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The Dutch & the dying.

In January 1990 the Dutch Ministers of Health and Justice appointed a commission to study physicians' practice regarding medical decisions and patient care at the end of life. The Remmenlink Commission, named for its president, examined the characteristics of physicians and patients involved in end-of-life decisions as well as the contexts in which such decisions are taken and the requirements of careful medical practice. The commission also addressed questions of the limits of medical duty to provide palliative care when healing has become impossible.

On 10 September 1991 the commission presented its final report based on the results of research conducted on its behalf by the Rotterdam Institute for Social Health Care. The research was spread over three separate studies: a limited number (405) of interviews with physicians; questionnaires sent to the physicians of 7,000 deceased persons; and follow-up with some of the physicians who participated in the first study concerning every death in their practices in the six months since the initial interview (2,250). The various results are reported in English in further detail by P.J. van der Maas and colleagues in "Euthanasia and Other Medical Decisions Concerning the End of Life," Lancet 338 (14 September 1991): 669-74.

The results show that of the 98,000 deaths annually not attributed to accidents or other sudden causes, some 49,000 involve explicit end-of-life decisions such as forgoing treatment, using painkillers that hasten death, assisted suicide, and active euthanasia, defined by the 1985 State Commission as "the termination of life of a person on his or her request, by another person." Though all physicians face end-of-life decisions, the study found that family physicians are most often involved in decisions regarding euthanasia, while nursing home physicians more often deal with questions of forgoing treatment.

The research indicates that every year about 5,800 patients choose to forgo or terminate treatment, intending thereby to bring the end of life closer. According to the commission, a physician also has the right to abstain from futile medical acts. The doctor may not be able to communicate his decision to demented, semicomatose or otherwise incompetent patients, but this does not invalidate the decision. Consultation with colleagues, however, is highly recommended and in fact is practiced in about half such cases. A well-founded estimate is that treatment is forgone in this way in about 22,500 cases every year.

In another 22,500 cases, treatment for pain is intentionally administered to shorten (by hours or days) the patient's dying process.

About 9,000 patients annually request active euthanasia, of whom 2,300 receive it (representing 1.8% of the total of 130,000 deaths annually, or 5% of nonaccidental deaths). The research also shows that in some 400 cases (0.3% overall), physicians assist patients to commit suicide. All of these cases involve unbearable suffering with no hope of improvement for the patient.

The study also addresses end-of-life decisions involving patients in four special categories. A first group consists of severely defective newborns. Active euthanasia is extremely rare for these patients; omitting life-prolonging treatment is more common. When parents and physicians disagree, treatment is usually continued.

Children with fatal diseases form a second special category, for which statistical data are very scarce. It seems that older children (aged twelve to nineteen) participate quite often in end-of-life decisionmaking.

A third category is psychiatric patients, many of whom suffer from no life-threatening somatic disease, yet request help in committing suicide. Such assistance is almost nonexistent in the Netherlands, the commission reports.

AIDS patients comprise the fourth category. Here decisions concerning the end of life are frequent, most involving forgoing treatment. The study found that between 10 to 20 percent of all deaths among terminal AIDS patients involve euthanasia or assisted suicide.

The Remmelink Commission's report recommends that not only should cases of euthanasia as defined by the State Commission be reported (as required by law), but so should cases in which the patient's life is terminated without his or her express request. It further urges that general practitioners consult specialists with regard to end-of-life decisions and vice versa, and that all physicians follow strictly the rules set out for careful implementation of euthanasia. Finally, the report recommends that people in various professional groups and sectors of health care be trained in making decisions concerning the end of life, and that the training of physicians as well as postgraduate programs devote greater attention to these issues.--Maurice A.M. de Wachter, director, Institute of Bioethics, Maastricht, The Netherlands
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Title Annotation:Dutch commission on end-of-life decisions
Author:Wachter, Maurice, A.M. de
Publication:The Hastings Center Report
Date:Nov 1, 1991
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