How I ended my patient's life

A Dutch GP who now lives and works in New Zealand describes the morning he carried out a dying cancer sufferer's wish.

Evans Mott was discharged without conviction after assisting his chronically ill wife to commit suicide. Photo / Greg Bowker
Evans Mott was discharged without conviction after assisting his chronically ill wife to commit suicide. Photo / Greg Bowker

It is a quiet Saturday morning when I leave the house. When I reach my patient's house the sun is starting to become quite fierce and even the birds seem to be a bit lazy in the heat. Mark's wife, Marja, opens the door and when I enter the living room I meet the rest of the family.

There is a projector standing in the corner of the room and some boxes full of projector slides. The boxes are marked with words like "Spain 1970" and "Italy 1972". After introducing me to the family members I do not know, Marja explains that these are the snapshots of family holidays. In the past few days they have been talking a lot about all the good memories and watched photos of the holidays, when the kids were still young, projected on the wall. They had laughed their heads off, says the eldest son, but they'd also talked about more serious things and even planned Mark's funeral in detail.

I walk over to the bedroom where 65-year-old Mark is waiting for me. He welcomes me and says he is glad it is going to happen.

It was about a month earlier that he saw me at our medical centre because he had coughed up blood. At that point he already had audible wheezing. The next day he saw the lung specialist and three days later we learnt what we'd already feared; he had a bronchus carcinoma. It was growing exactly where the trachea separates and was inoperable. The cancer was growing fast and he was literally choking to death. There were no therapeutic options.

When I saw Mark and Marja a week later, they had made up their mind, he wanted euthanasia when the choking got worse. He brought with him a copy of a living will they had downloaded from the NVVE-website (Dutch Organisation for Voluntary Euthanasia). We discussed the different aspects of his disease and his options. Then we made a new appointment for an hour the next day so we could discuss everything more thoroughly. At that point he was already on high doses of corticosteroids to reduce the volume of the tumour. The option of palliative sedative medication that would make him less short of breath was not acceptable for him. He wanted to die in a dignified way, still being able to talk to his family and friends. He did not want to end as a "sleeping plant" as he called it, losing control over his bodily functions. They had discussed it in great detail with their children and everybody had agreed, even though his daughters at times struggled to cope with the decision. This was the way he wanted to go. They respected their parent's wish.

We had several sessions, usually at their home, in which we talked about many different things: their kids, his life and hobbies, the disease and of course also the whole euthanasia process. I told them that according to the Dutch law a second independent doctor had to visit them to see if he met all the criteria stated in the Termination of Life on Request and Assisted Suicide Act (2002). That doctor visited him at their house and consulted the patient's file.

The same day I received a letter from this doctor saying she agreed with us and we had followed the requirements of "due care" as stipulated in the law. Although the family never expected anything else, it was an immense relief for them. By that time Mark had deteriorated and was really struggling to breathe.

We agreed to go ahead with the euthanasia on the next Saturday morning, so he had a few more days with his children and other family. He had already talked and written to friends and colleagues and was pretty tired. In that week I visited them a few times, most often just for a cup of tea or coffee and I talked with them about many different subjects and of course about the euthanasia.

I made it clear at every encounter that he could at any moment say that he wanted to cancel it.

Then it was Saturday. When I entered the house I sensed some tension, which quickly disappeared, when Mark yelled a funny remark from the bedroom. We had coffee sitting around his bed and it was like being with my own family with jokes and laughter. Then the family kissed Mark and left. I asked Mark again if he wanted to go ahead and Mark and Marja simultaneously said yes. Marja lay down at Mark's side. I inserted a cannula in his arm and prepared the syringes with the barbiturate which would introduce a deep sleep (coma) and the muscle relaxant which would paralyse the muscles and induce death. When I finished I asked Mark once more if he really wanted this. He nodded and said: "thanks, you're a hero", turned to Marja and kissed her, saying, "I love you". He rested his head on the pillow and closed his eyes. "I'm ready" he said. I injected the barbiturate and Mark fell asleep. I checked if Mark was in a coma; he was. I injected the muscle relaxant and just waited. After a while Marja said "I think he's gone." I checked his heart and Mark had passed away, as he wanted, in peace and in a dignified way with his wife at his side.

I gathered my things and told Marja I would wait in the living room. She asked me to send in the children.

In the living room I sat down at the table to complete the formalities. After completing all the forms I called the coroner, which is required by law. I had to wait until he arrived. When I finally left their house it was already late afternoon. I'm exhausted and relieved. It has taken up a lot of time, time added to a normal busy doctor's working week, but it was worth it.

