In 2013, the end-of-life clinic in The Netherlands, where patients can request euthanasia when they have run out of options, helped nine psychiatric patients end their lives or commit assisted suicide. These were all people of sound body. The clinic, which was founded at the beginning of 2012, received approximately 286 euthanasia requests from psychiatric patients last year. This is approximately one third of the total number of requests.

By Joke Mat

Providing euthanasia for people with psychiatric disorders is extremely controversial. Over sixty percent of Dutch GPs and specialists who took part in a study at the end of 2012 stated that committing euthanasia on psychiatric patients was “inconceivable”. An opinion poll carried out by the Royal Dutch Medical Association (KNMG) in 2011 highlighted the fact that 52 of the doctors questioned believed that the Euthanasia Act did not permit this. Trouw newspaper featured an article today about a conflict surrounding the euthanasia of a 35 year-old woman with psychiatric problems. A GP, who was consulted as an independent party in her request for euthanasia, felt that there were still more treatment options available. A psychiatrist, however, did not agree Many psychiatrists view their patients desire to die as a given considering their particular disorder.

Fourteen cases in 2012

In The Netherlands, the same legal demands are made of euthanasia for psychiatric patients as those made for people suffering from a physical disease. The request must be voluntary and well considered, the patient must be subject to unbearable and hopeless suffering and there should be no other reasonable recourse. The issue with psychiatric patients is that further treatment is always available and that it is harder to determine if a patient is of sound mind. In other words, is their request well considered?

Fourteen cases of euthanasia and assisted suicide for psychiatric patients were submitted to the regional assessment committees in 2012. There were thirteen similar submissions in 2011. These numbers precede the founding of the end-of-life clinic. The assessment committees deemed all fourteen cases from 2012 as ‘well considered’, as well as seven out of the nine cases reported by the end-of-life clinic in 2013 (the two remaining cases are still under assessment). It is not yet known how many doctors helped psychiatric patients commit euthanasia or assisted suicide in addition to the end-of-life clinic last year.

Nicole Visée, secretary of the assessment committee, underlines the fact that the law is not being stretched but that the understanding of the legal demands constantly continues to develop. She believes that psychiatrists are becoming less reluctant when it comes to requests for euthanasia. Visée feels that the founding of the end-of-life clinic has brought attention to the demand for euthanasia by psychiatric patients.

The end-of-life clinic employs thirty teams, consisting of a doctor and a nurse, that perform euthanasia across the country. In addition to the two psychiatrists employed, many GPs and internists work at the clinic. All doctors handle euthanasia requests made by psychiatric patients. One of the psychiatrists at the end-of-life clinic, Gerty Casteelen, has organised biweekly consultations for these patients. During these sessions, patients are given an hour during which they can explain their desire for euthanasia.

Mysophobia

The first psychiatric patient who received assisted suicide at the beginning of 2013 was a woman with mysophobia. Psychiatrist Gerty Casteelen first carried out eight hour-long sessions with the patient and received approximately eighty emails from her. Casteelen explains that she slowly started to understand the patient’s desire to commit euthanasia. “I couldn’t understand it at first. It was a long process. I came to understand that her fears completely controlled her life. All she could do was clean. It was impossible for the patient to maintain a relationship. Her whole development stalled.” The patient wanted to die in the evening, at eleven minutes past eight. She had already prepared the mourning cards.

The patient had bought champagne for the four women who would be present: a friend, her GP, Gerty Casteelen and a nurse employed by the end-of-life clinic. The group was given cover to put over their shoes when they arrived. Everything in the flat was protected from dirt. The woman (54) was wearing grey pyjamas and sat between grey sheeting. She was happy and relaxed. Casteelen: “At eight o’clock I said: We have to start preparing things now. She said no. I would like another glass of champagne. We asked her if she still wanted to die. She told us how she had been looking forward to this moment. How she was going to be free now.” Casteelen started the drip. “We wished her well on her journey. She fell asleep very quickly. That’s when I admitted the muscle relaxant to her.”

Pension fear

Another patient who received euthanasia in 2013 was a healthy 63 year-old man. He worked for a governmental organisation and all he did was work. He had never been on holiday. He also used to do volunteer work in his free time. He had already tried and failed to commit suicide once and did not want to go through that again. He also did not want to affect other people. The patient had been treated for depression for many years. However, this had not helped. Now, due to his age, he was close to retirement and wanted to die. “He managed to convince me that it was impossible for him to go on. He was all alone in the world. He’d never had a partner. He did have family but he was not in touch with them. It was almost like he’d never developed as a person. He felt like he didn’t have the right to live. His self-hatred is all consuming”, says Casteelen during the patient’s life-time. “It sounds bizarre when I put it like that. He functions well at work. His colleagues love him.” The man organised a farewell drink for his colleagues, the evening before his passing, in a café they regularly go to for lunch. His colleagues had been informed of his decision a few days in advance. “Lots of people were very sad” says Casteelen, who was also present at the event. “He was such a nice, pleasant person. People told him it was a shame he had to go. Is this really necessary was also something I heard people saying. They thought he had a good job. But he was so close to retirement. Many people knew how lonely he was and that he spent all his time working. People gave speeches and the patient received little gifts. Angels with messages. Things he could take with him.” Casteelen went to his house the next morning. “He was relaxed. He felt he was doing the right thing. We sat and chatted for a while. He then went and lay down. He drank the mixture. It’s what he wanted.” Most people pass away within ten minutes. However, this man was still alive two hours later. “He was sleeping peacefully. A real die-hard. We had discussed this situation beforehand. I told him that I would give him medication via a drip if this happened. That’s what I did.”