Introduction

Consultation of another physician is increasingly seen as an important way in which to review the practice of euthanasia or physician-assisted suicide (EAS).^1–7 In Oregon in the USA, where, under certain conditions, physician-assisted suicide is permitted, consultation is one of the prerequisites. In the Netherlands too, consultation is one of the requirements for prudent practice. These are requirements that have to be met if a physician wishes to avoid prosecution after reporting a case of EAS through the notification procedure.⁴ Euthanasia is defined as the administration of drugs with the explicit intention of ending a patient's life, at the patient's explicit request. Physician-assisted suicide is defined as the prescription or supply of drugs with the explicit intention of enabling a patient to end his or her own life.

Consultation implies that a physician must formally confer with an independent and knowledgeable colleague before performing EAS.⁴ Of course, it is not only important that a physician consults another physician before performing EAS, but also that the consultation is of good quality. Through the notification procedure, the law of precedent and discussions among medical professionals it has become increasingly clear as to what can be considered to be important criteria for good consultation: among other things, the consultant should have an independent position with regard to both the patient and the physician (that is, not knowing the patient and not working in the same practice as the attending physician), should talk to the patient and should also make a written report.⁴

In 1997, the Support and Consultation in Euthanasia in Amsterdam (SCEA) project was initiated to provide all general practitioners working in Amsterdam with a support group of approximately 20 specifically trained general practitioners for consultation or advice on EAS.⁸ The purpose was not only to make it easier for general practitioners to find an independent and knowledgeable consultant, but also to professionalise consultation. The latter is necessary because EAS consultations do not always meet the criteria for good consultation.⁹ To support the consultants in their work and to ensure uniformity, a protocol for consultation was developed, in which an attempt was made to clarify the existing criteria for consultation (where necessary) and to incorporate them into practical guidelines. This article reports on the development of the protocol and its contents, and describes some of the initial experiences of the physicians who worked with the protocol.

Methods

DEVELOPMENT OF THE PROTOCOL

The protocol was developed according to a Delphi-method. The purpose was to get a protocol that would be accepted and used by SCEA physicians. It involved the following steps:

1. An initial draft on the basis of the literature (which is very limited on this subject) and also the authors of this article did their own research.^4,9ndash;16

2. In the first round, ten experts were asked to comment on the draft. These experts included six general practitioners who were experienced in EAS and consultation, a psychiatrist, a social geriatrician, a professor in health law and a public prosecutor. Using a written questionnaire, they were asked whether they agreed with the structure of the protocol and the guidelines contained in the protocol. Except for two controversial issues (concerning the independence of the consultant and seeing the patient–discussed below) they all agreed on the structure and the content of the guidelines, but some suggestions were made for making them more precise.

3. In the second round, the draft of the protocol was not only sent to the experts, but also to the general practitioners (ten) who had agreed to function as consultants. In the questionnaire about this draft specific questions were asked about two issues that had appeared to be controversial in the first draft (could the consultant and the attending physician be participants in the same physician group, and should the consultant always see the patient), so that it was possible to follow the opinion of the large majority.

4. The version of the protocol that resulted from the second round was amended again after it had been used during the training of consultants to make it, where necessary, more usable in practice.

EXPERIENCES WITH WORKING WITH THE PROTOCOL.

On April 1 1997 SCEA was initiated with 20 participating general practitioners. Each time they were consulted, they filled in a registration form. On this form, among other things, they were asked how useful the protocol had been for that specific consultation (structured question), and they were also asked to clarify their answers (open-ended question). During the period between April 1 1997 and October 1 1998, 109 consultations took place, and for each consultation a registration form was filled in.

One year after the start of the intervention three focus group meetings were held, each attended by between five and seven consultants, in which the intervention was evaluated. One of the topics was working with the protocol.

