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Our findings suggest that physicians in the Netherlands have more reservations regarding less common reasons that patients request euthanasia and physician-assisted suicide than the medical staff working for the End-of-Life Clinic. The physicians and nurses employed by the clinic, however, often confirmed the assessment of the physician who previously cared for the patient; they rejected nearly half of the requests for euthanasia and physician-assisted suicide, possibly because the legal due care criteria had not been met.
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Legal Due Care Criteria for Euthanasia and Physician-Assisted Suicide in the Netherlands1

1. The attending physician has come to the conviction that the request from the patient is voluntary and well considered.

2. The attending physician has come to the conviction that the suffering of the patient is unbearable and without prospect of improvement.

3. The physician has informed the patient about his or her situation and prospects.

4. There are no more reasonable alternatives for the patient.

5. The physician has consulted at least one other, independent physician.

6. The physician has terminated the patient¡Çs life or provided assistance with suicide with due medical care and attention.


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The finding that patients who were married or living together and those who had more than one child were more likely to have requests granted suggests that the views of family and domestic partners are important and that their involvement and support influence the clinic¡Çs decisions. Previous studies23,24 have found that relatives have important roles in the process and can be a source of information when assessing the due care criteria.8 These prior studies, however, did not reveal the actual effect on the outcome of a request. For end-of-life decisions, a good physician-patient relationship is of great importance.24- 26 Family physicians, who perform most euthanasia or physician-assisted suicide in the Netherlands,3 often have long-standing relationships with their patients. In the absence of a long-lasting care relationship, as is the case for the clinic¡Çs mobile teams, the role of relatives may become more prominent because they can elucidate the patient¡Çs history and change in circumstances over time.


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Although the prevalence of euthanasia remains highest in patients with cancer, those with a college or university education, and those who die before 80 years of age, there are increasing numbers of requests and granted requests in patients with diseases other than cancer, those who die after 80 years of age, and those who reside in nursing homes.


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The slippery slope is an argument frequently invoked in the world of bioethics. It connotes the notion that a particular course of action will lead inevitably to undesirable and unintended consequences. .... In this issue of JAMA Internal Medicine, Snijdewind et al and Dierickx et al report recent findings about physician-assisted suicide and euthanasia from the Netherlands and Belgium, respectively. Although neither article mentions the term slippery slope, both studies report worrisome findings that seem to validate concerns about where these practices might lead. ... Although the euthanasia practices in the Netherlands and Belgium are unlikely to gain a foothold in the United States, a rapidly aging population demanding this type of service should give us pause. Physicians must primarily remain healers. There are numerous groups that are potentially vulnerable to abuses waiting at the end of the slippery slope - the elderly, the disabled, the poor, minorities and people with psychiatric impairments. When a society does poorly in the alleviation of suffering, it should be careful not to slide into trouble. Instead, it should fix its real problems.


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In Belgium, physical suffering without prospects of improvement was the most common reason given for granting euthanasia. However, as is the case in the Netherlands, there are worrisome trends. Applicants were allowed to list tiredness of life in their requests in 2013 (but not in 2007), and the fastest-growing populations receiving euthanasia include those potentially vulnerable to discrimination and stigma, such as women, people older than 80 years, those with less educational attainment, and nursing home residents.


the increasing rates of euthanasia may alternatively represent a type of reflexive, carte blanche acquiescence among physicians to the concept of patient self-determination. Or worse, is it simply easier for physicians to accede to these sad and ailing patients¡Ç wishes than to reembark on new efforts to relieve or cope with their suffering? As one Dutch ethics professor has said, ¡ÈThe risk now is that people no longer search for a way to endure their suffering.¡ÉIn other words, are the Netherlands and Belgium turning to physicians to solve with euthanasia what are essentially psychosocial issues? And one additional question: Did physicians in the End-of-Life Clinic diagnose unbearable suffering in patients previously not given that diagnosis because they are better diagnosticians or because the clinic was set up by Right to Die NL, a proeuthanasia organization?


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