MAiD in the Netherlands led by physicians
By Barbara Sibbald | CMAJ | Oct. 16, 2016
In the Netherlands, 90% of physicians support medical assistance in dying, said Dr. Gerrit Kimsma. (Photo credit: Barbara Sibbald)
From the beginning, Medical Aid in Dying (MAiD) in the Netherlands was doctor led and rooted in concern for protecting the physician. The result is a nation-wide system of expert consultants delivering MAiD and euthanasia review committees making sure it is done properly.
Canada would do well to adopt some of these protocols, Dr. Gerrit Kimsma, a family physician and philosophy professor at Radboud University Nijmegan Medical Center in the Netherlands, advised at the Ottawa Conference on MAiD, Oct. 14 and 15.
The Dutch law was initiated by the medical profession, “instead of being confrontational as it is so clearly in your country,” Kimsma said.
Canada’s MAiD legislation arose from the 2015 Carter case in the Supreme Court, in which Kimsma served as an expert witness. Bill C-14, which became law on June 17, removed prohibitions against assisted dying and established national guidelines while sparking uncertainty among health professionals on how exactly to proceed.
In the Netherlands, discussions began in 1984 with doctors wanting to protect oncologists who were providing MAiD to suffering patients who had no other medical recourse. “The medical system instigated it, but the judicial system supported it,” said Kimsma.
The rules and regulations in the 2002 Dutch Euthanasia law “were largely worked out by the medical profession… with a focus on ethics and medical science,” Kimsma told attendees at the University of Ottawa Centre for Health Law, Policy and Ethics event. The law is physician centered, he maintained.
The result has been widespread acceptance, he added. When initially discussed, only 20%-30% of Dutch physicians supported MAiD. Now that figure is 90% “because the practice developed in a supported way and physicians feel supported by it.”
In Canada, MAiD protocols include having two independent witnesses sign requests, two medical opinions that the patient meets criteria and a ten-day waiting period between the request and MAiD.
Kimsma elaborated on three safeguards in the Netherlands that protect the physician.
First is legal protection. If the physician acts in accordance with criteria of due care there will not be legal repercussions, Kimsma emphasized. These criteria require the patient to be fully informed, aware and communicative, and experiencing unbearable and hopeless suffering. The physician must also consult with another physician and use the prescribed protocol in ending life. In addition, there must be an absence of reasonable alternatives for both physician and patient.
“This is the relational aspect, whereas …your law focuses on the patient,” said Kimsma who practises MAiD. “I often feel there are medical options. I argue with my patients until we have agreement. If I’m going to do it, I have to be sure.”
Physicians refuse MAiD in two-thirds of cases, he said.
The second safeguard is a cadre of some 600 specially trained Support and Consultation on Euthanasia in The Netherlands (SCEN) consultants. “We found in practice a lot of variation,” in how MAiD was carried out, explained Kismsa. “You need special training and you need to do it repeatedly in order to do it right.”
“That is something that is highly valuable and you don’t get that in Canada. You should think about organizing it.”
SCEN consultants are available on short notice (within 48 hours), they meet with the family and patient, and with the patient alone, examine the records, and ensure the law is met and the doctor protected. The consultants are organized in regional groups and meet at least four times annually but communicate regularly.
“This is a procedure that is really flexible but also fast,” said Kimsma, who is a SCEN consultant and trainer. The 10-day waiting period in Canada may be problematic, he added. There is a protocol for sidestepping the requirement, “but that’s another step. You’re not really making it easy for your physicians. If I were a Canadian physician I would be irritated. In Holland, the people trust the medical profession. This may be a sign of distrust.”
The third safeguard occurs after the intervention. All the information is sent to a regional Euthanasia Review Committee (ERC) comprised of a lawyer, physician, and ethicist who meet monthly to review cases. Kimsma was on such a committee for a decade.
“They are not a policing committee. They are a committee that trusts the medical profession, the physicians and the consultant to provide adequate information so that they can do their work.” The committee determines that legal conditions were followed and the case falls within the parameters of the law. Sometimes physicians are asked to provide more information.
“I’ve been on both sides and I’m impressed with how much the committee was actually siding with the physicians and understands what the physician did,” said Kimsma.
You’re not really making it easy for your physicians. If I were a Canadian physician I would be irritated. In Holland, the people trust the medical profession.
MAiD was politically charged in The Netherlands, as it was in Canada. This was in part fuelled by misinformation, said Kimsma. In 1991, for example, some groups claimed there were 50 000 physician-assisted deaths per year; no one really knew. The Dutch partly depoliticized the issue by forming the Research Committee on Medical Practice on Euthanasia to gather data. In 1991, they found there were 1800 cases of MAiD (2.9% of all deaths). The committee has continued to gather these data every five years; in 2015, there were 5516 cases of MAiD (3.9% of all deaths). Of those cases, 109 patients suffered dementia, 56 were psychiatric patients and 183 had multiple ailments.
“The amount of data and the effects of the data are clearly undeniably positive,” said Kimsma. “This is what you do not have in Canada.”
Canadian law in fact stipulates that every province has to do surveillance, but so far only Quebec is complying, perhaps because its law came into effect seven months before the national legislation. But Quebec is having problems gathering data, said Isabelle Marcoux, an associate professor in the Interdisciplinary School of Health Sciences at the University of Ottawa. The questionnaire is unclear and too detailed, she said.
Canadian research is underway to improve data generation. Marcoux and colleagues, for example, have developed and piloted a questionnaire on different types of end-of-life practices. They are now starting a national project to assess the frequency of various end-of-life practices and determine how decisions are made.
Marcoux used the Dutch questionnaire for context, but adopting aspects of the Dutch system may be problematic, she told the conference. For example, Canada’s low population density makes it difficult to provide timely services in rural and remote areas.
There’s also a difference in where people die: 66% of Canadians die in hospital compared with 40% of the Dutch. This may affect delivery of MAiD. And many Canadians don’t enjoy long-standing relationships with their physician, like Dutch people typically have. “It’s hard to make an assessment when you don’t know the patient and their values,” said Marcoux. “Particularly in cases when intervention is urgent.”
“The challenge will be to see the quality of MAiD you can reach,” said Kimsma. “You will have to find your own way.”
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