77

Euthanasia
A. Peter M. Heintz, MD, PhD
Nicole B. Swarte, MD, PhD

and religious factors than by the state of technology and

medicine (1).
Death on request has always been an issue and a
dilemma. Many people have been confronted with it. In
times of war the bullet of a friend was often the only way to
put an end to intolerable suffering. But through the years
the arguments for- and against euthanasia have remained
essentially unchanged.

Introduction
Euthanasia and physician assisted suicide (EAS) was debated
and practiced as early as the days of early Greece and Rome
(1,2). Debates on EAS are often emotionally very charged, as
they concern matters of life and death, and life and death are
issues where religious and non religious convictions can be in
conflict with each other. Religions see life as a gift of God and
nobody but God can take someones life. These days many
people tend to see EAS as a part of modern terminal care, so
as a part of modern medicine. In most countries in the world
EAS are illegal. The Netherlands and Belgium are two of the
few countries where EAS is well regulated. Dutch research
has shown that EAS is widely supported by the public opinion,
doctors and case law (3-5).
To prevent confusion it is essential to recognize three
different medical decisions concerning the end of life (MDEL):
Non-treatment decisions (NTD)
Alleviation of pain and/or other symptoms with high
dosages of opioids (APS)
Euthanasia and physician assisted suicide (EAS)

Ethical Aspects
Sound medical ethical decisions are based on four principles:
Autonomy, beneficence, nonmaleficence, and justice.
Autonomy means that every patient who has a sound state
of mind has a right to self-determination over his/her own life.
The principle of beneficence means that it is the physicians
primary responsibility to relieve suffering and to keep the
patient alive. But continuation of life can cause more pain and
suffering than death. In such a case EAS is seen as a humane
act, as mercy killing and is supported by the principle of
beneficence. For this reason many people in the Netherlands
consider the value of protection of human life and the value of
respect for the desire of dying with dignity both as standards
of equal order. Nonmaleficence means that the physician
should not do anything that can harm the patient. However,
today treatment can sometimes cause more suffering than
the disease itself. In such a case EAS is not in conflict with the
principle of nonmaleficence. The principle of justice means
that equal health care should be available to all citizens. This
principle is especially important when the costs of care are
concerned. All patients have the same right to get the best
palliative care available. The prevailing medical view is the
only criterium to offer this care or not. The financial status of
the patients should not play a role.
For many, but not for all patients religion plays an
important role in the decision making about euthanasia. For
them human life is sacred and the ending of it can never be
approved of. This conviction needs to be respected as is the
opinion of patients who want to choose themselves on how
they want to die.

The most important distinctions between them are

the intention of the physician, the nature of the action and
the consent of the patient. APS is often referred to as the
principle of double effect, this means that hastening death is
accepted as a side effect of adequate palliative medication.
Euthanasia is defined as the intentional termination of the
life of a patient at his/her request by a physician (6). As a
consequence of this definition, termination of life without the
request of the patient, so called nonvoluntary euthanasia
as well as APS are not considered to fulfill the criteria of
euthanasia. Physician assisted suicide is the provision of
means by a physician to a patient with the understanding
that the person intends to use them to end his or her life. In
this chapter EAS are discussed in the context of terminally
ill cancer patients who have a sound mental state and who
request the procedure voluntarily.
The word euthanasia is derived from the Greece term
eu thanatos which means good death. With the rise of
Christianity there was an almost unanimous opposition to
Euthanasia among European physicians. In spite of major
advances in the treatment of pain by drugs and other
therapies in the last 120 years, the interest in eutahanasia
has actually increased. This reflects the fact that the level of
interest in EAS is influenced more strongly by social, political

Depression and the Request for Euthanasia

It is often suggested that in terminally ill patients an
association exists between depression and the request for
euthanasia or physician assisted suicide. Diagnosing major

