There have been several cases in the Netherlands where phenobarbital has been successfully used for assisted suicide.
Case 1
The assisted suicide took place on…… by the patient taking a drink containing 9 grams of phenobarbital.
Case 2
The doctor performed the assisted suicide by providing the patient with a drink containing 15 grams of phenobarbital, which she drank.
In the Netherlands, for assisted suicide, a barbiturate that crosses the blood-brain barrier relatively quickly, thus ensuring a rapid onset of action, is preferred for oral administration. The Royal Dutch Pharmacists Association (KNMP) recommends pentobarbital or secobarbital in the Euthanasia Standard.
However, there have been several cases in the Netherlands where phenobarbital has been successfully used for assisted suicide.
Case 1
The assisted suicide took place on…… by the patient taking a drink containing 9 grams of phenobarbital.
The doctor, by leaving the euthanasia drug with the patient, created a situation in which he no longer had control over the proceedings and in which the patient had the opportunity to take the euthanasia drug without the doctor being present, with all the possible consequences thereof.
Nature of the Suffering, Information, and Alternatives
The patient, a man aged 50-60, was diagnosed with esophageal carcinoma two years prior to his death, for which he received palliative treatment with radiotherapy and chemotherapy. In the fall of (…), a local recurrence and liver metastases were identified. Brachytherapy was performed without success, and the patient declined further chemotherapy. Six months later, a stent was placed. In the final months, the patient also underwent various alternative therapies. The patient's suffering consisted of weakness and increasing pain in the upper abdomen due to liver metastases and behind the sternum due to tumor ingrowth. Additionally, there was ascites and edema in the legs. The patient could no longer consume solid food, and liquid nutrition was poorly tolerated. The patient was increasingly unable to function. This suffering was unbearable for the patient. There was no prospect of recovery or improvement. The patient had been palliatively treated with diuretics, paracetamol, Oxycontin, morphine suppositories, and an escalating dose of Durogesic, which had only moderate effects and caused increasing drowsiness as a side effect. Beyond the palliative measures already taken, there were no further options to alleviate the suffering.
From the records, it can be inferred that the treating physicians in various hospitals and the attending doctor adequately informed the patient about his condition and prognosis. The doctor estimated that, had euthanasia not been performed, the patient would have died within two weeks.
b. Request for Termination of Life
During the course of the illness, the patient's wish for euthanasia had been raised multiple times. Approximately one week before his death, the patient made a concrete request for euthanasia for the first time. He reiterated this request several times thereafter. The request was made in the presence of the patient's partner and expressed to the doctor. A written advance directive is available.
According to the doctor, there was no external pressure, and the patient was fully aware of the implications of his request and his physical condition. The patient was fully compos mentis, and there was no evidence of depression or a psychiatric disorder.
The decision regarding euthanasia was discussed with the patient's partner and children, who respected his request for termination of life.
c. Consultation
An independent general practitioner, also a SCEN doctor, was consulted. This consultant visited the patient a few days before his death after extensive contact with the attending doctor and review of the patient's medical records. In his report, the consultant confirmed the patient's medical history. During the visit, the consultant found the patient in the living room, lying on the couch. He was emaciated and had a distended abdomen. He was rational and realistic during the conversation. The patient suffered unbearably from rapidly increasing pain, for which pain relief was often inadequate, as well as the prospect of more pain due to the failure of pain relief and the rapid progression of the disease. There was no future left. The patient was no longer capable of doing anything. He "couldn't take another step." He could no longer keep food down. He wanted to have control over his own death. The unbearable nature of the suffering was palpable to the consultant. According to the consultant, there was a voluntary and well-considered euthanasia request based on the reports from the attending doctor and the way the patient presented himself during their conversation. The patient's partner supported him and his wish. The consultant concluded that the due care criteria had been met.
d. Execution
The assisted suicide took place on … through the patient's ingestion of a drink containing 9 g of phenobarbital.
Assessment
The committee retrospectively evaluates the doctor's actions against the due care criteria outlined in Article 2 of the Termination of Life on Request and Assisted Suicide (Review Procedures) Act. The committee considers whether the actions align with prevailing scientifically responsible medical insight and the norms of medical ethics.
