A number of specialists have explored different stages patients can go through when they are given bad news: denial, anger, bargaining, depression, and acceptance can be experienced to a greater or lesser extent. I would want to add a further stage: requesting euthanasia.
This new stage came about in the social context in which we live, marked by a legislation decriminalising euthanasia under certain conditions; by media, sometimes encouraged by biased activists, publicising difficult and exceptional situations; and, finally, by the testimony of healthcare workers who have performed euthanasia and become cheerleaders of the practise so as not to be overwhelmed by second thoughts. These contextual factors have rendered a euthanasia request very nearly systematic for the seriously ill. Continual brainwashing has secured in people’s minds—without the slightest shadow of guilt—the option that an end can be put to their life ‘as and when they would like it’ and a euthanasia request has become a societal claim which we all have to contend with, avid defenders of life included. Requesting euthanasia has become the norm. Hence, I see a parallel between the request for euthanasia and the anger stage of grief. We need to integrate it in the process, but most of all see it as a temporary stage, not an endpoint. Nothing forces us to kill!
But what happens precisely in practise? A patient will arrive at the hospital with a note from their GP saying: ‘Thank you for taking care of Mr(s) X for euthanasia’, clear and to the point! This often happens with GPs who are not against euthanasia but do not wish to perform it themselves. They tell the patient ‘They will do it at the hospital’ and the patient is convinced that they will be euthanised within days of being admitted to the hospital, not realising it is not that simple. According to the law,Footnote 4 patients can be referred to the hospital either at a family’s request, who do not want to live where their loved one has died or at the GP’s request who asserts: ‘I’ve reached my limit!’ Euthanasia referrals rarely happen from one GP to another, rather, it is suggested that the patient goes to hospital.Footnote 5 But most hospital doctors refuse to perform euthanasia ‘on request’, and the patient ends up in a palliative care bed.
In order to rise above the ideological feud ‘for or against euthanasia’, one needs to remember that patients who are referred are people, first and foremost. We cannot shut them out of our care simply because they requested euthanasia. But this does not mean that we should accept putting people to death either. Admitting them to the palliative care ward requires us to accept the people as they are, with their understandable anger and unbearable anguish, and help them face up to their death, and working through anger and fear towards acceptance. When we support patients competently and with empathy, we may help them consider their demise differently than how it looks through a euthanasia-tinted lens, and help them to live life fully till the end.
A request for euthanasia is not the end of the road. We need to look at it as a new phase, among the other stages of grief, on the way to acceptance. At the end of this process, we hope that the person, with the help of the palliative care team, will be able to die a natural death, having lived their life to the full till the end. A patient who requests euthanasia is usually in the thralls of dread: fear of suffering, of dying, of being a burden… Euthanising them in that distress deprives them of the time to ease their worries and find answers to their questions. Furthermore, it confirms a failure and denies them the hope to overcome it.
The health professional who is aware of this possible care pathway will no longer feel apprehensive around a patient requesting euthanasia; they will take them by the hand and walk alongside them to the end of the road.
A patient arrived in our department accompanied by her husband. She was about 50 and had so far been living at home, taking 32 medications a day. Convinced that she was a burden to her husband and her two children, she repeated day in day out: ‘Let me go, I want to die, please don’t give me any more medication’. She attempted suicide four times. On the fourth attempt, she pushed herself down the staircase in her wheelchair. Her husband, who loved her deeply, was totally overcome. He was devastated at the thought that he could not prevent her throwing herself down the staircase. To the GP it was clear that she wanted to die and he referred her to the hospital for euthanasia.
When she came in her husband shouted: ‘Don’t let anyone get in our way, she is to be euthanised’. The team started to panic. I went to see the patient and we had a 4-hour conversation with husband and wife. We argued and as I was not agreeing to go ahead with euthanasia, he wanted to take his wife back home and have her referred elsewhere. I told him: ‘The choice is up to you, but right now, your wife cannot be transported; any movement is extremely painful and we need to take care of her pain first. I guarantee you we will do all we can to make her comfortable. When she is, you can still decide whether you want her to be transferred in order to be euthanised’. Thus, the situation calmed down, the husband decided to leave his wife in our department and we worked together. Seeing how, with the combined use of painkillers and controlled sedation, his wife rested peacefully in bed, he became convinced that palliative care was effective. A very tactile man, he appreciated the massages with essential oils we gave his wife. We encouraged him to bring the CDs they listened to together. The two children, both young adults, followed suit, even though they were ill at ease at the start. They feared they might betray their mother’s resolve who had been adamant from the start that she wanted euthanasia. We reassured them saying that she was receiving no more medical treatment and we did nothing to prolong her life, only to make her comfortable.
This lady died peacefully in her husband’s arms, listening to the music they had played at their wedding. After a week, her husband came back, asking to see me. He thanked me with a box of chocolates… and asked whether I could keep a place for him in our palliative care ward when his time came!
The sad thing is that it took 32 medications and four suicide attempts for this woman to be heard and cared for, rather than be the object of therapeutic obstinacy.
Too often, unreasonable and coercive therapies are maintained. Because healthcare professionals perceive death as a failure, they go ahead with heavy treatments and invalidating surgeries which take away patients’ quality of life and cause appalling suffering. Exhausted and desperate, euthanasia seems the only way out for the patient: they cannot go on like this! The doctor can no longer witness the suffering he brought on the patient either, and tends to go along with their euthanasia request. If only the patient’s wishes about having another course of chemotherapy or undergoing more debilitating surgery could be better assessed, they would have the choice, with the help of palliative care, to end their life with dignity.