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depression in patients with cancer can be very complicated

because sadness and a depressed mood can be seen as
a normal reaction to a (potential) terminal illness. Also the
somatic symptoms of a major illness like weight loss or
anorexia can be seen as symptoms of a major depression.
Another difficulty that has to be taken into account is the
difference between the desire for death, one of the most
important characteristics of depression in terminal cancer
patients, and the request for euthanasia. The incidence of
depression and the desire for death has mainly been studied
in circumstances where euthanasia was not an option. The
only studies in which depression was studied in a hospital
where euthanasia was an option has been conducted by
our group in 2003 and 2005 (7-9). In a single centre casecontrol study of 80 terminally ill cancer patients with a life
expectancy of three months or less we studied the prevalence
of psychological symptoms and their relation with physical
symptoms. We found a 14% prevalence of self-reported
anxiety and 25% prevalence of self-reported depression.
Anxiety and depression were related with decreasing physical
performance, especially shortness of breath, impaired wellbeing, pain, drowsiness, fatigue and inactivity. These findings
coincide with the findings of Massie and Hotopf (10,11). In
a second paper we reported on 138 consecutive cancer
patients with an estimated life expectancy of three months
or less. Here we found a depressed mood at inclusion in 32
patients, using the Hospital Anxiety and Depression Scale.
In this group of 138 patients 30 patients (22%) did an explicit
request for euthanasia. The risk to request euthanasia was
4.1 (95%CI 2.0 to 8.5) times higher than the risk of patients
without a depressed mood at inclusion. Depression will surely
contribute to the suffering in these patients. The consequence
of this finding must be that much effort must be done to
prevent and early diagnose depression or a depressed mood,
at an earlier stage in the disease. Physicians can simply do
that by asking patients if they feel depressed, just like we ask
our patients for side effects of medication. Physicians should
consult a psychiatrist whenever they have doubts about the
decision making ability of the patient. This would give the
opportunity of adequate treatment and probably can prevent
major depressive disorders when they come to the end of
life. Standard consultation by a psychiatrist is not necessary
as has been reported by Bannink et al. (12). The request for
euthanasia is not a symptom of a psychiatric disorder because
by far not all patients who did a request were suffering from
a depression or depressed mood. But the request can be
influenced by the mental status of the patient. At the end of
life it is often to late for adequate treatment of a depression or
depressed mood, but it contributes to the suffering and, like
severe physical symptoms, therefore not a reason to refuse
the request.

Who Wants Euthanasia?

Each year about 2800 people die by euthanasia in the
Netherlands, of whom 80% die of cancer. From three
nationwide studies in the Netherlands we know that many

patients ask their doctors if they would assist them to die

should suffering become unbearable, and that two-thirds of
these patients never end up making a serious and persistent
request (13-15). In fact medical decisions concerning the
end of life play a role in 37% of the dying patients. EAS is
practiced in nearly 3% of them (5).
It is sometimes suggested that lack of adequate palliative
care is the cause for the request of EAS (16). In general, the
suffering of the dying patient extends far beyond physical pain.
Other factors, such as loss mobility and activity, associated
with increasing helplessness and dependence on others, can
cause a lot of distress as well. Another component of suffering
that cannot be neglected is the loss of dignity. Although this
is a very subjective component, patients consider it very
important. This is very clear from the results of the Dutch
surveys (14,15). In these surveys the following reasons for
the requested EAS were reported: Loss of dignity: 57%, pain:
46%, unworthy dying: 46%, dependence on others: 33%,
tiredness of life: 23%. In only 10 of the 187 cases was pain
the single reason given.
In our own studies in a hospital based cohort 60% of all
patients with terminal cancer who had a life expectancy of three
months or less discussed euthanasia with their physician,
mostly at the time the cancer became incurable and in the
terminal phase of life (8,9). Of the patients who discussed
euthanasia 42% later explicitly requested, and 27% actually
died by euthanasia. Pain, insomnia and a depressed mood
were in this group associated with more explicit requests for
euthanasia. Religion was associated with fewer requests. We
could not find a relation between age, being dependent or
feeling dependent and the explicit request for euthanasia (79). This finding might be due to the fact that these patients
were hospitalized. Swarte found in her case-control study
of 89 terminally ill patients who died by euthanasia and who
were compared to 178 randomly selected cancer patients
who died otherwise that the ones who died by euthanasia had
more pain during admission and also at the day of dying the
presence of pain was more often reported in the records than
in the records of patients who did not receive euthanasia. In
these two groups neither gastro-intestinal symptoms nor other
complaints differed between the two groups (7). However the
palliative care team was significantly more often consulted for
the patients who died by euthanasia. In these patients there
was no reason to suggest a less optimal palliative care.

