Ciara Seccombe Junior reporter at Australian Doctor .

80-year-old man , to explain what happens and the role doctors have .

The doctor said he found the patient ’ s situation to be distressing

We look at cases in the real world .

According to the RTE review , the patient ’ s advance care directive had been composed 10 years earlier . In it he wrote that he would want

and humiliating , and that his suffering was palpably unbearable .

Other physicians involved in the case , as well as the independent

euthanasia if he became incontinent ; had to go into a nursing home ; became aggressive ; could no longer recognise his loved ones ; went into a coma ; had a stroke ; could no longer eat , drink or breathe

expert and the independent physician , shared this opinion .

At this stage , an independent psychiatrist found meaningful communication was no longer possible .

The treating doctor also spoke

of self-determination and autonomy — the freedom to choose through an advance care direc-

independently . The RTE said he had watched his siblings die from dementia and

with the patient ’ s wife and consulted an elderly care specialist as an independent expert who visited

A lawyer ’ s view

“ I would not say the living will

as a revocation or amendment of the previously drawn up advance

tive the circumstances of our own

concluded that the kind of suffer-

the patient and tried to have a con-

overrides the consent of a patient

directive ”.

death at a future point when we

ing involved would be unbearable

versation with him .

who has passed the point of deci-

But they are central to the doc-

lack the capacity to decide .

for him .

“ In view of the patient ’ s agitated

sional competence ,” says Dr

tor ’ s assessment of the fundamental

The issue , however , is vexed .

In the final few months of his

behaviour and possible outbursts

Thomas Mulder ( PhD ), a Dutch

question — whether the patient ’ s suf-

Can the changes wrought on our

life , the review board said he deteri-

of anger , frustration and physical

lawyer and legal academic based

fering at this point is unbearable as

identity as dementia advances end

orated rapidly .

aggression , it was decided , in con-

in Sydney .

explicitly defined in the advance care

in a separation between the self who

“ He no longer recognised his

sultation with everyone involved , to

“ Rather , the living will is the

directive , the legal basis on which

writes the directive and the self of

family , could not eat or drink unas-

administer a sedative before eutha-

consent of a patient expressed

euthanasia can be administered .

the future , whose existential expe-

sisted , and certain medications

nasia was performed ,” the report

before passing the point of deci-

The doctor is meant to look at

riences may be very , very different

made him fall more often .

stated .

sional competence .”

these indications in combination

from what is imagined ?

“ His emotional state also deteri-

“ This caused the patient to fall

On one level , this makes the

with the patient ’ s condition and

Doctors have discussed the

orated , switching between aggres-

asleep . The physician then carried

directive protective . No doctor can

behaviour as a whole as part of their

rights and wrongs of the idea on the

sion , to the point of physical

out the euthanasia procedure in

administer euthanasia at the urg-

assessment of the patient ’ s current

AusDoc website .

violence , and sorrow when he was

accordance with the guidelines in

ing of family and friends , Dr Mulder

physical and mental state , the review

But we can offer real-world case

cognisant of his memory decline .”

the presence of the patient ’ s wife

says , even if they claim it is what

board says .

studies — euthanasia is already being

He had not communicated —

and children .”

the patient would have wanted .

But according to Dr Mulder , even

performed by doctors on patients

either verbally or behaviourally — a

when a patient is living in condi-

with dementia .

The Netherlands

This article is about what happens in

the Netherlands .

The first point to make is that

change of heart , the board said .

Instead , on several occasions , he had apparently expressed that he no longer wished to live .

The key question for his treating doctor ( as it is for the Dutch

' The living will is the consent of a patient expressed before passing the point of decisional competence .'

tions they previously described as “ unbearable ” in their directive , the doctor is still legally required to discuss euthanasia with the patient in cases where the patient is still communicative .

it is not widespread . Of the 9068 deaths by euthanasia in the Netherlands in 2023 , 328 were patients

euthanasia system as a whole ) was whether the patient ’ s suffering was unbearable as laid out in the

Questions

There are many questions here .

But what happens if the patient ’ s comments and general behaviour

Intolerable suffering

Former Dying With Dignity Victoria

with dementia .

advance care directive .

The main one is the status of the

suggest they want to live ?

board member Associate Professor

Of those , just eight were patients

This was assessed during a

advance care directive . Is it a sover-

In the literature underpinning

Peter Lange says intolerable suffer-

with advanced dementia who had lost

series of visits made by a variety of

eign document ?

the Dutch system , these are termed

ing is front of mind for Dutch doc-

decisional capacity .

doctors to his residential aged care

Once decision-making capacity is

“ contraindications ”.

tors making these decisions .

Under the system , because eutha-

home .

lost in regard to each of the specific

They include , according to the

“ Even if all other criteria per the

nasia for a decisionally incompetent

“ The patient was very agitated ,

directives written out by the patient ,

RTE board , “ clear verbal utterances

advance care directive are met and

patient based on an advance direc-

visibly frustrated and , on sev-

do the directives trump all other

or consistent behaviour on the part

the patient agrees , if the patient

tive is considered an “ exceptional

eral occasions , shouted that he no

considerations ?

of the patient [ which ] do not match

appears to not be suffering ( eg , sing-

case ”, each case is scrutinised by

longer wanted to live ,” the review

Or put another way , once a doc-

the essence of the request [ laid out

ing with the others in the nursing

the Regionale Toetsingscommissies Euthanasie ( RTE ) review boards .

A case example

We start with one case from 2023 ,

board said .

“ He was aggressive and would suddenly hit another person . He was receiving medication for this , but that caused him to fall more

tor judges that the circumstances laid out in the directive have been met , is there scope for the directive to be ignored , say at the request of a family or in the view of the patient ' s

in the directive ]”. The board stresses that contraindications arising when the patient is no longer capable of expressing their wishes with regard to

home activities ), voluntary assisted dying ( VAD ) will not proceed .”

Ultimately , the doctor must be confident that the patient has not changed their mind .

which involved the death of an

frequently .”

own doctor ?

euthanasia “ cannot be interpreted

But it is complicated .