1. Public Policy PhD Course Research Methodology on Public Policies: some “success stories” Euthanasia in Netherlands From Evidence Based Medicine to Evidence Based – Decision Making (Legalization)?

2. Public Policy PhD Course INTRODUCTION Background Netherlands was one of the few countries where euthanasia and physician- assisted suicide was regulated by law, under strict conditions; The enactment of the euthanasia law was preceded by several decades of debate among medical practitioners, lawyers, ethicists, politicians, and the general public. 2002 euthanasia act came into effect in the Netherlands, under strict conditions

3. Public Policy PhD Course INTRODUCTION Background Robust empirical research should be done to assess the end-of-life care consequences of legalizing euthanasia in this country. At the end-of-life many patients needs comfort oriented – care… (What is comfort oriented – care?); Such care might include end of life decision making; Suffer becomes overwhelming; Patient Explicit Request; What is considered older people / incompetent patients;

4. 1973 1984 1985 1990 2002 Before 1973, euthanasia was illegal in the Netherlands. In that year, a doctor was arrested and put on trial for killing her terminally ill mother with morphine. The court gave her a suspended sentence of one week in jail and a year's probation. This set a precedent, and the courts quickly established a set of guidelines for when it was permissible for physicians to assist a patient in committing suicide, such as requiring certain consultations, insisting that the patient must be suffering from a terminal illness, and that the patient must request it. the Royal Society of Medicine issued "rules of careful conduct" for euthanasia. These called for the doctor to inform the patient of his condition, consult his nearest relatives (unless he objects), consult at least one other physician, keep written records, and, in the case of a child, obtain the consent of the parents or legal guardians. In 1985 a court dropped the "terminal illness" requirement in a case involving a young girl with multiple sclerosis. While her disease was incurable, there was no reason why she could not have lived indefinitely. (In a more recent case a woman who was perfectly healthy but suffering from severe depression was euthanized at her request.) By the late 80's it had become routine to "euthanize" babies born with handicaps, like Down's syndrome and spina bifida. Three nurses in Amsterdam killed several comatose patients without any consent. They were convicted, not of homicide, but of failing to consult a physician. In 1990, physicians in the Netherlands were involved in 11,610deaths, or 9% of all deaths in the country. of these, half were labeled "active involuntary euthanasia", that is, the patient was killed without his consent.11,610deaths, The Dutch Parliament legalize euthanasia and assisted suicide. Euthanasia in Netherlands: a Brief History c Public Policy PhD Course

5. Patients Euthanized, Netherlands, 1990 Sources: Medische Beslissingen Roknd Het Levenseinde: Rapport van de Commissie Onderzoek Medische Praktijk inzake Euthanasie (Medical Decisions About the End of Life: Report of the Committee to Investigate the Medical Practice Concerning Euthanasia) The Hague, 1991 Wich Public Policy PhD Course

6. 1171 Journal of Medical Ethics 1508 PubMed 3822 Medicine, Health Care and Philosophy A simple search: Euthanasia and Netherlands Public Policy PhD Course

7. INTRODUCTION J Med Ethics. 2006 April; 32(4): 240–245.

8. Public Policy PhD Course INTRODUCTION J Med Ethics. 2006 April; 32(4): 240–245.

9. Public Policy PhD Course Clarifying some concepts. Euthanasia – Administering a lethal drugs by a physician with the explicit intention to end a patients life on the patients explicit request. Physician Assisted Suicide The patient self –administers medication that was prescribed intentionally by a physician to end a a patients life.. Voluntary Euthanasia – (Explicit Consent) the person concerned asks someone to help them die, perhaps by asking for help to take an overdose of painkillers Involuntary Euthanasia – (No Explicit Consent) euthanasia is carried out without the patient’s consent, for example, if they are in a persistent vegetative state and no longer able to live without a life-support machine, which is then switched off http://www.bbc.co.uk/ethics/euthanasia/overview/forms.shtml INTRODUCTION

10. Clarifying some concepts. Euthanasia (active and passive) Voluntary, non-voluntary and involuntary euthanasia can all be further divided into passive or active variants. Passive euthanasia entails the withholding of common treatments, such as antibiotics, necessary for the continuance of life. Active euthanasia entails the use of lethal substances or forces, such as administering a lethal injection, to kill and is the most controversial means. http://www.bbc.co.uk/ethics/euthanasia/overview/forms.shtml Public Policy PhD Course INTRODUCTION

