Background. One enduring criticism of the Dutch euthanasia policy is the ‘slippery slope’ argument that suggests that allowing physicians to conduct legal euthanasia or assisted suicide would eventually lead to patients being killed against their will. What we currently know about euthanasia and its practices in The Netherlands is predominantly based on retrospective quantitative or interview-based studies, but these studies fail to detail the mechanisms of day-to-day practice.
Objective. To examine the practices that surround euthanasia, particularly among vulnerable patients, using qualitative observation-based data.
Methods. A 15-month qualitative, observation-based study of home death and general practice in the greater Amsterdam region of The Netherlands. Study included observation and interviews with a sample of 15 (GPs and 650 of their patients, 192 of whom were living with terminal or life-threatening illness (with and without requests for euthanasia).
Results. Euthanasia practice typically involves extensive deliberations, the majority of which do not end in a euthanasia death. Euthanasia discussions or ‘euthanasia talk’ share at least two consequences: (i) the talk puts the onus on patients to continue discussions towards a euthanasia death and (ii) there is a socio-therapeutic component, which tends to affirm social bonds and social life.
Conclusion. While this qualitative evidence cannot disprove existence of abuse, it suggests that euthanasia practices have evolved in such a way that patients are more likely to talk about euthanasia than to die a euthanasia death.
Keywords. Assisted dying, euthanasia, general practice, palliative care, qualitative research.
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Introduction |
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One recurring criticism of the Dutch euthanasia policy is the argument popularly known as the ‘slippery slope’ argument, or phrased in a Dutch metaphor, the ‘hole in the dyke’ argument, which claims that allowing physicians to conduct euthanasia or assisted suicide may eventually lead to patients being killed against their will.1 Since the first national Dutch study on the presence and prevalence of euthanasia and other life-terminating behaviours, the subject of life-terminating behaviour without the explicit request of patients has frequently been cited by opponents of Dutch end-of-life (EOL) policies as evidence for a ‘slippery slope’. In 2001, for example, it was estimated that the number of euthanasia and assisted suicide cases in The Netherlands was 2.6% and 0.2% of all deaths, respectively, a relatively low figure in relation to all deaths. In addition to this figure, however, were a number of deaths that critics claimed raised concerns. Approximately 20.1% of all deaths were cases in which death occurred following an increase of medication to alleviate pain symptoms; 20.2% of all deaths that year were cases in which life-prolonging treatments were withheld or withdrawn and 0.7% of deaths fell under a category of life-terminating acts without the explicit request (LAWER) of the patient. The first two of these categories are clearly legal; the LAWER cases are not. The majority of LAWER cases included patients who were close to death, no longer able to communicate and appeared to be suffering severely.2,3 Arguments suggesting the presence of a ‘slippery slope’ in The Netherlands contend that cases of LAWER and death following pain relief where there is an intention by the physician to hasten death are examples of a slippery slope in effect. Others suggest that these practices are similar to rates found elsewhere in Europe and that many of these life-terminating behaviours constitute ‘normal medical practice’ in The Netherlands.3,4
The problem with many of these arguments for and against life-ending acts without explicit patient requests is that they tend to cite data that originate largely from retrospective quantitative surveys and interview-based studies.5–7 These studies are used by both critics and defenders of Dutch practice to argue for the presence or absence of abuse but do not clarify the complexity and multi-faceted nature of the trajectory of discussions and behaviours that occur at the EOL.8 Two observation-based, qualitative studies of modern-day euthanasia have also been published, but both were conducted in The Netherlands and both focus on euthanasia in the hospital setting.9,10
The present research examines the day-to-day phenomenon of euthanasia practice on the basis of a 15-month, observation-based study of home death and general practice in The Netherlands. Our study is based on observation and interviews with a sample of 15 physicians (13 of whom were GPs) and 650 of their patients, 192 of whom were living with terminal or life-threatening illness (with and without requests for euthanasia). This article is the third in a series that explores different aspects of data from this study for different audiences and a book that considers Dutch euthanasia and EOL care practices in comparison with US practices and policies.11–13
The following research questions guided the research and analysis: (i) What is the day-to-day practice of euthanasia? and (ii) Is there evidence based in observation that suggests that patients, and especially patients who might be particularly vulnerable, are being killed against their will? Using data gathered on house calls and in GP offices with patients, we examine 192 EOL cases for examples of any life-terminating treatment where the patient was capable of making a request for euthanasia but did not; any life-terminating treatment where the patient was not capable of making an explicit request; euthanasia used in lieu of palliative care alternatives and euthanasia that was predominantly the intention of the physician and not the patient. Our focus is on all patients and, in particular, patients who might be unable to advocate for themselves or are otherwise vulnerable at the end of life.
