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Death and the Physician
The emotional impact on physicians of hastening the death of a patient
Ilinka Haverkate, Agnes van der Heide, Bregje D
Onwuteaka-Philipsen,
Paul J van der Maas and Gerrit van der Wal
MJA 2001; 175: 519-522
For commentaries, see Kelly and Ryan
Abstract -
Methods -
Results -
Discussion -
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References -
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Objective: To investigate the emotional feelings
reported by physicians in the Netherlands after having performed
euthanasia or other medical end-of-life decisions.
Design: Nationwide interview study in the
Netherlands, November 1995 through February 1996.
Participants and setting: A random sample of 405
physicians (general practitioners, nursing home physicians, and
clinical specialists).
Main outcome measures: Subsequent feelings of
physicians about their most recent cases (if any) of euthanasia,
assisted suicide, life-ending without an explicit request from the
patient, and alleviation of pain and other symptoms with high doses of
opioids.
Results: The response rate was 89%. In 52% of all cases
of hastening death, physicians had feelings of comfort afterwards,
which included feelings of satisfaction in 44% and of relief in 13%.
Feelings of discomfort were reported in 42%, most frequently
referred to as emotional (28%) or burdensome (25%). Feelings of
discomfort were highest for euthanasia (75%; P < 0.000).
95% of physicians were willing to perform euthanasia or assisted
suicide again in similar situations. Afterwards, 5% had doubts, but
none had regrets, about performing euthanasia.
Conclusions: Hastening the death of a patient evokes
different feelings among physicians. Although performing
euthanasia is often experienced as burdensome and emotional,
granting the ultimate wish of a competent patient may also give
physicians a feeling of having contributed to the quality of the dying
process.
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In the Netherlands, the Dutch Termination of Life on Request and
Assisted Suicide (Review Procedures) Act has been accepted by the
Dutch parliament and will be effective probably by the end of 2001.
Under this law, euthanasia and assisted suicide are still criminal
offences, but the penal code has been amended to exempt doctors from
criminal liability if they report their actions and show that they
have satisfied the requirements for prudent practice. The most
important requirements are unbearable and hopeless suffering;
voluntary, persistent and well-considered request; consultation;
written reporting of the decision; and notification. In most other
countries, no such procedure exists. Although the open debate about
euthanasia and assisted suicide in the Netherlands has resulted in
relatively transparent medical practice, they are still
exceptional acts that go beyond "normal" medical decision-making
and are potentially emotionally troubling for doctors.
We know of just a few studies of the personal feelings of physicians
after participating in euthanasia and assisted suicide.1-3 Here we
present the results of an analysis of the emotional feelings reported
by doctors in the Netherlands after performing euthanasia or other
medical end-of-life decisions. The data are derived from the
1995/1996 nationwide survey on end-of-life decision-making in the
Netherlands.4,5
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Study population | |
The study design and methods of this study are the same as those
described in the 1995/1996 investigation.4 A random sample of 405
doctors was interviewed. The sample was obtained from the
registration files of the Royal Dutch Medical Association and the
Dutch Institute for Health Care Research, and included 124 general
practitioners, 74 nursing home physicians, and 207 clinical
specialists from five fields of medicine (cardiology, surgery,
internal medicine [including oncology], respiratory medicine and
neurology). Physicians in these categories attend 87% of all deaths
which occur in hospitals, and almost all other deaths outside
hospitals, in the Netherlands. Inclusion criteria were that doctors
must have been practising in their registered specialties since 1
January 1994, and that they had been working in the same institution
ever since.
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Data collection |
Interviews were conducted from November 1995 through February 1996
by over 30 experienced doctors who had received intensive training
for this purpose. Interviews were guided by a semistructured
questionnaire (participants were not paid). In the interview,
doctors were asked to provide detailed information about their last
case, if any (1 or 0), of euthanasia, assisted suicide, the ending of
life without an explicit request from the patient, and alleviation of
pain and other symptoms with high doses of opioids. For the purpose of
this study, the questionnaire contained questions about doctors'
subsequent feelings, doubts or regrets and support-seeking. The
responses were partly open-ended (prestructured for the research
team only, which meant that the interviewers made their own judgement
on the content and then categorised it; this was checked with the
respondents) and partly closed to questions. Further, the reported
feelings were categorised for the analyses as either feelings of
"comfort", which included feelings of satisfaction and relief, or
feelings of "discomfort", which included feelings described as
burdensome, emotional or a heavy responsibility.