11. Public Policy PhD Course INTRODUCTION A Longitudinal Study Published online July 11, 2012 www.thelancet.com

12. Public Policy PhD Course METHODS Study Design A Longitudinal (retrospective) Study Random Sample Central death registry os Statistics Netherlands (all deaths and causes reported) Period studied was Aug 1 – Nov 1 in all studied years; Questionnaire (mailed 8496 – 6263 returned – rate 74%) (1) Whether the respondent had withheld or withdraw medical treatment while taking into account the possible hastening of death; (2) Whether the respondent had intensified measures to allevite pain or other symptoms while taking into account or party intending the possible hastening of death; (3) Whether the respondent had withheld or withdrawn medical treatment with the explicit intention of hastening death; (4) Whether the respondent had admnistered, supplied, or prescribed drugs with the explicit intention of hastening death, resulting, in the patient death’s.

13. Public Policy PhD Course RESULTS In: The Lancet 2012, July 11

14. Public Policy PhD Course RESULTS Euthanasia Act Came Into Effect In: The Lancet 2012, July 11

15. Public Policy PhD Course RESULTS In: The Lancet 2012, July 11

16. Public Policy PhD Course RESULTS In: The Lancet 2012, July 11

17. Public Policy PhD Course RESULTS In: The Lancet 2012, July 11

18. Public Policy PhD Course RESULTS n = 252 n = 251 n = 496 n = 270 In: The Lancet 2012, July 11

19. Public Policy PhD Course RESULTS n = 252 n = 251 n = 496 n = 270 In: THE LANCET Published online June 17, 2003 http://image.thelancet.com/extras/03art3297web.pdf

20. Public Policy PhD Course RESULTS Euthanasia and Physician Assisted Suicide Ending of Life Without Explicit Request Intensified Alleviation Symptoms AGE SEX Euthanasia and Physician Assisted Suicide Ending of Life Without Explicit Request Intensified Alleviation Symptoms

21. Public Policy PhD Course RESULTS Euthanasia and Physician Assisted Suicide Ending of Life Without Explicit Request Intensified Alleviation Symptoms Cause of Death Type of Physician Euthanasia and Physician Assisted Suicide Ending of Life Without Explicit Request Intensified Alleviation Symptoms

22. Public Policy PhD Course RESULTS Euthanasia and Physician Assisted Suicide Ending of Life Without Explicit Request Intensified Alleviation Symptoms Discussion Drugs Euthanasia and Physician Assisted Suicide Ending of Life Without Explicit Request Intensified Alleviation Symptoms - Neuromuscular Relaxants – Barbiturates – Benzodiazepines / Opioids – Benzodiazepines – Opioids - Others

23. Public Policy PhD Course CONCLUSION / FINDINGS In 2010, of all deaths in the Netherlands, 2.8% were the result of euthanasia; In 2005, of all deaths in the Netherlands, 1.7% were the result of euthanasia; Distribution of sex, age and diagnosis was stable between 1990 and 2010; In 2010, 77% of all cases of euthanasia or PAS were reported to a review committee; Ending of life without an explicit consent request in 2010 occurred less often than 2005, 2001, 1995, 1990. Continuous deep sedation until death, occurred more frequently in 2010 than 2005; All of deaths in 2010 were the result of the patient’s decision to stop eating and dinking to end of life; In half of these cases the patient had made a euthanasia request that was not granted.

24. Public Policy PhD Course CONCLUSION / FINDINGS The most widely used drugs in ending of life were neuromuscular relaxants in E & PAS and barbiturates in end of life without explicit patient request; Cancer is, in a general way, the most important cause of death; General Practiniores were the professional medical speciality more envolved in all end- of-life pratices;

25. Public Policy PhD Course CONCLUSION / FINDINGS The most importante reasons for the physician to grant the euthanasia request that were mencioned most often in 2010 were: - The wish of the patient -No prospect of improvement -No more options for treatment -Loss of dignity THANKS FOR THE ATTENTION

26. Public Policy PhD Course RESULTS In: The Lancet 2012, July 11

27. Public Policy PhD Course In: The Lancet 2012, July 11

28. Public Policy PhD Course RESULTS In: The Lancet 2012, July 11

29. Public Policy PhD Course In: The Lancet 2012, July 11