Refusing to Become a “Potted Plant”

Ann loved life,but it had been a hard life. Her father died before she was born, and she had also sadly lost two children, one as a baby and another, a daughter, at young age due to cancer. What’s more, Ann was almost blind owing to macular degeneration and suffered from heart problems that required an implantable cardioverter defibrillator (ICD). I first met Ann when she was diagnosed as having a severely metastasized neuroendocrine tumor, just 1 year after she had lost her daughter. I was her oncologist, and she repeatedly told me that she did not want to become a “potted plant,” and from our first meeting Ann was very much in the driver’s seat. But despite her numerous health problems, she continued to live an intense and full life for more than 3 years.

At 71 years,Ann still fulfilled rewarding roles as a wife and grandmother, and she loved spending time in their house in Florida, with their American friends and a garden filled with orange and lemon trees. She would have pleasure in describing her garden to me in detail, and I could visualize how beautiful it must be. She continued to travel to Florida, and I provided care in person when she was in the Netherlands and remotely when she was in the United States. Modern communications enabled Ann to enjoy maximum freedom.

Six months earlier, while in Florida, Ann’s speech became slurred and she became confused. This was found to be the result of two brain metastases. She received dexamethasone, which restored her ability to speak and communicate effectively. Immediately after recuperating,Ann returned to her house in the Netherlands. She told me that she was frightened by the idea that this might occur again and would be permanent, which would realize her biggest fear of becoming a “potted plant” (ie, being alive but unable to communicate, and dependent on the care of others). If that happened, she felt she would suffer unbearably, and she wished to be euthanized before that.

Residents of the Netherlands have legal access to euthanasia, but under the strict condition that they are of sound mind and are able to express their wish for euthanasia themselves. Consequently, Ann wanted to make this wish as clear as possible while she could still do so.

The Dutch regulations regarding euthanasia require verification of the condition and the authentic wish of the patient by an independent, trained SCEN physician (Support and Consultation in case of Euthanasia in the Netherlands). The SCEN physician visited Ann and judged her to be clear of mind and fully able to understand what euthanasia meant and verified that she had not been influenced or pressured by anybody to consider euthanasia. At that time, Ann expressed her wish that I would conduct her euthanasia when the time came.

Despite attempted palliation with stereotactic radiotherapy, Ann’s condition deteriorated, and she started to have seizures that were difficult to control. Because she was unable to return to her Florida home, at her request friends in the United States helped clear out the house in Florida and shipped her precious household items and memorabilia back to the Netherlands. This process was highly emotional for her, but she was comforted by all the heart-warming calls and emails from her US friends. After a few months, Ann’s health began to further deteriorate. During a status epilepticus, it became obvious how well educated she was, speaking fluent German before being treated in the intensive care unit. After waking up, she spoke French, then English, and finally returned to Dutch. She recuperated for a few months, and I was impressed by how well she could enjoy life despite now having severe limitations. During that period, she indicated no wish for euthanasia at all.

However, shortly thereafter she began to experience alternating periods of confusion and mental clarity. During hospitalization, it became obvious that therapeutic options for her neurological problems were exhausted. It was only then that she told me that she would request euthanasia soon.

While hospitalized, she had already asked her cardiologist to turn off the ICD. Her family members were very warm and caring, though intensely sad that they would be losing her soon; however, they also respected and understood her wish.

During her final weeks, Ann received 24/7 home care by nurses and increasingly experienced frequent periods of confusion and difficulty in expressing herself.

Throughout this phase she was treated by all calmly and respectfully. When I visited her before her death, the atmosphere in her apartment was friendly, cozy, and serene. Her wish to undergo euthanasia had become strong, and she wanted it before her condition deteriorated even further. She was resolute in her wish not to reach a “potted plant” level of existence.