A few days later I received a letter from the court saying I was the subject of an investigation that could take weeks. Although I knew I had done everything by the book, it still made me a bit nervous. Funnily, the letter arrived on the same day as two letters from Mark's children to thank me. When the final letter from the court arrived, weeks later, to tell me I would not be prosecuted (they've got a funny way of saying you're not a criminal) it was again a relief.

I have helped six patients with euthanasia and one with assisted suicide back in the Netherlands. It may sound strange, but it is the most beautiful thing you can do for a patient when there are no therapeutic options left and palliative care is not sufficient or unacceptable for the patient.

What is unacceptable? Look at the case of poor Tony Nicklinson, a 58-year-old Englishman who had locked-in-syndrome after suffering a stroke. Doctors couldn't do anything for him any more and he had to be helped with literally everything. He was suffering and lived a life of indignity and misery. For this kind of suffering there is absolutely no palliative care. Painkillers won't help, sedation does not help and antidepressants don't help. His life was hell and society failed this man enormously.

The euthanasias I performed were all done at request of the patient and with full support of the family. It is an energy-consuming process and it takes a lot of time talking with the patient, family and colleagues. But in the end, in a setting, determined by the patient, most often surrounded by family, having said goodbye to them and having made all the arrangements they had to make. It is very peaceful and beautiful. Without exception I have only met very grateful families - grateful the suffering has come to a peaceful end, grateful they had the opportunity to say goodbye, grateful they could be there for the patient in their last moment and that the patient could die in a dignified way.

Euthanasia is termination of life by a doctor at the request of a patient. In the Netherlands around 10,000 people a year ask their family physician for euthanasia. Less than one-third of those people will eventually die due to euthanasia, 2.3 per cent of the annual deaths in the Netherlands.

Involuntary euthanasia is absolutely non-existent in the Netherlands. Since the introduction of the Termination of Life on Request and Assisted Suicide Act in the Netherlands, the number of patients who die of euthanasia has dropped.

To meet the criteria a patient has to be well informed by the physician, it has to be a voluntary and well considered decision, and there has to be unbearable and lasting suffering. There should be no other reasonable solutions for the situation the patient is in and the patient has to have consulted at least one other, independent physician. This doctor has to have seen the patient and given his written opinion, taking into account the requirements of due care. The court investigates every single case but will not prosecute if the requirements are met. A doctor is not legally obliged to perform euthanasia but most doctors will refer to a colleague or the "termination-of-life clinic".

Euthanasia is a controversial subject here in New Zealand. There are a lot of misunderstandings. Some doctors call it unethical and say a doctor should not harm a patient. But we harm patients all the time. We stick needles in them, we cut them open, we remove breast or limbs, we give them chemotherapy. This does harm, I can tell you, it hurts, physically and mentally. But we don't consider that to be unlawful or unethical harming because we do it with the intention to help a patient.

And what is ethical? Ethics is a moral philosophy that changes over time, and so the opinion about euthanasia can and should change. Look at the face of Tony Nicklinson. Not having helped him, that is unethical.

There are doctors who state we don't need euthanasia because we have palliative care here. The hospices here in New Zealand do great work, but euthanasia is not an alternative for palliative care, just as palliative care is not always an alternative for euthanasia.

It should be a choice, that only the patient makes. The patient should be assisted in his choice by the doctor who provides the necessary information, by politicians who draw up a law to decriminalise euthanasia and to set the boundaries, and by family and friends who support the patient in this difficult choice.

What about the religious aspect? The fact that there are so many religions is because they all interpret the holy books a bit differently. I am not religious but my interpretation of the 6th Commandment is that "you should not kill with malicious intent". There is no malicious intent in euthanasia. The whole intention of the holy books is to be good. Showing mercy when someone is suffering is good in that way.

This week, Evans Mott, the man who assisted his chronically ill wife to commit suicide, was discharged without conviction by the High Court. Although the court emphasised the decision was based on the particular circumstances of his case, it offers a unique opportunity to politicians to create legislation around euthanasia.

Prime Minister John Key said last month he could accept doctors turning off a life support machine or increasing morphine to end the life of a terminally ill patient in pain. He added that he thought this already happened a lot in hospitals.

However, strictly speaking, death following a higher dose of morphine is not euthanasia. The morphine is given for pain or shortness of breath and as a side effect the already weakened body could give up. It's a grey area and whether Key was right is something only the doctors who administered the medication at that time know.

I'm really happy Key is a supporter for euthanasia and I hope this article will help with the discussion New Zealand needs.

- NZ Herald

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