Consultants in cases of intended euthanasia or assisted suicide in the Netherlands

Consultation takes place in about 99% of reported cases of EAS (41% of cases are reported) and in about 37% of unreported cases. In 88% of cases of EAS in which consultation took place the consultant had seen the patient.^2,3 In a consultation, a physician formally confers with an independent colleague in considering whether to grant a request for EAS. The consultant determines whether the patient's physician has acted according to the requirements for prudent practice: the patient's request is voluntary, well-considered and persistent, the patient's suffering is unbearable and hopeless, and there are no alternatives for treatment remaining. A consultant should be competent and independent of both the attending physician and the patient, and should visit the patient.^1,4

Consultation for EAS is a relatively new task for physicians, and is not part of general medical training. Physicians generally are not used to pronouncing formal judgement on the decision-making process of their colleagues and are not used to seeing patients in a consultancy role. Moreover, consultants need to have knowledge relevant to EAS, such as the possibilities of palliative care.⁵ Gaining experience as a consultant seems to be important for a physician to become comfortable in this role.

As part of a nationwide study on EAS and other practices involving the end of life in the Netherlands,^3,6 we set out to determine how often physicians act as a consultant, whether physicians frequently consult the same colleague (or vice versa), whether groups of physicians are asked to be a consultant more often than other groups, the reasons why consultants do not agree with the intended performance of EAS, and the extent to which the consultant feels responsible for the attending physician's final decision to grant or refuse a request for EAS.

To interview the desired number of physicians, 559 were included in the sample; 83 did not meet the selection criteria and 21 had a chronic illness or could not be located. Of the remaining 455, 50 (11%) did not respond.

The final sample of 405 physicians included 124 general practitioners, 74 nursing home physicians (nursing homes in the Netherlands are multifunctional institutions which care for predominantly elderly patients with chronic diseases and physical and/or mental disorders and handicaps) and 207 specialists in cardiology, surgery, internal medicine, respiratory medicine and neurology (oncology and palliative care are not distinct specialties in the Netherlands, but are practised by specialists in other disciplines, such as internal medicine). Physicians in the above-listed specialties attend 87% of all deaths occurring in hospitals. Together with the general practitioners and nursing home physicians, they attend about 95% of all deaths in the Netherlands. Physicians who were not practising in their registered specialty in the same institution since 1 January 1994 were excluded.  

Estimates of the number of consultations in 1995 were based on the (weighted) data on how often each physician had acted as consultant in 1994 and 1995.

Multiple logistic regression analyses were used to obtain insight into determinants of whether physicians had ever been a consultant. Because of the stratification according to specialty, the variable "specialty" was included in all analyses. To deal with this categorical variable we used indicator variables, choosing the general practitioners as the reference category.

Eleven per cent of the physicians had been a consultant more than three times (Box 3), and in 1995, 3% had been a consultant three or more times.  

The forming of "pairs" of consultants suggests that familiarity is very important in the choice of consultant. An earlier study found that an important reason for choosing a consultant is accessibility and that physicians mainly consult physicians of their own specialty.² A problem with these consultations may be that the independence of the consultant with regard to the attending physician might be threatened. This is suggested by the fact that "consultants of a pair" more often agree with the intended performance of EAS than other consultants, although this difference is not statistically significant. A possible way of assuring independence of the consultant while safeguarding the consultant's accessibility would be to appoint independent trained consultants who could be contacted by all physicians in a region. Such a system was implemented for general practitioners in Amsterdam in 1997.⁸ It might also be useful in increasing the frequency of consultation, and possibly the reporting of EAS.

The reasons given by consultants for advising against EAS all related to the requirements for prudent practice; the fact that physicians very rarely carry out EAS when the consultant advises against it suggests that consultation can have an important function in assuring the quality of this kind of medical practice. However, our results do not show how often consultants agreed with EAS in cases in which not all the requirements for prudent practice were met.

Nursing home physicians, neurologists, surgeons and cardiologists are less likely than general practitioners to have been a consultant. A possible explanation is that, for being asked to act as a consultant, it is not only important to have carried out EAS, but also to have done so relatively frequently: general practitioners, respiratory specialists and specialists in internal medicine carry out EAS more frequently than other physicians.⁶

In general, Dutch physicians do not have much experience in acting as a consultant in cases of intended EAS. Of the 42% of physicians who have been a consultant, only 27% had been a consultant more than three times, and only 3% more than 10 times. Because acting as a consultant differs greatly from a physician's normal working relationship with colleagues and patients, and because the consultation concerns a matter of life and death, it is important that consultants are experienced and specifically trained. A training program for consultants, in which the skills needed, knowledge about the requirements for prudent practice, palliative care and medicotechnical aspects of EAS are addressed, has been developed by the Royal Dutch Medical Association. In the future it might be advisable to permit only specifically trained physicians to act as a consultant.

1. Board of the Royal Dutch Medical Association. Vision on euthanasia. In: Euthanasia in the Netherlands. 5th ed. Utrecht 1996. 24-56.
2. Van der Wal G, van der Maas PJ. Euthanasia and other medical decisions concerning the end of life. The Hague, the Netherlands: Staatsuitgeverij, 1996 (in Dutch).
3. 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.
4. Van der Wal G, Dillmann RJM. Euthanasia in the Netherlands. BMJ 1994; 308: 1346-1349.
5. Onwuteaka-Philipsen BD. The role of the consultant. In: Legemaate J, Dillmann RJM, editors. Physician-assisted death: between norm and practice. 105-114. Bohn Stafleu Van Loghum, Houten 1998 (in Dutch).
6. 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.
7. Armitage P, Berry G. Statistical methods in medical research. 3rd ed. Oxford: Blackwell, 1994; 436-440.
8. Dillman RJM, Krug CHM, Onwuteaka-Philipsen B, et al. Support and consultation in cases of euthanasia in Amsterdam. Med Contact 1997; 52: 743-745 (in Dutch).

Department of Public Health, Erasmus University, Rotterdam, The Netherlands.
Paul J van der Maas, MD, PhD, Professor.

Reprints will not be available from the authors.
Correspondence: B D Onwuteaka-Philipsen, Vrije Universiteit, Institute for Research in Extramural Medicine, Van der Boechorststraat 7, 1081 BT Amsterdam, The Netherlands.
Email: B.Philipsen.EMGOATmed.vu.nl

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