In the Netherlands, euthanasia at home is generally performed by the general practitioner (GP). Ann’sGP understood her wish but felt incapable of performing the euthanasia himself. The End of Life clinic was potentially willing to help her at home. But they told me that it would be much better for my patient if I, as her longstanding treating physician, would perform this “termination of life on request” at home in accordance with her repeated request. I talked with Ann at home about this and told her that I would see whether I could be the administering physician. It was moving to see how relieved she was. As I left the house, her husband told me that their American friends had expressed how fortunate Ann was that euthanasia is legal and available in the Netherlands. Once outside, however, I wondered whether American oncologists were perhaps better off than Dutch ones.

In the 8 days before the scheduled euthanasia date, I thought about it almost constantly. It did not leave me alone. This was not because I thought euthanasia was wrong, but because it is so big, so final for somebody who is loved by her family and whom I became fond of during the years of being her physician.

The formal legal procedure started. First, the hospital board had to give permission for me to administer euthanasia outside the hospital. Then the SCEN physician had to visit the patient again to verify whether euthanasia was still her authentic, independent, strong wish, and I had to prepare all the forms to justify the procedure and explain the process.

Then the pharmacy was informed, and they started their formal procedures for dispensing the euthanizing medications. I studied the euthanasia guidelines of my institution repeatedly. One of my colleagues offered to join me for the actual procedure, which was very comforting for me. On the day itself, I prepared my satchel, which contained the
euthanizing medications that were handed over to me personally in duplicate by the hospital pharmacist, a clothes hanger (which I brought from home to facilitate hanging the intravenous drip in her living room), and several other items.

During my preparation for the procedure I received great support from my colleagues; they clearly acknowledged how important it was for me to perform this duty out of respect and caring for the patient, her wishes, and the duty to provide a continuum of care. This support gave me solace and courage. On the scheduled day I bicycled to the patient’s home. Ann, her husband, and all their children with their partners were there. The atmosphere was very peaceful and comforting.We talked a bit, I got everything ready, and my colleague arrived. Ann still had the same strong wish and touchingly expressed her appreciation that I was willing to help her in fulfilling this wish. She then hugged her husband and children goodbye and said she was ready for me to start the procedure.

My colleague handed me the euthanasia medications, which I administered intravenously. Ann quickly and quietly fell asleep with her loved ones around her. Giving the family privacy in this special time, my colleague and I went into the hallway where there was a little couch, just big enough for the two of us. We agreed that everything had gone
peacefully. I finalized the paperwork and fulfilled my obligation to call the municipal physician, whom I had already informed before the procedure.

The municipal physician came, verified the situation, and collected my paperwork, which would be sent to the regional review committee. Such committees comprise, at the minimum, a physician, an ethicist, and a legal expert. They assess whether the processes of consent and administration of the euthanasia fulfilled the statutory criteria for due process. After the municipal physician had completed her task, I spoke with Ann’s husband and children, who were going to meet with the grandchildren, who were waiting elsewhere.

I bicycled back to the hospital and returned the remaining medications to the pharmacist, who also debriefed me. I talked with colleagues about my feelings and went to my home and husband. For several days, I was acutely aware of the magnitude of the process. Of course, Ann often returns in my memories. Six days later, on July 20th, 2017 the Wall Street Journal published an opinion piece by a Dutch politician in the Christian Party about euthanasia, with a headline provided by the newspaper: “In the Netherlands, the Doctor Will Kill You Now.”1 This gave me a feeling of severe nausea, but I was comforted by the memories of Ann and the knowledge that I had fulfilled what she wished me to do. Six weeks later, the committee confirmed that the euthanasia had complied with the statutory requirements. The patient’s family invited me to have dinner together to honor their wife and mother and to thank me for having fulfilled Ann’s wish.

Elisabeth E. G. de Vries

MD, PhD
Department of Medical Oncology, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands.

Published Online: March 8, 2018.
Additional Contributions: I thank the patient’s family for granting permission to publish this information.
1. Van der Staaij K. In the Netherlands, the doctor will kill you now. https://www.wsj.com/articles/in-the-netherlands-the-doctor-will-kill-you-now-1500591571