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In Reply

Department of Clinical Psychology, Utrecht University, Utrecht, the Netherlands

Johanna G. van der Bom

Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, the Netherlands

Nikkie B. Swarte, A. Peter M. Heintz

Department of Gynecology, University Medical Center Utrecht, Utrecht, the Netherlands

Alexander de Graeff

Department of Medical Oncology, University Medical Center Utrecht, Utrecht the Netherlands

Jan van den Bout

Department of Clinical Psychology, Utrecht University, Utrecht, the Netherlands

Schäfer et al point to some important issues in their reaction to our article "Euthanasia and Depression: A Prospective Cohort Study Among Terminally Ill Cancer Patients."¹ We are happy to have the opportunity to provide more information on these issues.

Schäfer et al raised the suggestion that patients may be admitted to the hospital because their families were exhausted, and therefore patients felt themselves a burden to their family, which may have resulted in their request for euthanasia. The family's exhaustion is not a reason for a patient to be admitted to the academic hospital—a tertiary referral center for cancer patients. Patients were admitted because they were in need of specialized palliative care. If families become exhausted they will receive help at home from specialized nurses, or the patient will be admitted to a nursing home or hospice.

In the Netherlands, we have criteria that have to be fulfilled before a euthanasia request can be legally accepted. One of these criteria is that the request must be voluntary. This implies that the request has to come from the patient without any pressure from family members or others.

We have invited the relatives of the patients that participated in our study to be interviewed several times before and after the death of the patients. My clinical impression, as a clinical psychologist who has spoken with most of these relatives, is that most relatives wanted to keep their loved one with them as long as possible. However, with love and compassion, most of them were able to accept the wish of the patient to end his or her suffering by euthanasia.

In a previous study we interviewed 189 relatives after the death of a relative by euthanasia.² Nine percent indicated that consideration for the family was (for the large part or completely) a reason for the request for euthanasia.³ Thus, consideration for the family does play a role in a few cases according to the relatives.

We disagree with the suggestion that patients were transferred to the academic hospital because of exhaustion of the family and this was an underlying factor for the request for euthanasia.

Another issue discussed by Schäfer et al is that we have focused on depressed mood, while there are many different factors that may be associated with a request for euthanasia. The point is that in the article under discussion, we have chosen to focus on depressed mood and euthanasia. It is highly probable that there is a mutual relationship between the factors mentioned, such as fatigue, loneliness, and pain and depressed mood. Depressed mood may aggravate these symptoms, and these symptoms in turn may increase the risk for depressed mood. The studies of these factors are of course also of great interest. Reports on these factors are currently in preparation. For this article, however, we intended simply to describe the association between depressed mood and euthanasia, without any causal interpretation. Concerning the factor of unbearable suffering mentioned by Schäfer et al as one of the possible factors associated with euthanasia, we would like to say the following: According to the Dutch criteria for euthanasia, unbearable suffering must be present for the physician to accept the request for euthanasia—unbearable suffering in these patients is a given fact. Schäfer et al also state that we selected hopeless cases; however, these are the patients that requested euthanasia. It may not be common knowledge that in the Netherlands the estimated interval by which the patient's life is shortened through euthanasia, is less than 1 month in most cases,⁴ thus these patients are at the end of their lives.

Another important criterion is that the request for euthanasia must be consistent. Hence, the reference by Schäfer et al that the will to live may vary, is not relevant for a request for euthanasia, since the wish to die will only be considered a serious request for euthanasia if it is consistent, and fulfils the other criteria mentioned earlier.

Before we conclude we would like to state that we did not use the terms "depression" and "depressed mood" synonymously. We assessed depressed mood by the Hospital Anxiety and Depression Scale (HADS) and depression by the Composite International Diagnostic Interview (CIDI-auto). Our intention was to study depression in all patients with a request for euthanasia. Because we did not succeed in assessing depression in a considerable proportion of patients, we based our conclusion on the HADS: depressed mood was associated with an increased likelihood of requesting euthanasia. In our discussion we add that depressed mood as assessed by the HADS has been shown to be predictive of the development of a clinical depression in cancer patients at the end of life.

We are sure Schäfer et al agree with us that we can draw the clinical conclusion that early detection of depressed mood is important for quality at the end of life for patients and their relatives.

Authors' Disclosures of Potential Conflicts of Interest

The authors indicated no potential conflicts of interest.

REFERENCES

1. van der Lee ML, van der Bom JG, Swarte NB, et al: Euthanasia and depression: A prospective cohort study among terminally ill cancer patients. J Clin Oncol 23:6607-6612, 2005[Abstract/Free Full Text]

2. Swarte NB, van der Lee ML, van der Bom JG, et al: Effects of euthanasia on the bereaved family and friends: A cross sectional study. BMJ 327:189-192, 2003[Abstract/Free Full Text]

3. Swarte NB: Euthanasia among hospitalised cancer patients and the consequences for the bereaved. Utrecht University, 1999

4. Van der Heide A, Deliens L, Faisst K, et al: End-of-life decision-making in six European countries: Descriptive study. Lancet 362:345-350, 2003[CrossRef][Medline]

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