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Definitions |
Euthanasia: Administering drugs with the explicit
intention of ending a patient's life at the patient's explicit
request.
Assisted suicide: Prescribing or supplying drugs
with the explicit intention of enabling the patient to end his or her
own life.
Life ending without an explicit request:
Administering drugs with the explicit intention of ending the
patient's life without a concurrent explicit request from the
patient.
Alleviation of pain and other symptoms with opioids:
Administering drugs in doses which the interviewees believed large
enough to have a probable life-shortening effect.
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Statistical analysis | |
To extrapolate the findings to all physicians in the Netherlands,
weights were calculated based on the percentages of the various types
of physicians represented in the sample. Our estimates of the
different variables were corrected for the 13% of in-hospital deaths
attended by physicians in specialties other than the five sampled, on
the assumption that among these remaining deaths the various types of
medical end-of-life decisions were as frequent as among the deaths
studied. Associations between physician or patient
characteristics and reported feelings were tested for statistical
significance with  2 tests for categorical
variables and with t tests for continuous variables.
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Response rate |
Of the original random sample of 559 physicians, 83 did not meet the
inclusion criteria, 21 either had a chronic illness or could not be
located, and 50 were unwilling to participate in the study, giving a
response rate of 89%.
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Feelings reported by physicians | |
Data on the feelings of physicians after "perceived" hastening of the
death of a patient by giving life-ending drugs were available for 159
cases (by 159 physicians) of euthanasia, 34 cases of assisted
suicide, 74 cases of ending life without an explicit request from the
patient, and 291 cases of alleviation of pain or other symptoms with
potentially life-shortening effects. Our findings are shown in Box
1. In 52% of all cases, physicians reported that they had feelings of
comfort afterwards, while feelings of discomfort were reported in
42% (most frequently, emotional or burdensome).
Feelings of comfort and discomfort were analysed for possible
associations with the type of end-of-life decision and physician or
patient characteristics (Box 2). The percentage of physicians who
had feelings of comfort (satisfaction or relief) afterwards was
lowest in cases of alleviating pain or other symptoms and highest when
they had assisted with suicide, but the differences between the
various types of end-of-life decisions were not significant. For
physicians who had feelings of discomfort (burdensome, emotional,
heavy responsibility) there were significant differences between
the end-of-life decisions (see Box 2). General practitioners
reported both feelings of comfort and discomfort more frequently
than clinical specialists and nursing home physicians, but other
physician characteristics, such as age, sex, religious affiliation
and the number of previous cases of euthanasia or assisted suicide,
were not related to feelings of comfort or discomfort.
Patient characteristics significantly related to a higher
frequency of feelings of comfort were female sex, and shortening of
life by less than one month. Feelings of discomfort were related to
patients' younger age, male sex, a diagnosis of cancer, and
shortening of life by more than one month. The degree of suffering
(assessed only for cases of euthanasia and assisted suicide) was
related to feelings of comfort in that more severe suffering was more
frequently related to feelings of comfort. Finally, ending a
patient's life without an explicit request, and alleviation of pain
or other symptoms, more frequently evoked later feelings of
discomfort when the explicit intention of the physician had been to
hasten death, compared with cases where the intention had only
partially been to hasten death.
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Most recent case compared with former cases | |
Of the 110 physicians who had performed euthanasia previously, 45%
reported that their most recent case of euthanasia had been just as
difficult as previous cases. Among all physicians, 26% found their
most recent case less difficult than previous cases and 29% thought it
had been more difficult. The percentages finding their most recent
case equally difficult, less difficult and more difficult for
assisted suicide (n = 14) were 38%, 23% and 40%, respectively,
and for life ending without an explicit request from the patient
(n = 45) 55%, 34% and 10%, respectively.