Results

STRUCTURE OF THE PROTOCOL

The protocol includes guidelines for consultation and differentiates between steps that are necessary in a consultation and steps that are recommended. The guidelines were structured not only on the basis of distinguishing between procedural and substantive aspects, but also to distinguish between whether the guidelines concerned the consultant or the consultation. In this way, four important aspects of consultation could be distinguished: independence of the consultant (procedural, consultant); expertise of the consultant (substantive, consultant); tasks of the consultant (procedural, consultation), and judgment of the consultant (substantive, consultation). Guidelines for each of these aspects are included in the protocol.

The introduction to the protocol explains both its structure and its goal: to support consultants in systematically acting as consultants. It is also emphasised that not all guidelines will be applicable in each situation, but that it is important at least to explain why following a certain guideline would not be necessary in a specific situation.

INDEPENDENCE OF THE CONSULTANT

Box 1 shows the guidelines given for the independence of the consultant. The general question a consultant should ask him or herself before agreeing to act as consultant in a specific case is whether he or she is independent of both the attending physician and the patient. In the second round a specific question was asked about a controversial aspect of independence: is the independence of a consultant threatened if the consultant and the attending physician participate in the same physician group (physicians who perform on-call services for each other)? Seven persons said the consultant should never be of the same physician group, two said this was no problem and 11 said this should sometimes be possible (if it was difficult to find another physician or if the consultant really could be independent even if a member of the same physician group). Taking these results together with the notion that legally there is no objection to the consultant being of the same physician group, it was decided it should be recommended that a consultant should consider his or her independence even more carefully if the attending physician participated in the same physician group.

EXPERTISE OF THE CONSULTANT

Box 2 shows the guidelines concerning the knowledge and skills which are necessary for being a consultant. The most important question a consultant should ask him or herself before agreeing to act as a consultant in a specific case is whether he or she has the required knowledge and skills for this case. Moreover, during the consultation a consultant should always be able to determine whether it is necessary to involve someone else, for example a psychiatrist, if there are any doubts about the patient's competence.

TASKS OF THE CONSULTANT

Box 3 lists the activities a consultant should perform during a consultation in order to be able to make the correct decision: discussing with the attending physician; studying the patient's files; seeing the patient, and making a written report of the consultation. In the second round the experts and physicians were explicitly asked about the controversial issue of seeing the patient. All (19) but one thought the patient should always be seen, but seven added that in very exceptional cases (for example when they thought that after reading the patient files and talking with the physician, seeing the patient would not add information) it would not be necessary.

JUDGMENT OF THE CONSULTANT

Box 4 shows the guidelines for the judgment of the consultant. The main question concerning the judgment of the consultant was subject to discussion because the law is only concerned with whether the requirements for prudent practice are met in consultation. However, the majority of experts and physicians thought that medical standards were equally important, and were of the opinion that the consultant should also check whether the attending physician also worked with due medical-professional care. Another subject of discussion was the status of the consultant's judgment. The attending physician has the final responsibility for the decision on whether or not to perform EAS and can, if a consultant disagrees, always consult another physician. To prevent attending physicians from continuing to consult physicians until they find a consultant who agrees, the guidelines stipulate that an attending physician should only consult one other physician if the first consultant disagrees with the decision.

EXPERIENCES WITH THE PROTOCOL

In most consultations the SCEA physician found the protocol useful to some extent: 23 (21%) “very useful”; 55 (51%) “useful”, and 16 (15%) “somewhat useful”. In three (3%) of the consultations the SCEA physician did not find the protocol useful (with no further clarification). In 12 (11%) of the consultations the SCEA physicians did not use the protocol because they had already memorised its contents.

In 46 of the 109 consultations the SCEA physicians clarified their answers. It was most frequently mentioned that the protocol was useful as a checklist: 27 (59%), for example said it was “useful in working systematically”, or “useful to check whether all aspects had been addressed”. Other clarifications given by the SCEA physicians were that they had already memorised the protocol (13: 28%); that they did not use the protocol (4); that it did not provide sufficient support in a specific complex case (1), and that the central question that had to be answered in a consultation could have received more attention (1).

