’Unbearable Suffering,’ Multiple Syndromes Lead to Death Requests in Elderly Patients

A combination of medical, social, and existential issues that created suffering without a life-threatening condition was linked to requests for euthanasia and physician-assisted suicide (EAS) by elderly people in the Netherlands, a qualitative study found.

An analysis of 53 case summaries published by the Dutch Regional Euthanasia Review Committees showed that multiple geriatric syndromes — including vision or hearing loss, pain, and chronic tiredness — may have led to suffering in many dimensions and a subsequent request to die, reported Els van Wijngaarden, PhD, of the University of Humanistic Studies in Utrecht, and coauthors.

“This qualitative study suggests that an accumulation of geriatric syndromes leading to a request for EAS is often intertwined with the social and existential dimension of suffering,” they wrote in JAMA Internal Medicine.

“The variety of relevant elements in these complex cases raises the question of what the role of these different elements should be in the assessment of requests for EAS and which expertise is needed for optimal care for these older persons,” they added.

After noting increased euthanasia requests that involved multiple geriatric syndromes, the Dutch Regional Euthanasia Review Committees, which reviews and assesses euthanasia requests in the Netherlands, identified 53 cases (of 1,605 involving multiple geriatric syndromes between January 2013 and December 2019) that van Wijngaarden and colleagues reviewed. Of those, 77% involved women. Twelve cases involved people 80-89 years old, and 41 involved people age 90-100.

About half (28 patients, or 53%) always had perceived themselves as independent, active, and socially involved. “None of the patients suffered from life-threatening conditions,” van Wijngaarden and colleagues noted.

Common geriatric syndromes included visual impairment (64%), hearing loss (53%), pain (47%), and chronic tiredness (42%). The request for euthanasia often was preceded by a sequence of events, particularly recurrent falls (62%). Physical suffering was determined in all cases, but case descriptions suggested that suffering occurred on several dimensions, including loss of mobility (83%), fears (40%), dependence (43%), and social isolation (36%).

“According to these findings, an accumulation of geriatric syndromes alone is insufficient to explain the unbearableness of suffering that leads to a request for euthanasia in older persons with multiple geriatric syndromes,” the researchers noted.

“Given that patients were already suffering from the geriatric syndromes for a long time, the findings suggest that it is not only the total number of these geriatric syndromes that is associated with unbearable suffering (and a granted request), but also the sum of these problems (often in combination with a tipping point incident) in conjunction with the patient’s medical history, life history, personality, and values that gives rise to suffering that the patient in question experiences as unbearable and without prospect of improvement,” they added.

This report of physician-assisted death or euthanasia in the Netherlands “with unbearable suffering attributable to multiple geriatric syndromes should cause alarm,” said Diane Meier, MD, of the Icahn School of Medicine in New York City, in an accompanying editorial.

“Patient despair and suffering should be met with human connection and support to relieve suffering and improve quality of life, not a rush to put an end to things to reduce collective distress at the confrontation with finitude,” she wrote. “Meaningful and committed human connection—not 2 g of secobarbital—is the right prescription.”

In 2019, a review of euthanasia practices and trends in the Netherlands described a shift in justification of euthanasia from an inherently conflicted physician role to one of patient autonomy and request, rooted in provisions that included both mental and physical factors in judging the appropriateness of euthanasia in individual cases.

In the U.S., legal challenges have established that there was no constitutionally protected right to die and states would decide. In 1997, Oregon became the first state to legalize physician-assisted suicide. Physician-assisted death is now legal in nine U.S. states and the District of Columbia and is under consideration in 17 more, Meier noted.

The American Medical Association (AMA) recognizes that “thoughtful, morally admirable individuals hold diverging, yet equally deeply held and well-considered perspectives about physician-assisted suicide” and that “supporters and opponents share a fundamental commitment to values of care, compassion, respect, and dignity; they diverge in drawing different moral conclusions from those underlying values in equally good faith.” Euthanasia is considered separately by the AMA, which states that “permitting physicians to engage in euthanasia would ultimately cause more harm than good,” and that euthanasia “is fundamentally incompatible with the physician’s role as healer.”

In the U.S., safeguards regarding physician-assisted death are “fairly strict,” requiring the likelihood of death within 6 months, decisional capacity, and no evidence of coercion or psychiatric disease, Meier said.

But countries where physician-assisted death has been legal for considerably longer than the U.S. “have revised their original laws to remove prognostic requirements, eliminate psychiatric exclusions, broadly define unbearable suffering (to include such conditions as geriatric syndromes and existential distress), and reduce reporting requirements,” she pointed out.

“The expansion of eligibility criteria and the failure of the initial regulatory constraints to contain physician-assisted death to a narrowly defined and small group of patients demonstrated by the study underscore real societal harms in the Netherlands and the potential for such harms in the U.S.,” Meier emphasized. “Once access to physician-assisted death becomes legal, when does a right become an obligation, especially when families are strained and society denies patients and families the resources needed to receive safe and reliable care?”

Limitations of the study include its sample size: it was based on 53 cases chosen from 1,605 that involved multiple geriatric syndromes. Data were extracted from secondary official state documents and represented “a shortened and specific version of realities, suitable for publication on an open access website,” the researchers acknowledged.

1. A combination of medical, social, and existential issues that created suffering without a life-threatening condition was linked to requests for euthanasia and physician-assisted suicide (EAS) by elderly people in the Netherlands, a qualitative study found.

2. An analysis of 53 case summaries published by the Dutch Regional Euthanasia Review Committees showed that multiple geriatric syndromes — including vision or hearing loss, pain, and chronic tiredness — may have led to suffering in many dimensions and a subsequent request to die.

Paul Smyth, MD, Contributing Writer, BreakingMED™

Cat ID: 494

Topic ID: 398,494,494,570,935,192,151,925