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Materials and Methods |
Study design and setting
For 15 months spanning from 2000 to 2001, FN conducted observation and field-based interviews with 15 physicians [13 GPs and 2 nursing home physicians (verpleeghuisartsen)] and 650 of their general population patients. From this sample, 192 EOL cases were selected for review. These included cases of persons who were terminal or seriously ill (with and without requests for euthanasia) and living in the greater Amsterdam region of The Netherlands. The study was conducted primarily with GPs, who perform the majority of euthanasia cases each year. In 2001, the year of the study, for example, 66% of all euthanasia deaths and 87% of all assisted suicides were performed by Dutch GPs.5 Euthanasia takes place most frequently at patients’ homes, though it is also performed by the GP in elder care homes (bejaardenhuizen), nursing homes (verzorgingscentra) and in institutions for assisted living (aanleunwoningen). Our study was conducted in all these locations in the greater Amsterdam region.
Participants
Using a combination of snowball and stratified purposeful sampling techniques,14 GPs were approached for the study through other doctors or researchers and then selected according to whether they matched population characteristics by gender, age and type of practice. All data collection was conducted by one researcher (FN) with regular reviews throughout the study of data collection progress by both Dutch- and American-based advisory committees. The researcher conducted interviews or observation with a total of 15 physicians (13 of whom were GPs, including two GPs who were not willing to perform euthanasia). Patients for the study were selected by a combination of snowball and criterion sampling.14 The researcher met general population patients during observation in the GP's office and on house calls with the GP. Study physicians often posted study consent forms and notices in their offices and each physician introduced patients to the researcher prior to each office or home visit, giving patients the opportunity to decline to participate in the study. A typical verbal consent would include, for example, the physician introducing the researcher as an American EOL researcher and asking the patient if they were comfortable being observed. Through periodic direct observation with each GP and via periodic self-reporting by GPs, 25 EOL patients were identified and approached to participate in more intensive case study research, including periodic home visits with the GP and one-on-one interviews conducted with patients, family members and the researcher alone. All interviews included in this study were completed only after both written and verbal consent were obtained. All consent forms and study literature were made available to participants in the Dutch language.
The sample of 192 EOL cases included 67 who were terminal or actively dying. Of the 67 who were terminal or actively dying, 18 had euthanasia requests and 27 did not. An additional 22 were reported cases of euthanasia or assisted suicide by GPs or family members discussed in depth during taped interviews, but did not include direct observation by the researcher. Twenty-five EOL cases were followed by intensive case study, which included multiple observations and interviews (taped and not taped) with patients, families, physicians and home care employees over the course of the person's remaining life or until the completion of the study year. See Table 1.
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The EOL sample also included 125 persons living with life-threatening illnesses who might be particularly vulnerable at the end of life, including persons living with serious and life-threatening illness who were 70 (n = 91), persons with mental illness or dementia (n = 10), persons being treated for depression or benauwdheid (a combination psychological–physical complaint that includes ‘tightness of the chest’, ‘fear’ or ‘anxiety’) (n = 17), and persons with physical disabilities (n = 7). These patients were typically suffering from a range of serious illness, including cancer, heart disease, stroke or mobility issues related to injuries or old age. These cases were seen by observation from one to multiple occasions over the course of the study and included short interviews (not taped) with GPs following each observation.
Study methodology
Observation activities included patient visits in GP offices and on house calls with patients. Each observation included at minimum an observation and a short interview with the GP about each case. In addition, structured taped interviews were conducted with GPs throughout the study, including introductory and exit interviews, a follow-up survey to confirm patient data, and multiple interviews throughout the study regarding specific patients. Interviews included interview guides and structured surveys which elicited information about the details and timeline of each study case, verification of researcher observations, opinions and concerns about each case, in addition to background information about the participant. Most patients included in the larger sample were seen by the researcher only once for the duration of a home or office visit, but 25 EOL case study patients were tracked more closely. These patients were typically seen on multiple occasions and included both observation and interviews designed to track shifts in views and practices through the course of a person's final illness. Intensive case studies typically included observation and interviews with patients, family members, homecare employees, friends, and the attending GP. With a few exceptions, all interviews and observations were conducted in the Dutch language. Names and other identifying information have been excluded to protect the identity of patients, families, and GPs. Otherwise, the details of the cases are accurate.
