Facts and figures on euthanasia and PAS The practice in the Netherlands Annemieke Horikx, Pharmacist, KNMP
Disclose Nothing to disclose Non-approved use Thiopental, mixtura nontherapeutica (seco- or pentobarbiturate), anti-emetics, neuromuscular blockers (rocuronium, atracurium, cisatracurium) Injection, infusion, elastomeric pump
Practice in the Netherlands Euthanasia: 4% of total number of deaths Database of more than 5000 records from 1998-2015 First presentation of the 2013-2015 data (3000 records)
Development of the Guideline in the Netherlands Method Questionnaires Topics Facts and figures Results of implementation practice Note: the period analysed, is the period 2013-2015 If it is different, I tell you on the slide
Development of the guideline Publisher Year Stafleu 1977 P. Admiraal Report about euthanasia in hospital NVVE (Dignity in Dying 1980 Brochure Responsible Euthanasia The Netherlands) KNMP (Dutch 1987 Technical report Euthanasia Pharmacists Association) KNMP 1994 Euthanasia in practice and constitution of the euthanatic agents KNMP 1998 Euthanasia in practice and constitution of the euthanatic agents KNMP 2007 Standard Euthanasia KNMG (physicians association)/knmp 2012 Guideline for the practice of Euthanasia and Physician-Assisted Suicide
Guideline 2012
Development of the Guideline in the Netherlands Method Questionnaires Topics Facts and figures Results of implementation practice Note: the period analysed, is the period 2013-2015 If it is different, I tell you on the slide
Euthanasia - Intravenous method Coma-inductor thiopental 2 grams or propofol 1 gram Check deep coma Neuromusculair blocker rocuronium 150 mg or atracurium 100 mg or cisatracurium 30 mg
Differences current and previous guideline intravenous method Thiopental 2 grams (prior 1.5 grams) Propofol added as coma induction medication Elastomeric pump as intravenous administration
Elastomeric pump
Physician-Assisted-Suicide (PAS) oral method Premedication: Start anti-emetic 12 hours in advance. Mixtura Nontherapeutica 100 ml 15 grams pento- or secobarbital sodium
Differences current and previous guideline oral method Barbiturate 15 grams (prior 9 grams) Advise on when to use the oral method Agreement about when to use the IV method in addition to the oral method Use of elastomeric pump in case patient wishes to be in control
Development of the Guideline in the Netherlands Method Questionnaires Topics Facts and figures Results of implementation practice Note: the period analysed, is the period 2013-2015 If it is different, I tell you on the slide
Questionnaires Physicians: since 1987 Pharmacists: since 1998 On voluntary basis Anonymous Objective: to improve the guideline NOT to check whether the procedure has been carried out correctly
What kind of questions? Patient details (age, underlying disease) Method used Location of the procedure Problems and symptoms experienced during procedure Communication and cooperation physician and pharmacist Suggestions for improving the guideline
Questionnaires returned
Development of the Guideline in the Netherlands Method Questionnaires Topics Facts and figures Results of implementation practice Note: the periode analysed, is the period 2013-2015 If it is different, I tell you on the slide
Underlying disease 2015 (n=1000)
Methods 1998-2015
Location of euthanasia procedure (n=3000)
Location of euthanasia procedure and methods (n=3000)
Underlying disease and method used (n= 3000)
Focus on the oral method
Shift oral method to pump
Decision to use oral method n=163
Underlying disease and choice for oral method (n=3000)
Time lapse between ingesting and dying
What did the physician / patient notice? Symptoms Numbers Physcian observation Retching 9 Snoring 3 Asleep before finishing the 100 ml drink 3 Muscle contraction 2 Some return of vital functions 2 Patient comment/remark Bad taste 3 Pain in throat 1 Pain in stomach 1 Heat sensation 1
Intravenous (IV) in addition to the oral method
Communication and cooperation pharmacist and physician
Communication and cooperation before the procedure 93% discussed the guideline together 7% did not discussed the guideline together Reasons for not discussing: - General practitioner has his own pharmacy - Physician and pharmacist recently discussed the guideline
Communication and cooperation after procedure Evaluation of the technical aspects Return of unused life-ending agents Experiences of the patient and next of kin Reflection and closure of the cooperative trajectory
Return of unused life-ending agents
Take-home message The barbiturate drink is used less and is partly replaced by elastomeric pump Due to the improved screening of patients and/or the increased dosage barbiturate, more patients die within 30 min The recommendation, that physicians and pharmacists take sufficient time afterwards for face tot face evaluation of the complete trajectory
Thank you for your attention English version of the Guideline is available on www.knmp.nl or www.knmg.nl (search for guideline euthanasia ) For more information contact a.horikx@knmp.nl