In the focus group meetings, all SCEA physicians stated that the protocol had been very useful, and more specifically they mentioned that it was useful as a checklist. There were differences in the way the protocol was used: some SCEA physicians did not refer to it anymore because they had memorised it, some read it at the beginning of the week they would be on call (approximately one week every two months) and a few always took it with them when visiting the attending physician and the patient. It was also mentioned that the protocol had a more general function in representing the consensus on consultation that existed among the SCEA physicians. The SCEA physicians made only one suggestion about guidelines that should be amended, omitted or supplemented: expertise of palliative care should be necessary and not just recommended.

Discussion

In an ideal situation, in the development of a protocol, existing literature will be a major source of information. In developing the protocol for consultation, however, this was not the case. The few empirical studies which have been conducted are only descriptive, and furthermore there is only limited literature available in which physicians and lawyers describe what they consider to be good consultation. Nevertheless, with the help of experts, it was still possible to develop a protocol that was used and also considered to be useful by the SCEA physicians, especially as a checklist. The involvement of the physicians who were supposed to use the protocol, the SCEA physicians, in the development of the protocol was probably also important for the positive results, not only by encouraging commitment, but also by making the protocol practical in use.

In a consultation, the fields of medicine and law are combined. It was noteworthy that the experts often chose the medical, more strict, perspective, in which the main focus is on optimising care, over the judicial perspective, which focuses on the least you have to do in order not to be prosecuted. One example is the exact central question that should be answered in a consultation. In the literature this has never been clearly stated. In formulating the central question, it was decided to consider consultation from a predominantly medical perspective. From the judicial perspective, only the question of whether the requirements for prudent practice were met would be of importance and not the way in which the decision to grant a request was made. For instance, the fact that the physician can be pressured by the patient or members of the family to make a rapid decision, does not necessarily have an effect on whether or not the physician meets the requirements for prudent practice, but it does have an effect on the quality of the physician's decision making. Another example is that from a medical perspective, talking to the patient is considered to be a necessary step in every consultation, whereas according to the law of precedent this is only necessary if the patient's suffering is primarily psychological.⁴

In view of the continuous developments in the field of euthanasia and assisted suicide, and the way in which it is safeguarded (such as the enactment of the notification procedure in 1994, the changes in the notification procedure in 1998 and the developments in the field of palliative care), it is important that the protocol is updated regularly. For instance, it is increasingly important that a consultant has the necessary knowledge of palliative care. Early in 1997, when the protocol was being developed, this was mentioned as a recommendation. However, the general opinion, also in the United States, is that good palliative care is considered to be a sine qua non of physician-assisted suicide.^1,5 Evaluation of the SCEA project showed that the SCEA physicians thought that if more attention was paid to palliative care, for instance during training, they would feel more secure in this area, especially in determining possible alternatives for treatment. Therefore, in a future update of the protocol, adequate knowledge of palliative care will be included as a prerequisite.

Obviously, some aspects of the protocol apply specifically to consultations on euthanasia and assisted suicide in the Netherlands. For instance, the requirements for prudent practice are not the same in the Netherlands as they are in Oregon.^1,4 In Oregon, for instance, the aim of the consultation is to confirm the patient's diagnosis, prognosis and informed decision and not, as in the Netherlands, whether the other requirements are met. Furthermore, in most countries, euthanasia and assisted suicide are unacceptable. It is debatable whether the protocol is of interest in those countries. If somebody would never consider granting a request for euthanasia or physician-assisted suicide, the protocol is not useful. However, in some of these countries, for instance in the US and Australia there is debate on the acceptability of euthanasia and the conditions under which it would be acceptable.^{1–3,5,7,17,18} In this debate, similar conditions occur as the ones used in the protocol. For instance, independence and expertise have already been mentioned by Alpers and Lo as important characteristics of a consultant.¹ Moreover, the protocol could also be of use in requests for withdrawal of treatment. In decision making taking place after such a request, the seriousness of the patient's request, the suffering of the patient and the alternatives for treatment will probably (together with the legal situation) be important considerations. Therefore, at least some aspects of this protocol developed in the Netherlands might also contribute to the development of consultation as a method of safeguarding the practice of physician-assisted suicide and/or euthanasia or the withdrawal of treatment elsewhere.