Study measures
Observation data were recorded in handwritten notes throughout the day and then expanded in electronic form within 72 hours of an event. Interviews were conducted in Dutch, then later transcribed by a native Dutch speaker and translated into English by FN. Data were examined for evidence of harm to patients. All data were coded and analysed based on a theme/pattern analysis, which included a count of the most common themes or patterns and an analysis of the nuances within the most common themes. Codes were generated from the current literature and included examination of any case demonstrating vulnerabilities, including patients who are elderly, disabled (especially with a cognitive disability or mental illness), depressed or from an ethnic minority group or economically disadvantaged background.6,7,15–22 Codes were also generated from the data and included patients at the end of life who are unable to advocate for themselves for any reason (including being on high doses of morphine, unconscious or unable to communicate), those who express fear of death or complain of benauwdheid (tightness of the chest or anxiety) or those who initiate a request for euthanasia and are unable to get out of it (including requests initiated by physicians or family or requests initiated by patients but taken up and moved along without significant involvement by the patient).
Validity and reliability
Triangulation, use of an on-site expert advisory team, review of data by participants and examination of outlier cases were used to control for validity and reliability of data.23,24 Responses to earlier published findings by experts from various disciplines both within The Netherlands and outside of it suggest that the overall findings may be valid to a larger geographic area.11,12 In addition, the congruency of study findings to existing research suggest that there may be some indication of external validity as well. Overall findings should be considered suggestive but not necessarily conclusive of medical behaviour that impacts the larger Dutch population.
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Results |
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Our study revealed that the daily practice of euthanasia in the home and nursing home typically involves extensive deliberations, the majority of which do not conclude in a euthanasia death. We examined seriously ill and EOL cases for evidence of (i) life-terminating treatment where the patient is capable of making a request for euthanasia but did not; (ii) life-terminating treatment where the patient is not capable of making an explicit request; (iii) euthanasia used in lieu of palliative care alternatives and (iv) euthanasia that is predominantly the intention of the physician and not the patient. With one exception, we did not find such cases. What we did find was a pattern in euthanasia discussions that in part serves a palliative effect, affirming social bonds and social identity at the end of life, and putting the onus on patients to continue discussions towards a euthanasia death.
Termination of life, patient capable
We examined data for indications of life-terminating treatment without the explicit request of the patient and where the patient was capable of making a request. Data revealed no instances of termination of life without explicit request by patients capable of communicating. Observation reveals that communication among GPs, patients and their families is strong at all stages of illness and particularly after treatments at the EOL have been largely suspended.
Dutch general practice is structured by, among other factors, a Dutch cultural tendency towards overleg (deliberation). Overleg is a decision-making process that Dutch people often use in business, policy-making, and in this case, in medical practice, where each participant has an equal chance to reflect on a topic and weigh in. Thus, the majority of the office and the home visits are conducted as a discussion and less often as a physical examination of the body. In a typical morning of general population office visits, for example, the study GPs used the examination room in less than half (five of 11) visits and the average length of a visit was 12 minutes, time usually spent in discussion. In addition, Dutch GPs continue a strong tradition of making house calls (on average seven of 28 visits each day were conducted in the home or nursing facility). Most cases of euthanasia occur either after a lengthy illness and multiple lengthy discussions over the course of weeks or months, such as in the case study in Figure 1, or following an acute terminal illness and multiple discussions over the course of days and weeks. Overall, the frequent presence of the GP in the home, their tendency to treat multiple members of a single family and their acceptance and encouragement of family participation in EOL discussions, including talk about euthanasia, results in a form of general practice that favours communication between GPs, patients capable of communicating and their families.
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Termination of life, patient not capable
We also examined data for indications of life-terminating treatment without the explicit request of the patient and where the patient was not capable of making a request or advocating for themselves. Six of 10 GPs interviewed said that they are not comfortable with euthanasia requests where there is not enough time to discuss the request with patients or if the patient is no longer able to communicate well. Observation and informal interview data backed this up, revealing that most GPs are not comfortable proceeding with a euthanasia request when patients are not capable of making a current explicit request. The tendency is to avoid pursuing euthanasia requests made by persons who have been diagnosed with dementia, mental illness or depression or are exhibiting signs of depression, such as benauwdheid or unresolved family conflict.
