Euthanasia in the Netherlands: a claims data cross-sectional study of geographical variation

A. Stef Groenewoud, Femke Atsma, Mina Arvin, Gert P. Westert, Theo A. Boer

Euthanasia in the Netherlands: a claims data cross-sectional study of geographical variation

Abstract

Background The annual incidence of euthanasia in the Netherlands as a percentage of all deaths rose from 1.9% in 1990 to 4.4% in 2017. Scarce literature on regional patterns calls for more detailed insight into the geographical variation in euthanasia and its possible explanations.

Objectives This paper (1) shows the geographical variation in the incidence of euthanasia over time (2013–2017); (2) identifies the associations with demographic, socioeconomic, preferential and health-related factors; and (3) shows the remaining variation after adjustment and discusses its meaning.

Design, setting and methods This cross-sectional study used national claims data, covering all healthcare claims during 12 months preceding the death of Dutch insured inhabitants who died between 2013 and 2017. From these claims all euthanasia procedures by general practitioners were selected (85% of all euthanasia cases). Rates were calculated and compared at three levels: 90 regions, 388 municipalities and 196 districts in the three largest Dutch cities. Data on possibly associated variables were retrieved from national data sets. Negative binomial regression analysis was performed to identify factors associated with geographical variation in euthanasia.

Results There is considerable variation in euthanasia ratio. Throughout the years (2013–2017) the ratio in the three municipalities with the highest incidence was 25 times higher than in the three municipalities with the lowest incidence. Associated factors are age, church attendance, political orientation, income, self-experienced health and availability of voluntary workers. After adjustment for these characteristics a considerable amount of geographical variation remains (factor score of 7), which calls for further exploration.

Conclusion The Netherlands, with 28 years of legal euthanasia, experiences large-scale unexplained geographical variation in the incidence of euthanasia. Other countries that have legalised physician-assisted dying or are in the process of doing so may encounter similar patterns. The unexplained part of the variation may include the possibility that part of the euthanasia practice may have to be understood in terms of underuse, overuse or misuse.


Groenewoud AS, Atsma F, Arvin M, Westert GP, Boer TA. Euthanasia in the Netherlands: a claims data cross-sectional study of geographical variation BMJ Support Palliat Care. 2021 Jan 14:bmjspcare-2020-002573. doi: 10.1136/bmjspcare-2020-002573. Epub ahead of print. PMID: 33446488.

Is Euthanasia Psychiatric Treatment? The Struggle With Death on Request in the Netherlands

Damiaan Denys

The American Journal of Psychiatry

A 42-year-old married woman with three children was referred to our department for treatment of treatment-resistant depression. Pharmacotherapy, psychotherapy, and ECT were unsuccessful. We applied deep brain stimulation, which was partially effective and reduced depressive symptoms by 30%, but the patient still suffered. During our struggle to find optimal deep brain stimulation parameters in the course of treatment, the patient requested that her general physician provide euthanasia. Following guidelines in the Netherlands, our team was consulted, but we disapproved because her suffering was not prospectless and there still were treatment options with deep brain stimulation. Although we had treated her intensively for 2 years, our advice was disregarded. Eight weeks later we received the obituary of the patient.


Denys D. Is Euthanasia Psychiatric Treatment? The Struggle With Death on Request in the Netherlands. Am J Psychiatry. 2018 Sep 1;175(9):822-823. doi: 10.1176/appi.ajp.2018.18060725.

Legal and ethical aspects of organ donation after euthanasia in Belgium and the Netherlands

Jan Bollen,Rankie Ten Hoopen, Dirk Ysebaert, Walther van Mook, Ernst van Heurn

Journal of Medical Ethics

Abstract

Organ donation after euthanasia has been performed more than 40 times in Belgium and the Netherlands together. Preliminary results of procedures that have been performed until now demonstrate that this leads to good medical results in the recipient of the organs. Several legal aspects could be changed to further facilitate the combination of organ donation and euthanasia. On the ethical side, several controversies remain, giving rise to an ongoing, but necessary and useful debate. Further experiences will clarify whether both procedures should be strictly separated and whether the dead donor rule should be strictly applied. Opinions still differ on whether the patient’s physician should address the possibility of organ donation after euthanasia, which laws should be adapted and which preparatory acts should be performed. These and other procedural issues potentially conflict with the patient’s request for organ donation or the circumstances in which euthanasia (without subsequent organ donation) traditionally occurs.


Bollen J, Ten Hoopen R, Ysebaert D, van Mook W, van Heurn E. Legal and ethical aspects of organ donation after euthanasia in Belgium and the Netherlands. J Med Ethics. 2016 Aug;42(8):486-9. doi: 10.1136/medethics-2015-102898. Epub 2016 Mar 24.

Clinical Problems with the Performance of Euthanasia and Physician-Assisted Suicide in the Netherlands

Johanna H. Groenewoud, Agnes van der Heide, Bregje D. Onwuteaka-Philipsen, Dick L. Willems, Paul J. van der Maas, Gerrit van der Wal

NEJM

Background and Methods

The characteristics and frequency of clinical problems with the performance of euthanasia and physician-assisted suicide are uncertain. We analyzed data from two studies of euthanasia and physician-assisted suicide in the Netherlands (one conducted in 1990 and 1991 and the other in 1995 and 1996), with a total of 649 cases. We categorized clinical problems as technical problems, such as difficulty inserting an intravenous line; complications, such as myoclonus or vomiting; or problems with completion, such as a longer-than-expected interval between the administration of medications and death.

Results

In 114 cases, the physician’s intention was to provide assistance with suicide, and in 535, the intention was to perform euthanasia. Problems of any type were more frequent in cases of assisted suicide than in cases of euthanasia. Complications occurred in 7 percent of cases of assisted suicide, and problems with completion (a longer-than-expected time to death, failure to induce coma, or induction of coma followed by awakening of the patient) occurred in 16 percent of the cases; complications and problems with completion occurred in 3 percent and 6 percent of cases of euthanasia, respectively. The physician decided to administer a lethal medication in 21 of the cases of assisted suicide (18 percent), which thus became cases of euthanasia. The reasons for this decision included problems with completion (in 12 cases) and the inability of the patient to take all the medications (in 5).

Conclusions

There may be clinical problems with the performance of euthanasia and physician-assisted suicide. In the Netherlands, physicians who intend to provide assistance with suicide sometimes end up administering a lethal medication themselves because of the patient’s inability to take the medication or because of problems with the completion of physician-assisted suicide.


Groenewoud JH, van der Heide A, Onwuteaka-Philipsen BD, Willems DL, van der Maas PJ, van der Wal G. Clinical Problems with the Performance of Euthanasia and Physician-Assisted Suicide in the Netherlands. N Engl J Med 2000; 342:551-556 February 24, 2000 DOI:10.1056/NEJM200002243420805