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Willingness to perform again | |
Box 3 shows that the vast majority of the physicians would be willing to
perform euthanasia or assisted suicide again in similar
circumstances. Afterwards, 9 of the physicians (5%) had doubts, but
none had regrets, about performing euthanasia; these doubts
concerned, among other things, the consideration of treatment
alternatives, the amount of time and latitude involved in the
decision-making, the choice between euthanasia and assisted
suicide, and the role of the relatives. In 85% of cases, the physician
thought that the quality of dying had been improved considerably by
euthanasia, and 12% thought that it had been improved somewhat.
Six physicians (7%) had subsequent doubts about ending a patient's
life without an explicit request. These doubts concerned (each
mentioned once) the amount of time taken to make the decision, the
involvement of the patient, the competence of the patient, possible
pressure from others, the delay in administering the drugs, and
neglect of the formal aspects of the decision-making. Three
physicians (4%) had regrets; one about the amount of latitude
involved in decision-making, one about being pressured by others and
one because the relatives were not sufficiently involved in the
decision-making. In 67% of cases, the physician thought that the
quality of dying had been improved considerably by the end-of-life
decision, and in 26% the physician thought it had been improved
somewhat. In two cases, the physicians thought the quality of the
dying process had not been improved at all.
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Support afterwards | |
Box 3 shows that, among the 159 physicians who had performed
euthanasia, 43% later sought support in coping. Most sought support
privately from friends or family and many sought support from
colleagues. One sought professional help. Of the 74 physicians who
had ended a life without an explicit request from the patient, 16%
sought support later. Again, most sought support privately, many
sought support from colleagues, and none sought professional help.
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We found that approximately half of the physicians who had performed
euthanasia or assisted suicide found it emotional or burdensome, but
almost the same percentage of physicians felt satisfaction
afterwards. The use of the word "emotional" in this context deserves
some explanation. By "emotional", we mean a mixture of feelings such
as being "touched", "out of balance" or "upset". We are aware that the
classification in the analyses of emotional under the heading of
"discomfort" is a simplification which does not fully capture the
nuance of the feeling.
One limitation of our study is that the design was retrospective, and
may therefore be prone to recall bias. Further, all data are based on
self-reporting by the physicians, and the number of cases in some
subgroups was small.
We realise that the process of decriminalisation of euthanasia and
assisted suicide is quite unique to the Netherlands. However, we
believe that, to a degree, our data are transferable to other
countries, as these data involve decision-making that is
potentially emotionally troubling for physicians outside the
Netherlands as well. Although our data are five years old, we have no
reason to assume that our findings regarding the emotional impact on
physicians would have changed.
It is striking that ending a patient's life without an explicit
request later evoked feelings of discomfort (burdensome, emotional
or a heavy responsibility) less frequently than did performing
euthanasia or assisted suicide. Also, more physicians sought
support after they had performed euthanasia than after they had ended
the life of a patient without an explicit request. Thus, life-ending
without an explicit request from the patient seems to have a different
emotional impact on physicians than life-ending on request (ie,
euthanasia or assisted suicide). This may be associated with other
findings, such as the distribution of causes of death, the amount of
time by which life is shortened and the medications administered,
which suggests that life ending without an explicit request is more
comparable with decisions to alleviate pain (where morphine was
virtually the only drug given) than with euthanasia (in which
neuromuscular relaxants were mostly used).4
The number of previous cases of euthanasia or assisted suicide
performed by a physician seems to have had no effect on the reported
emotional impact. Thus, our data do not indicate that repeated
performance "numbs" the emotions or that this emotionally laden type
of medical decision-making becomes part of "normal" medical
practice. This was confirmed by our finding that the percentage of
physicians who found their most recent case of assisted suicide less
difficult than any previous cases was similar to the percentage who
found their most recent case more difficult than previous cases.
Despite our finding that many physicians find performing euthanasia
burdensome and emotional, the vast majority indicated that they
would be willing to perform euthanasia again for a patient in a
comparable situation, and only a few (5%) had doubts or regrets. In a
study among American oncologists, it was found that a greater
percentage of oncologists (24%) later regretted having performed
euthanasia. However, most of those who had participated in
euthanasia or assisted suicide (54%) found comfort in knowing that
they "helped a patient end his or her life the way the patient wished",
and this is comparable with the results of another US
study.1,3 Granting the ultimate
wish of a competent patient may give many physicians a feeling of
having contributed positively to the quality of the dying process.
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This study was supported by a grant from the Dutch Ministry of Justice
and Health, Welfare and Sports.