Effects of Euthanasia on the Bereaved Family and

Friends
Grief is a normal reaction to the death of a loved one and
normally does not require any professional help. Traumatic
grief refers to situations where grief symptoms take too longer
too short, are too intense or not intense enough, or come too
late (17). Depending on the definition, 10-20% of bereaved
people will suffer from traumatic grief.
Unnatural death, such as suicide, can cause severe
grief reactions in family members (18). As euthanasia is also
considered as an unnatural death, it has been suggested that

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euthanasia may induce traumatic grief (17,18). The only data

on grief after EAS are published by our group in 2003 (19).
In our cross sectional study 189 bereaved family members
and close friends of terminally ill cancer patients who died
by euthanasia and 316 bereaved family members and close
friends of comparable cancer patients who died a natural
death between 1992 and 1999 were studied. Symptoms of
traumatic grief were assessed by the inventory of traumatic
grief. Current feelings of grief by the Texas revised inventory
of grief, and post-traumatic stress reactions were assessed by
the impact of event scale. We found that the bereaved family
and friends of the euthanasia group had less traumatic grief
symptoms (adjusted difference -5.29(95% CI -8.44 to -2.15)),
less current feeling of grief (adjusted difference 2.93 (0.85
to 5.01)), and less post-traumatic stress reactions (adjusted
difference -2.79 (-5.33 to -0.25)) than the family and friends
of patients who died of natural courses. These differences
were independent of other risk factors for traumatic grief. The
bereaved family and friends in the euthanasia group scored
somewhat better on general wellbeing, while depressive
symptoms were similar for both groups. The opportunity to
say goodbye and take leave while the patient was still fully
aware was an important determinant of less grief symptoms.
In our opinion this result reflects the more open way patients
and family deal with each other when euthanasia is discussed
and the more intensive way patient and family are taken
care of by doctors and nurses. When a patient requests
euthanasia family members and friends are often involved
in the discussions and decision making. In this way they are
better prepared than when the coming death is not discussed.
Finally the close family members and friends are present and
able to take leave at the day and hour the patient passes
away. This is not always happening in patients who die in a
natural way. These results should not be interpreted as a plea
for euthanasia, but as a plea for the same level of care and
openness in all patients who are terminally ill.

The Process of Euthanasia

In the Netherlands EAS is not a crime as long as the doctor
follows the precise criteria as written down in the law. The
most important ones are:

The patient requests euthanasia on his/her own free will

The patient requests euthanasia repeatedly
The patient is sound of mind
The medical prognosis is hopeless and certain to result
in death
The decision is made by a team of closely involved
doctors, nurses and caretakers
The case is reviewed and agreed by an independent
physician who is not a member of the team
When the patient has died the coroner must examine the
body and check the facts.
All euthanasia cases have to be reported to an
independent committee. This committee has to check if
all precise criteria have been respected and if the law has
been followed.

In general four factors are important in the process of

euthanasia:
The condition of the patient: Is the communication with
the patient adequate? Is it possible for the patient to have
an accurate overview of the situation and has everything
been done to palliate the patient?
The wish of the patient: We must be sure that the request
is made by his/her own free will. In daily practice we ask
the patient to sign a will in which the request is written
down.
The opinion of the family: Family is important for the
patient during the last phase of life. Normally the
discussions about the wishes of the patient take place in
good harmony with the family and friends. But in cases
where the family ties are disturbed the opinion of the
family does not play a role.
The opinion of the team in attendance: This opinion
finds its expression in group conversations with all
personnel concerned. This includes doctors, nurses,
social workers, the family practitioner and sometimes
a pastor. The most important task of such a team is to
ensure that the necessary caution is exercised during the
decision making. Important conditions are that nobody
has to participate in euthanasia against his or her will and
that the euthanasia has to be performed by the doctor
in attendance, ideally the doctor who has supported the
patient during her illness.
After the decision to grant the request has been taken the
day and hour of the euthanasia are chosen by the patient
and the doctor. It is important to have the euthanasia done
at a moment that nobody is hindered by daily duties and
by the general business of the ward.
There are several factors that can hinder the decision
making and the discussions in the team. It is the doctors
responsibility to manage them:

The team is not well informed or contributes conflicting

information. This situation can lead to resistance and
refusal to cooperate.

A lack of knowledge of the problems of terminal care.

Too young or too inexperienced nurses. It is the

responsibility of the team to introduce the inexperienced
to this special field of medicine.

Frequent changes of personnel. Ideally the people

involved in the euthanasia are free of other duties during
the process. Preferably the attending physician is on call
for this particular patient during nights and weekends.