However, our study revealed one case (see Figure 2) where the patient died after an increase of morphine with the physician intending to hasten death and alleviate suffering at the request of the family. This case highlights a now-criticized practice of the use of increased morphine, with the intention to alleviate suffering and at the same time also shorten life. Under current Dutch law, this case appears to fall outside of accepted boundaries for euthanasia and terminal sedation.17,18 To be considered an acceptable euthanasia case, a consultation by a second physician would have been ordered and it would have had to be clearly established that the patient's initial request was ‘well considered’. With the revision of Dutch law in 2002, such a case would be considered legal if the patient had made a clear and well-documented request in advance of his incompetency, although such cases are almost never acted upon by the physician. This case, however, antedates the revision in the law. To be considered an acceptable terminal sedation case, the physician would have needed to use a consciousness-lowering drug other than morphine, thus this case challenges boundaries for EOL practice. It is, however, the only case of its kind revealed in this data set. It also demonstrates this physician's tendency towards openness and dialogue with family members and the physician's and family's attempt to honour the patient's previously expressed wishes even in cases where the patient is no longer capable of communication.
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Euthanasia in lieu of palliative care
Data revealed no instances of hastening death in lieu of palliative care alternatives. In general, we found many aspects of palliative care that are well integrated in Dutch general practice and home care, in spite of earlier claims that palliative care (including hospice) is not a well-developed medical specialty in The Netherlands.25 Dutch general practice is quite unique. The level of physician involvement, especially at the end of life, is higher than in the USA and the nature of the doctor–patient–family relationship is quite different. Even in city settings, the relationship between doctor and patient is much more personal, focused on illness in the context of that person's family and life stresses. It was quite common, for example, to hear GPs initiate discussions about a patient's relationships, work stress and other non-somatic indicators of health and well-being.
In EOL cases, consultations typically included discussions about symptom management, as well as discussions about how the illness was emotionally impacting the patient and his or her family. On more than one occasion, for example, GPs attempted to reconcile estranged family members of a dying patient. In cases where euthanasia was requested, discussions were acutely focused on how the patient and family felt about that person's request for euthanasia. Expressed wishes for death are not equated with euthanasia requests but in practice are used as a starting point for deeper discussions about life and death, as demonstrated by Mr van Sluit in the following case study, see Figure 3. Euthanasia talk often provided a structure for EOL discussions that in most cases resulted in patients finding reasons to continue living.
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The most common complaint by EOL patients was of ‘too many strangers’ in the home. The level of care that could be provided in the home was extensive and not one patient in the study sample complained of an inability to receive care due to lack of financial means. GPs regularly made house calls to their patients who were less able to travel to the office. In times of crisis or near the end of life, GPs would visit the home more frequently, sometimes once every few days or daily if needed. Thuiszorg was available on a sliding scale fee, or free of charge to those who could not afford it, and was used in many of the EOL cases. Thuiszorg provided nursing assistance in the home up to four times per day and included help with self-care, medications, meals, house cleaning, nursing care and overnight respite. Waitlists for Thuiszorg services are common in The Netherlands, but persons who are at the end of life are given priority. No one who was nearing the end of life in the study sample failed to receive requested services from Thuiszorg. While GPs demonstrated strengths in terms of presence and involvement at the end of life, several GPs expressed an interest in additional training in palliative care and in treating depression at the end of life.
Momentum in euthanasia cases
Finally, we examined data for indications of a euthanasia request that came from someone other than the patient or a request that appeared to gather momentum towards a euthanasia death against the patient's wishes. In addition to the one case (Figure 2, Mr de Bok) where the final request for euthanasia was initiated by the family, we found one other case of a request that appeared to have been initiated by someone other than the patient, see Figure 4. In Ms Bosma's case, the GP was not sure about the integrity of the patient's request and, given the manner in which euthanasia talk progresses and most importantly pauses, allowed this patient the time and structure for processing the meaning of her request. Ultimately, she did not receive euthanasia and instead died of her disease.
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Probably, the single most compelling finding from this study was that euthanasia talk follows a rather uniform structure discernible by regular stages decreasing in frequency—from initial verbal requests, to the written declaration, to repeated verbal and written requests, to a consultation with a second and independent physician, to the scheduling of the euthanasia and to a euthanasia death. Only rarely does euthanasia talk actually end in a euthanasia death. In practice, euthanasia talk has developed stages and pauses, where GPs typically stall the development of the discussions (the trajectory of the euthanasia request), leaving the option of euthanasia open to the patient, while at the same time putting the onus on the patient to continue forward towards a euthanasia death. In our sample of 18 cases of euthanasia talk, where euthanasia was invoked as an EOL option in the face of life-threatening illness, 12 patients made written declarations for euthanasia, 6 were seen by a second physician, 5 scheduled dates for euthanasia and 3 died euthanasia deaths (see Figure 5).