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None declared.
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- Emanuel EJ, Daniels ER, Fairclough DL, Clarridge BR. The practice
of euthanasia and physician-assisted suicide in the United States:
adherence to proposed safeguards and effects on physicians.
JAMA 1998; 280: 507-513.
-
Ponsioen BP. How does the physician learn to live with euthanasia?
[in Dutch]. Ned Tijdschr Geneeskd 1983; 127: 961-964.
-
Meier DE, Emmons CA, Wallenstein S, et al. A national survey of
physician-assisted suicide and euthanasia in the United States.
N Engl J Med 1998; 338: 1193-1201.
-
Van der Maas PJ, Van der Wal G, Haverkate I, et al. Euthanasia,
physician-assisted suicide, and other medical practices involving
the end of life in the Netherlands 1990-1995. N Engl J Med 1996;
335: 1699-1705.
-
Van der Wal G, Van der Maas PJ, Bosma JM, et al. Evaluation of the
notification procedure for physician-assisted death in the
Netherlands. N Engl J Med 1996; 335: 1706-1711.
(Received 23 Apr, accepted10 Jul, 2001)
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Vrije Universiteit Medical Centre, Institute for Research in
Extramural Medicine, Department of Social Medicine, Amsterdam, The
Netherlands.
Ilinka Haverkate, PhD, Psychologist;
Bregje D
Onwuteaka-Philipsen, PhD, Researcher;
Gerrit van der
Wal, MD, PhD, Professor.
Department of Public Health, Erasmus University Rotterdam,
Rotterdam, The Netherlands.
Agnes van der Heide, MD, PhD, Epidemiologist;
Paul J van
der Maas, MD, PhD, Professor.
Reprints will not be available from the authors.
Correspondence: Dr I
Haverkate, VU Medical Centre, EMGO-Institute, Van der
Boechorststraat 7, 1081 BT Amsterdam, The Netherlands.
I.Haverkate.gpnhATmed.vu.nl
©MJA 2001
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© 2001 Medical Journal of Australia.
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| 1: Physicians' feelings
after their most recent case of euthanasia, assisted suicide, life ending
without an explicit request, and alleviation of pain and symptoms (weighted
percentages) |
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|
Euthanasia
(n=159) |
Assisted
suicide (n=34) |
Life ending
without an
explicit request
(n=74) |
Alleviation
of other
symptoms
(n=291) |
Total
(n=558) |
|
| Feelings of "comfort"* |
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|
|
|
| Satisfactory |
43% |
60% |
43% |
42% |
44% |
| Relief |
13% |
7% |
18% |
14% |
13% |
| Total* |
52% |
63% |
56% |
48% |
52% |
| Feelings of "discomfort"* |
|
|
|
|
|
| Burdensome |
50% |
40% |
19% |
7% |
25% |
| Emotional |
48% |
49% |
24% |
11% |
28% |
| Heavy responsibility |
32% |
22% |
12% |
6% |
17% |
| Total |
75% |
58% |
34% |
18% |
42% |
| Other feelings* |
|
|
|
|
|
| Unnatural |
3% |
—† |
3% |
—† |
1% |
| Natural |
—† |
—† |
—† |
52 |
10% |
| Other |
2% |
3% |
20% |
9% |
8% |
|
| * More than one answer
possible. †Not reported. |
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| Back to text |
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| 2: Physicians' feelings after having made
an end-of-life decision: relationship with type of decision and physician
characteristics, and with patient characteristics (weighted percentages)
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Feelings of comfort |
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Feelings of discomfort |
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Yes |
No |
P* |
|
Yes |
No |
P* |
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| Type of end-of-life decision |
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|
0.1 |
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|
0.000 |
| Euthanasia (n=159) |
52% |
48% |
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|
75% |
25% |
|
| Assisted suicide (n=34) |
63% |
37% |
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|
58% |
42% |
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| Life ending without an explicit |
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|
|
|
|
|
|
| request from the patient (n=74) |