Based on the above facts and circumstances, the committee is of the opinion that the doctor could reasonably conclude that the patient's request was voluntary and well-considered and that there was hopeless and unbearable suffering. The doctor sufficiently informed the patient about his situation and prognosis. The doctor and the patient could reasonably conclude that there was no other solution for the patient's situation. The doctor consulted at least one other independent physician, who saw the patient and provided a written opinion on compliance with the due care criteria.
Regarding the medically careful execution of the termination of life, the committee considers the following: The execution of euthanasia or assisted suicide must be pharmacologically and medically careful. When assessing whether assisted suicide was provided in accordance with prevailing scientifically responsible pharmacological insight, the committee generally uses the Euthanasia Standard (2007) of the Royal Dutch Pharmaceutical Society (KNMP) as a guideline.
Based on the medical-professional standard, the doctor must personally hand the euthanasia drug to the patient, be present during its ingestion, and remain with the patient until death is confirmed. This allows the doctor to intervene immediately if the euthanasia drug does not work as expected and to prevent its use at an unintended time or by someone for whom it was not intended. The doctor and patient must discuss the procedure for assisted suicide and the choices to be made in case of complications in advance.
In this case, the doctor, after consulting with the pharmacist, obtained 9 g of phenobarbital. The doctor discussed with the patient the timing of the assisted suicide, the necessity of the doctor's presence, and the procedure in case of complications. However, the doctor left the euthanasia drug with the patient, and the patient, contrary to the agreement, took it without notifying the doctor in advance and thus without the doctor being present. By leaving the euthanasia drug with the patient, the doctor created a situation in which he no longer had control over the proceedings, allowing the patient to take the drug without the doctor's presence, with all the possible consequences thereof. The committee must therefore conclude that the doctor did not provide assisted suicide in a medically careful manner, thereby failing to meet the due care requirement under Article 2, paragraph 1, sub f of the Termination of Life on Request and Assisted Suicide (Review Procedures) Act.
The committee notes that it has no doubts about the doctor's integrity. From the doctor's oral explanation, it is clear that the doctor carefully prepared the assisted suicide. He discussed the procedure with the patient multiple times, consistently emphasizing that the drink had to be taken in his presence. The doctor took precautions for potential complications and, when the patient wished to postpone the assisted suicide, agreed that he would be contacted when the patient was ready to take the euthanasia drug. The doctor offered the patient the opportunity to contact him at any time and relied on the good relationship they had when leaving the euthanasia drug. During the discussion with the committee, the doctor indicated that he has learned never to leave euthanasia drugs with a patient, despite a sense of trust.
Regarding the use of 9 g of phenobarbital, the committee notes that, according to the Scientific Institute of Dutch Pharmacists (WINAp), part of the KNMP, a lipophilic barbiturate that crosses the blood-brain barrier relatively quickly and thus has a rapid onset of action is preferred for oral administration (source: Technical Report on Euthanatica, 1987). The KNMP recommends pentobarbital or secobarbital in the Euthanasia Standard (2007). The committee uses the KNMP/WINAp advice as a guideline and notes that, in this case, a non-recommended agent was used on the advice of a pharmacist, though it achieved the intended effect.
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Case 2
The doctor performed the assisted suicide by providing the patient with a drink containing 15 grams of phenobarbital, which she drank.
Based on the reports from the physician and the consultant, as well as other received information, the following has been established regarding:
a. Nature of the suffering, information provided, and alternatives
The patient, a woman aged 90 or older, suffered from multiple conditions. She experienced significant pain following a total hip prosthesis fifteen years prior to her death. Her mobility was also increasingly limited, partly due to instability in her left knee. Additionally, the patient suffered from severe abdominal complaints. It was suspected that she had experienced diverticulitis two years before her death.
One year before her death, she underwent gallbladder surgery due to gallstones. In the last year of her life, the patient lost considerable weight. Six months before her death, she was admitted to the hospital with severe abdominal cramps. Based on the suspicion of recurrent gallstones, an ERCP was performed. Recovery was no longer possible, and treatment was solely palliative in nature.
