working group—including the association, the ministries of health and justice, and ex-minister Borst—has now been launched to provide clarity under the present law on the validity of advanced directives for patients with dementia. It hopes to report in six months.


Cite this as: BMJ 2013;346:f3545