This study showed that EAS requests have a large impact on physicians. Concerns about specific aspects of the EAS process, such as the emotional burden of preparing and performing EAS, were commonly reported by physicians. Amongst physicians who refused a request, a substantial number experienced pressure to grant the request. Especially general practitioners who were 55 years or older felt pressured by the patient to grant the request, more so if the patient was older than 80 years, had a life-expectancy of 6 months or more and did not have cancer. The large majority of physicians who performed EAS reported contradictory emotions afterwards. Older physicians who had little experience with euthanasia requests, who experienced pressure and who were concerned about administering lethal drugs were more likely to report burdensome feelings after performing EAS.
Concerns about the EAS process
The results show that concerns about the euthanasia process are common amongst physicians who receive EAS requests. Concerns about the emotional burden of preparing EAS and performing EAS were reported by around 50% of both the physicians who reported on a refused request and the physicians who reported on a granted request. Physicians who refused a request were more likely to dread assessing the due care criteria and dealing with the relatives of the patient compared to physicians who granted a request. Previous research has shown that relatives may have difficulties with understanding and accepting the decision of the physician to refuse the request, which can be a reason for concern for physicians who refuse a request . Although, only 0.2% of all EAS cases are judged to be not conform the due care criteria, a substantial number of physicians who granted a request dreaded the administrative burden, and found waiting for the judgment of the euthanasia review committee burdensome . Concerns were common amongst those who reported on a granted request, but there was a relatively high frequency of concerns amongst those who reported on a refused request. This may be an indication that these requests were more complex [9, 16]. However, it is also possible that physicians who experienced more concerns, were more inclined to refuse the request.
Pressure to grant the request
Literature from the past 5 years confirms our findings that physicians may experience pressure to perform EAS from the patient (29%) and the relatives (34%), and pressure to perform EAS as soon as possible (44%) . Our study adds to this general observation by demonstrating that pressure is experienced more frequently when requests are refused than when they are granted. It is, however, unknown whether physicians refused the request because of the pressure by patients or relatives or whether physicians felt pressured because they refused the request.
The results from a recent interview study by Snijdewind et al. indicate that pressure experienced by physicians frequently stems from a difference in or unrealistic expectations: patients and relatives often do not understand why physicians are not (yet) willing to grant the request . A lot of confusion seems to be caused by the written advance euthanasia directive. For example, the large majority of the general public and patients’ relatives is of the opinion that incompetent patients with advanced dementia should be able to receive EAS on the basis of a written advance euthanasia directive [17,18,19]. Few physicians, however, are willing to carry out EAS on the basis of such a directive . Unmet expectations like these may lead to disappointed patients and this may contribute to the pressure physicians experience [21,22,23].
The association between the physician being older and experiencing pressure seems to contradict evidence that physicians who have more experience with providing EAS are better able to withstand pressure from patients . There is, however, also evidence showing that performing EAS does not become easier for physicians who have more experience with it [25, 26]. It is possible that the increasing number of EAS requests from patients who do not suffer from life-limiting illnesses increases pressure [27, 28].
Feelings after performing EAS
Seventy eight percent of the physicians who reported on a granted request reported uncomfortable feelings (the act felt burdensome, as a heavy responsibility and had emotional impact) after having performed EAS. Simultaneously, 67% reported comfortable feelings (satisfaction and relief). The simultaneous occurrence of these seemingly contradictory feelings shows the impact these requests have [24, 29]. The positive feelings physicians experience may be related to the fact that EAS is can be seen as an act of beneficence. The physician’s willingness to perform EAS can, therefore, be viewed as a supreme final act of care for the patient, that is associated with positive emotions such as satisfaction and relief. At the same time, the act can evoke negative emotions because of its extraordinary nature [24, 29, 30]. A significant association was found between burdensome feelings and age. Physicians aged between 40 and 54 were more likely to perceive performing EAS as burdensome compared to physicians aged 39 or younger. This may be explained by the fact that the younger physicians were trained in a context where euthanasia was legally regulated and, therefore, have a stronger tendency to regard it as ‘normal’. However, this does not explain yet why the oldest group of physicians (55 years or older) were equally likely to experience performing EAS as burdensome as the youngest group.
Over the past 20 years, ambiguity about performing EAS appears to have increased. The percentage of physicians reporting uncomfortable feelings after performing has remained largely stable: 72% in 1995 versus 80% in 2016, although the percentage of physicians reporting emotional feelings increased, from 30 to 44%. The percentage of physicians who reported comfortable feelings after having performed EAS increased from 54% in 1995 to 67% in 2016 . This increase is mainly attributed to an increase in the percentage of physicians who reported feelings of satisfaction, which increased from 46 to 60%.
The percentage of physicians who reported uncomfortable feelings is higher for those who performed EAS compared to those who took other end-of-life decisions. Of physicians who administered opioids to alleviate pain or other symptoms in doses which the physician believed to be large enough to have a probable life-shortening effect, only 18% reported uncomfortable feelings including the act being burdensome (7%), emotional (11%) and a heavy responsibility (6%), whereas of physicians who performed EAS, 80% reported uncomfortable feelings including the act being burdensome (50%), a heavy responsibility (56%) and emotional (44%) . This difference can be explained by the direct, causal relation between the act of EAS and the death of the patient which may be experienced as unnatural.
Strengths & limitations
The most important strength of this study is the nationwide sample of physicians working in different specialties. In addition, stratification for outcome of the request had several advantages. First, it provides an unique insight into the characteristics of refused EAS requests, on which literature is scarce. Second, by stratifying physicians to either answer questions about a refused or a granted request, we ensured that there were a sufficient number of cases for both outcomes of the requests.
A possible limitation is selection bias. The response was relatively low, mainly because of a low response amongst medical specialists (37%). Non-responders might differ from responders in their views on the impact of EAS requests. Another possible limitation is recall bias. Physicians were asked about concerns, pressure and emotions experienced in the most recent case in which they refused or granted a request. People may remember events differently from what really happened and memories may change over time. Furthermore, by asking physicians to describe a request from a patient who did not have cancer, there might be an overestimation of experienced pressure. Lastly, a power problem in the group of physicians who reported on a granted case may be the reason for the absence of significant associations for perceived pressure. Despite these limitations, this study provides valuable insights in the impact of EAS requests on physicians about which literature is scare.