Annemieke Horikx,

Pharmacist, KNMP

Facts and figures

on euthanasia

and PASThe practice in the Netherlands

Nothing to disclose

Non-approved use

• Thiopental, mixtura nontherapeutica (seco- or pentobarbiturate), anti-emetics, neuromuscularblockers (rocuronium, atracurium, cisatracurium)

• Injection, infusion, elastomeric pump

Disclose

• Euthanasia: 4% of total number of deaths

• Database of more than 5000 recordsfrom 1998-2015

• First presentation of the 2013-2015 data(3000 records)

Practice in the Netherlands

• Development of the Guideline in the Netherlands

• Method

• Questionnaires

• Facts and figuresResults of implementation practice

Note: the period analysed, is the period 2013 - 2015If it is different, I tell you on the slide

Topics

Publisher Year

Stafleu 1977 P. Admiraal – Report about euthanasia in hospital

NVVE (Dignity in DyingThe Netherlands)

1980 Brochure Responsible Euthanasia

KNMP (Dutch Pharmacists Association)

1987 Technical report Euthanasia

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 (physiciansassociation)/KNMP

2012 Guideline for the practice of Euthanasia and Physician-Assisted Suicide

Development of the guideline

Guideline 2012

• Development of the Guideline in the Netherlands

• Method

• Questionnaires

• Facts and figuresResults of implementation practice

Note: the period analysed, is the period 2013 - 2015If it is different, I tell you on the slide

Topics

• Coma-inductorthiopental 2 grams or propofol 1 gram

• Check deep coma

• Neuromusculair blockerrocuronium 150 mg or atracurium 100 mg or cisatracurium 30 mg

Euthanasia - Intravenous method

• Thiopental 2 grams (prior 1.5 grams)

• Propofol added as coma induction medication

• Elastomeric pump as intravenous administration

Differences current and previous guideline – intravenous method

Elastomeric pump

• Premedication:Start anti-emetic 12 hours in advance.

• Mixtura Nontherapeutica 100 ml15 grams pento- or secobarbital sodium

Physician-Assisted-Suicide (PAS)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

Differences current and previous guideline – oral method

• Development of the Guideline in the Netherlands

• Method

• Questionnaires

• Facts and figuresResults of implementation practice

Note: the period analysed, is the period 2013 - 2015If it is different, I tell you on the slide

Topics

• 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

Questionnaires

• 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

What kind of questions?

Questionnaires returned

• Development of the Guideline in the Netherlands

• Method

• Questionnaires

• Facts and figuresResults of implementation practice

Note: the periode analysed, is the period 2013 - 2015If it is different, I tell you on the slide

Topics

Underlying disease2015 (n=1000)

Methods 1998-2015

Location of euthanasia procedure(n=3000)

Location of euthanasia procedure andmethods (n=3000)

Underlying disease and method used(n= 3000)

Focus on the oral method

Shift oral method to pump

Decision to use oral methodn=163

Underlying disease andchoice for oral method (n=3000)

Time lapse betweeningesting and dying

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

What did the physician / patientnotice?

Intravenous (IV) in addition to the oralmethod

Communication and cooperation pharmacist and physician

• 93% discussed the guidelinetogether

• 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 before the 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 cooperativetrajectory

Communication and cooperation after procedure

Return of unused life-ending agents

• The barbiturate drink is used less and is partly replacedby elastomeric pump

• Due to the improved screening of patients and/or theincreased 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

Take-home message

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

Thank you for your attention