The patient's suffering consisted of progressive physical decline, severe general fatigue, abdominal complaints, pain while walking, standing, lying, and sitting, limited mobility, and loss of strength. She was highly unsteady on her feet. Due to her increasing limitations, she had become housebound. Furthermore, she experienced loneliness, despite daily visits from friends.
She suffered from her increasing limitations and the loss of her independence. Every day of life was, for her, a day too many. She had a great fear of falling and ending up in a nursing home, which she absolutely did not want.
The patient experienced her suffering as unbearable. The physician was convinced that the suffering was unbearable for the patient and, according to prevailing medical opinion, without prospect of improvement. There were no acceptable options left to alleviate her suffering. The documentation indicates that the physician and specialists sufficiently informed the patient about her situation and her prospects.
b. Request for termination of life
The patient had previously discussed euthanasia with the physician. More than eight months before her death, she explicitly requested the physician to carry out the termination of her life. She repeated her request multiple times and discussed it extensively with the physician. According to the physician, the request was voluntary and well-considered.
c. Consultation
The physician consulted an independent SCEN physician as a consultant. The consultant visited the patient approximately three months before the termination of life, after being informed about the patient by the physician and reviewing the relevant medical documentation.
In his report, the consultant provided a summary of the patient's medical history and the nature of her suffering. The consultant formed the impression of a "completed life" issue. The consultant deemed the patient's suffering not to be without prospect of improvement. Based on his conversation with the patient, the consultant concluded in his report that the due care criteria had not been met. In his opinion, "there were insufficient substantiated due care criteria to perform euthanasia."
The consultant suggested that psychiatric evaluation for an underlying depression or personality disorder might provide further insight. There could potentially be treatment alternatives to make the suffering more bearable for the patient.
Following the consultant's advice, the physician consulted an independent psychiatrist approximately eight weeks before the patient's death. The psychiatrist determined that the patient suffered from a combination of age-related ailments and unbearable, untreatable suffering. The psychiatrist deemed the patient competent regarding her euthanasia request and concluded that her suffering was without prospect of improvement and that no treatment alternatives were available.
d. Execution
The physician carried out the assisted suicide by providing the patient with a drink containing 15 grams of phenobarbital, which she consumed.
Assessment
The committee retrospectively evaluates the physician's actions against the due care criteria set out in Article 2 of the Termination of Life on Request and Assisted Suicide (Review Procedures) Act.
Regarding the voluntary and well-considered request, the committee finds that the physician acted with utmost care. Since the patient made a concrete request for termination of life, the physician frequently and extensively discussed her request with her. Based on this, the committee is of the opinion that the physician could reasonably conclude that the patient's request was voluntary and well-considered.
Regarding the unbearable suffering without prospect of improvement, the committee considers that in cases where a patient suffers from a combination of age-related conditions, this combination can cause unbearable suffering without prospect of improvement. The cumulative effect of one or more of these conditions and related complaints can result in suffering that, in the context of the patient's medical history, biography, personality, values, and resilience, is experienced by this patient as unbearable and without prospect of improvement.
Based on the information provided by the physician, the committee is of the opinion that the physician could reasonably be convinced that the patient suffered unbearably and without prospect of improvement due to this combination of conditions.
The physician sufficiently informed the patient about her situation and her prospects. The physician and the patient reached the conclusion that there was no reasonable alternative solution for her situation. The physician consulted at least one other independent physician, who saw the patient and provided a written opinion on the due care criteria. The physician carried out the assisted suicide in a medically careful manner.
Decision
The physician acted in accordance with the due care criteria set out in Article 2, paragraph 1 of the Termination of Life on Request and Assisted Suicide (Review Procedures) Act.
Source
Regional Euthanasia Review Committees
The Regional Euthanasia Review Committees evaluate all euthanasia cases reported in the Netherlands. These committees operate independently in their assessments.
https://english.euthanasiecommissie.nl/
