Examination of Witnesses (Questions 1720
- 1739)
FRIDAY 17 DECEMBER 2004
DR DIRK
RAYMAKERS, DR
MARIJANNE VAN
DER SCHALK,
DR ROELI
DIJKMAN, DR
MARLIES VELDHUIJZEN
VAN ZANTEN-HYLLNER,
DR TJOMME
DE GRAAS,
MS MURIËL
HOUTHUYSE and MS
HELMA HESLOOT
Q1720 Chairman: Will the SCEN doctor
himself or herself from time to time be a family physician too,
and carry out such procedures himself or herself?
Dr de Graas: Do I perform euthanasia myself?
Q1721 Chairman: I am wondering whether,
when you are a SCEN doctor, you are only a consultant in these
procedures or whether from time to time you can, as it were, cast
aside the role of SCEN doctor and be yourself a dispensing doctor?
Dr de Graas: Yes.
Dr Dijkman: But not at the same procedure. A
SCEN doctor can perform euthanasia himself, but not at a procedure
where he is himself the SCEN doctor.
Q1722 Chairman: No, quite so. He
becomes the dispensing or the original doctor then?
Dr Dijkman: Yes.
Q1723 Lord Carlile of Berriew: Thank
you very much for your excellent presentation. I wanted to ask
how many euthanasia deaths there have been in this establishment
in the last three years?
Dr van der Schalk: In the last three years we
have only had one euthanasia in the palliative care unit and,
as far as I know, there have been no other euthanasias in our
nursing home. In our nursing home there are the same conditions
in terms of the procedure for euthanasia. I think that in general
we have one euthanasia every four or five years here.
Q1724 Lord Carlile of Berriew: Approximately
how many deaths do you have here in a year, on an average?
Dr Raymakers: In Sint Jacob, about 80.
Q1725 Lord Carlile of Berriew: So
your euthanasia rate, if I can call it that, will be something
well under one per cent?
Dr van der Schalk: Yes.
Q1726 Lord Carlile of Berriew: About
that one death, was it a death which could in your view have been
dealt with by pain control management but was a euthanasia, because
that was the autonomous choice of the patient?
Dr van der Schalk: The euthanasia case was a
very specific request of the patient. It was a patient who had
been here for a long time. It was a young man, 48 years old. He
had a very tragic life. He had suffered a stroke when he was 46.
He recovered completely from the stroke and then he developed
a very rapidly progressing stomach tumour. He had a young daughter
of about six years old and he was very rapidly fading away, losing
weight. In the end, he was only 33 or 34 kg, and his little daughter
was scared of him. She did not dare enter the room.
Q1727 Lord Carlile of Berriew: But
it was choice, rather than necessity?
Dr van der Schalk: Yes, it was his choice. He
suffered from the fact that his own tumour—
Q1728 Lord Carlile of Berriew: I
do not want to know any more about his particular situation. What
I want to ask you, having established that, is why is it that
2.7 per cent of deaths in The Netherlands are by euthanasia generally
when, with good palliative care in this institution, there are
no deaths by necessary euthanasia? What is happening in the rest
of Holland, or what are you doing here that is not being done
in the rest of Holland?
Dr van der Schalk: Speaking about palliative
care in nursing homes in The Netherlands, I think that is more
recently at a high level. It can always be improved, and I have
done a lot of excellent training in Cardiff. I think that the
quality of palliative care in nursing homes is at a very reasonable
level. In the rest of Holland, I think that for general physicians
palliative care is a subject of growing interest.
Dr Dijkman: There is a difference between the
population dying at home or dying in a nursing home. The people
dying at home have more autonomy to think about what they want
in life and how far they will go in terms of losing their dignity
in dying. It has something to do with autonomy, and dignity in
dying—and the thinking about that. Some people think that
to lose functions or to fade away during dying is a concept of
life. I can accept that, but some people cannot accept it. The
example Marijanne gave you was an excellent one—of dignity,
but also of having your own self-consciousness about your relations
with your daughter, which conflicts with that. It is another population.
When you have a terminal illness at home and you do not want to
die by fading away, with palliative care, you decide to have euthanasia
at home. Most euthanasias are by general practitioners.
Q1729 Earl of Arran: You are fundamentally
a Catholic hospice.
Dr Raymakers: Yes.