56% |
44% |
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|
34% |
66% |
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| Alleviating pain or other symptoms (n=291)
|
48% |
52% |
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|
18% |
82% |
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| Physician characteristics |
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| Specialty |
|
|
0.001 |
|
|
|
0.02 |
| General practitioner (n=221) |
56% |
44% |
|
|
45% |
55% |
|
| Nursing home physician (n=62) |
43% |
57% |
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|
26% |
74% |
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| Clinical specialist (n=275) |
39% |
61% |
|
|
34% |
66% |
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| Age |
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|
0.2 |
|
|
|
0.5 |
| <45 (n=239) |
49% |
51% |
|
|
40% |
60% |
|
| >44 (n=312) |
54% |
46% |
|
|
57% |
43% |
|
| Sex |
|
|
0.5 |
|
|
|
0.1 |
| Female (n=81) |
49% |
51% |
|
|
49% |
51% |
|
| Male (n=470) |
52% |
48% |
|
|
40% |
60% |
|
| Religious affiliation |
|
|
0.3 |
|
|
|
0.1 |
| Yes (n=230) |
49% |
51% |
|
|
38% |
62% |
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| No (n=328) |
53% |
47% |
|
|
44% |
56% |
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| Number of previous cases of euthanasia and
assisted suicide (mean [SD])† |
1.5 (2.1) |
1.2 (2.0) |
0.2 |
|
1.3 (2.1) |
1.4 (1.9) |
0.8 |
| |
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| Patient characteristics |
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|
|
|
|
|
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| Age in years (mean [SD])† |
66 (13) |
64 (18) |
0.1 |
|
61 (18) |
68 (14) |
0.000 |
| Sex |
|
|
0.04 |
|
|
|
0.04 |
| Female (n=316) |
47% |
53% |
|
|
46% |
54% |
|
| Male (n=239) |
55% |
45% |
|
|
38% |
62% |
|
| Diagnosis |
|
|
0.1 |
|
|
|
0.004 |
| Cancer (n=359) |
55% |
45% |
|
|
46% |
54% |
|
| No cancer (n=120) |
46% |
54% |
|
|
30% |
70% |
|
| Shortening of life |
|
|
0.001 |
|
|
|
0.000 |
| More than one month (n=74) |
36% |
64% |
|
|
86% |
14% |
|
| One to four weeks (n=155) |
59% |
41% |
|
|
47% |
53% |
|
| Less than seven days (n=329) |
52% |
48% |
|
|
29% |
71% |
|
| Degree of suffering‡ |
|
|
0.002 |
|
|
|
0.3 |
| Extreme (n=108) |
63% |
37% |
|
|
67% |
33% |
|
| Unbearable (n=50) |
51% |
49% |
|
|
76% |
24% |
|
| Moderately severe (n=35) |
36% |
64% |
|
|
77% |
23% |
|
| Intention with which the act was performed§
|
|
|
0.001 |
|
|
|
0.1 |
| Hastening death was partially the intention
(n=304) |
54% |
46% |
|
|
19% |
81% |
|
| Hastening death was the explicit intention
(n=58) |
32% |
68% |
|
|
28% |
72% |
|
|
*P value for 2 test.
†Mean (SD) for cases that resulted/did not result in feelings of comfort
and that resulted/did not result in feelings of discomfort, respectively;
P value for t test.
‡Degree of suffering was assessed only for cases of euthanasia and assisted
suicide.
§Includes only cases of life ending without an explicit request from the
patient and alleviation of pain or other symptoms. |
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| Back to text |
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| 3: Willingness of physicians
to assist in death again, subsequent doubts or regrets and seeking support
after performing euthanasia or ending a patient's life without an explicit
request (weighted percentages) |
| |
|
|
|
Euthanasia
(n=159) |
Life ending
without
an explicit request
(n=74) |
|
| Willingness to perform physician-assisted
death again |
|
|
| Yes |
95% |
82% |
| No |
3% |
9% |
| Don't know |
2% |
9% |
| Subsequent doubts or regrets |
|
|
| Doubts |
5% |
7% |
| Regrets |
—* |
4% |
| No |
95% |
89% |
| Physician sought support afterwards |
|
|
| Yes |
43% |
16% |
| If yes, from whom |
(n=57) |
(n=12) |
| Professional |
0 |
|
| Colleagues |
60% |
44% |
| Privately (friends
or family) |
83% |
72% |
| Other |
0 |
—* |
|
| *Not reported. |
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| Back to text |
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