Technique of Euthanasia and Assisted Suicide

Several methods of euthanasia have been developed
which can be administered orally as well as intravenously.
We prefer to start with Midazolam iv to induce sleep and
after that we commence an iv infusion of thiopental and
pancuroniumbromide or another muscle relaxans in 200 ml
saline. Shortly after drug administration the patient loses

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consciousness, duration of dying being dependent on the

speed of drug infusion. In our experience patients want to
know what is happening when they are unconscious. They do
not want to be kept in a chemical coma for hours or days and
prefer to die soon.
An alternative for the i.v. administration is the combination
of antiemetic drugs followed by a drink containing a
barbiturate. In this situation the doctor must be prepared that
the drink is not enough and that a muscle relaxants has to be
given iv.

The Practice of Euthanasia

The practice of euthanasia is best illustrated by a case history.
Mrs. A was a 47 year old single woman who was referred
to us because of a large pelvic mass. She was diagnosed as
having ovarian cancer stage IIIc. After a successful debulking
operation she was treated with paclitaxel/carboplatin
chemotherapy. During the talks we had before and after the
operation she told me frequently about her worries concerning
the course of her disease. In fact she had emotionally opposed
the treatment. She was a very well educated woman and had
lived a life with many emotional ups and downs. Now she
found herself in this situation: Single, no children, a couple
of very close friends, of whom one was a doctor, and facing
a treatment which would probably not result in cure but with
serious side effects such as alopecia, nausea, a chance on
neuropathy. I tried to convince her that it was worthwhile to
try this treatment. During our talks she frequently expressed
her wish to have euthanasia as soon as she considered the
quality of her life as not high enough anymore. I promised
that I would help her if necessary. After three courses of
chemotherapy her Ca-125 started to rise and progressive
disease was diagnosed. At that moment she decided to stop
the chemotherapy. For the next three months she was well and
did not need any special medication. She got her hair back.
After 4 months she started to develop some ascites and a few
weeks later she was admitted to the hospital with symptoms
of a sub-acute ileus. After admission she told me that her time
had come and that she wanted to die. She had written down
her choice in a last will. We discussed her wish in the medical
team of the ward together with the nurses that took care of her
and her general physician. I asked a medical oncologist from
another hospital in town to review the case and to see her.
His report confirmed that the precise criteria were respected.
Than the team decided to grant her request. Together
we chose a Saturday morning as the time to perform the
euthanasia. The patient preferred the intravenous technique
instead of a drink. She wanted to die shortly after she had lost
her consciousness. On the Saturday morning the nurse and
resident who had taken care of her on the ward, and I went
to her. A few friends were present. The patient took leave of
all of us in a very personal way. After that I asked her to lie
down in a comfortable position. The friends were holding her
hands. After administering the drugs she fell asleep and died
a few minutes after the thiopental and pancuroniumbromide

were administered. The laying out of the body was taken care
of by the nurse and one of the girlfriends. Afterwards we sat
down, had a cup of coffee and felt that the patients wishes
had been fulfilled and that all was well. The case was reported
to the coroner and carefully investigated. Two months later I
evaluated the process of terminal care with the friends that
had been present at the euthanasia. They all felt that the right
decision had been taken. They were grateful that their friend
had not been forced into hopeless suffering.

Conclusion
Euthanasia and physician assisted suicide are part of
terminal care in a few countries in the world. In discussions
concerning euthanasia, much attention is paid to legality,
ethics and technique. The experience in the Netherlands has
learned that euthanasia can be practiced in accordance with
the ethical principles of medical decision making and acting.
Especially the fact that the Netherlands has a 100% coverage
of the population against the costs of protracted illness helps
a lot against misuse of euthanasia. The Dutch experience has
also learned that most requests are coming from terminally ill
cancer patients. A depressed mood or depression plays a role
in the request but does not influence the decision to grant the
request. For family members and friends the process of losing
a family member or friend by euthanasia has no negative
influence on their process of mourning. It is important to
realize that the emotional burden assumed by the doctor and
the nurses is also important. The doctor performs an act that
directly results in the end of someones life. In our personal
experience one can only proceed with this action if a good
mutual relationship has been developed with the patient.
The consequence of this relationship is that one becomes
involved in the process of taking leave and mourning. This can
be demanding, especially because the doctor and the nurse
have to give priority to their professional duties. Euthanasia
is not an easy answer to a difficult question. To the contrary,
euthanasia requires great preparation with the patient and
their family and can take place only as a part of terminal care
which is given with great effort and personal concern.

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