Q1730 Earl of Arran: Is a prerequisite
for your staff and your patients that they are Catholic, or does
that make no difference at all?
Dr van der Schalk: No, it does not make any
difference at all. Many people come to us in Sint Jacob because
of a specific religious background, so we have a lot of religious
inhabitants—which I think also counts for the staff. With
the passing of time, I would not know exactly how many, but it
is not a prerequisite—which was your question.
Q1731 Earl of Arran: And you have
no worry about the delivery, from the policy point of view, of
euthanasia?
Dr van der Schalk: Myself or our house?
Earl of Arran: You are quite happy to
conduct euthanasia.
Chairman: I think it is for the house—not
just her own personal point of view.
Q1732 Earl of Arran: Yes, I mean
the house.
Dr van der Schalk: Are we happy? I think that
we are happy with the possibility, yes. It does not create a conflict
with our religious background.
Q1733 Earl of Arran: There is no
conflict?
Dr van der Schalk: No, not any more. There has
also been a lot of discussion in our house. When I came here 15
years ago, our first euthanasia came after a long discussion.
It took us weeks to come to a common opinion. We talked with one
another for a very long time but, in the end, we reached a compromise.
Q1734 Baroness Finlay of Llandaff:
May I thank you all for your presentations and for explaining
the role of nursing home medicine, and particularly the nursing
aspect as well. My questions are really of the SCEN doctor. The
SCEN doctors whom I have known have said that, as they learn more
about palliative care, they have become more aware of possibilities
they are able to suggest when someone telephones to discuss a
patient, when they are considering euthanasia. I wondered whether
you thought that was true from your discussion among SCEN doctors
in Amsterdam. The ones whom I know are in the north of Holland.
Do you feel that is correct?
Dr de Graas: In principle, it is always correct.
Also, I think that I am a young SCEN doctor and, talking to my
colleagues who are nursing home physicians but also working on
a palliative care unit, it is true that you need the insight of
good palliative care to be a good SCEN physician. However, I cannot
stress enough that the time factor is very important in the whole
of our legislation and in thinking about the concept of euthanasia,
but also the thinking about palliative care—how palliative
care, SCEN and euthanasia, together, can provide the best care
for the patient.
Q1735 Baroness Finlay of Llandaff:
The doctors who have performed euthanasia have often described
it, certainly initially, as being emotionally draining, emotionally
difficult, and that they have taken some time off, have perhaps
not worked the next day, to have a break and then to carry on
working. Has that been your experience?
Dr de Graas: It certainly has been, but I think
that a lot is changing in that regard. The first letter of SCEN
is the "s" for "support", and that is essential.
Also as a nursing home physician confronted with euthanasia, I
know that it is emotionally draining; but it is absolutely important
to discuss it, not only with the SCEN doctor but with all your
colleagues, to keep yourself healthy. I think that it is changing
rapidly, because we have the possibility to talk about euthanasia
and we know what we are talking about. We know what we are doing,
and so we can go on in that sense—because it is essential.
Q1736 Baroness Finlay of Llandaff:
Do you think that it has become less stressful, as the process
has become more developed over the time that you have had it?
Dr de Graas: For the individual physician it
never becomes less stressful. That is absolutely impossible. What
we are learning as a group, however, is that, before we become
emotionally worn-out, there are a lot of possibilities to keep
yourself in a good emotional state.
Q1737 Baroness Finlay of Llandaff:
Could you clarify this? There was some publicity over the euthanasia
of babies who had multiple congenital abnormalities. I wondered
whether, as a SCEN doctor, you would ever be consulted by those
neonatologists or paediatricians and, if so, how you would respond.
Dr de Graas: To be honest, luckily I have never
been confronted by such a case. I think that it is extremely exceptional
and extremely difficult.
Dr Dijkman: Most of the time—and I know
this from the Royal College of Physicians—it is not euthanasia,
because it is the ending of curative medicine.
Q1738 Baroness Finlay of Llandaff:
But we have been told that these cases were euthanasia. That is
why I am asking about it.
Dr Dijkman: Who told you that?
Baroness Finlay of Llandaff: I think
that we understood that there was a protocol.
Q1739 Chairman: Not euthanasia.
Dr Dijkman: It is not on request, so that is
not euthanasia.
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