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Euthanasia discussions can span anywhere from several years to several days. Initial requests tend to occur after the first sign of serious illness but can also take place well before or after that for a number of different reasons. Initial requests and initial written declarations establish the official evidence necessary for a ‘voluntary and well-considered’ euthanasia request (as per Dutch regulations); they can serve as a type of emotional insurance (a just-in-case plan for future suffering); they establish the GP's willingness to perform euthanasia and they allow the GP an opportunity to communicate any formal and informal rules for euthanasia negotiations.
Initial requests, written declarations and repeated requests are as far as most patients go in the trajectory of euthanasia talk. Repeated requests, because they occur frequently over the course of weeks and months, are difficult to measure, but could also be considered another stage in euthanasia talk. The second opinion is a collegial evaluation from an independent physician for the purpose of assessing whether the medical and legal conditions for euthanasia have been met prior to a euthanasia death. If a second opinion does takes place, then the chances of a euthanasia death occurring increase dramatically. Of six patients in our sample who received a second opinion, five scheduled a date for euthanasia and three died euthanasia deaths. Most second opinion appointments are arranged by the GP and take place within 24–48 hours prior to the euthanasia death.
Even if a second opinion is scheduled, however, there are several reasons why a euthanasia death may not occur. Patients will be asked after the second opinion appointment if they want to schedule a date and will need to repeat their reasons for wanting to do so. If the individual changes his mind, they may tell the GP or a family member or they may merely hesitate when asked why they want the process to proceed. Any hesitation (like in the cases of Mr Van Sluit and Ms Bosma) and the GP halts or stalls the proceedings. Family members may also oppose a euthanasia death, and even though they have no formal power to stop the proceedings, patients will often relent when a key family member is adamantly opposed to a euthanasia death. Just as likely, however, the illness itself may impact how a patient dies. A disease can progress so quickly that the patient dies of his disease or a patient's illness may go into remission. Of six patients who went into the second ‘consultation stage’, one woman died in her sleep the day of that consultation, one woman died due to complications after a fall and one woman cancelled her intention for euthanasia due to pressure from her daughter.
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Discussion |
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Our finding that the euthanasia process most often occurs as ongoing talk and not simply as a life-ending act provides evidence against the existence of abuse in The Netherlands. This finding is substantiated by figures from the van der Maas and van der Wal studies on the prevalence of euthanasia in The Netherlands. In 2001, for example, of those who initiated a request for euthanasia with their physician (which includes those who initiate requests in the event of a future serious illness), only one in 10 died a euthanasia death and less than two-fifths of those who made ‘serious’ requests (requests made after life-threatening illness was diagnosed) died by euthanasia or assisted suicide. By 2005, less than one in 10 who initiated requests and only one-third who made concrete requests died by euthanasia or assisted suicide.5,26
Is it possible that these 15 physicians (mostly GPs) are unlike their GP counterparts in other parts of the country? It is possible that GPs, particularly in the more religious sections of the country, have practices around EOL that differ. However, the mixed sample of GPs within Amsterdam and in a small cluster of towns outside of it suggest a strong likelihood of uniformity to ‘euthanasia talk’. The one case (Figure 2) of death hastened by morphine illustrates that grey areas do exist in EOL care. Although the study sought any evidence suggesting that patients, and especially patients who might be particularly vulnerable, are being killed against their will, in particular examples of any life-terminating treatment where the patient was capable of making a request for euthanasia but did not; any life-terminating treatment where the patient was not capable of making an explicit request; euthanasia used in lieu of palliative care alternatives and euthanasia that was predominantly the intention of the physician and not the patient, insofar as it is the only such case detected over the course of 15 months spent with 15 GPs and 192 of their EOL patients, it is not clear whether it could constitute evidence of a larger slippery slope.
Euthanasia is neither a singular event nor the result of a one-time decision. It is a dynamic emergent process that is well situated in cultural norms of overleg (deliberation). ‘Euthanasia talk’ has two very important consequences. First, because the interchange typically occurs in stages in which the GP pauses or stalls the trajectory of euthanasia discussions, the onus is on patients to move euthanasia talk forward. Euthanasia talk is not something that once initiated, continues towards euthanasia death without repeated effort by the patient. It is also not something that once initiated by a patient is difficult to stop. Practices around euthanasia, such as terminal sedation and other medical practices that may hasten death, however, will need further monitoring to ensure that pain relief that may contribute to death does not become a substitute for cases that do not meet the requirements of euthanasia.
Second, because much of euthanasia practice is based in dialogue with patients, family and physicians around someone's choice for euthanasia, participation tends to foster and affirm both familial and societal relationships, providing a kind of socio-therapeutic environment for processing meaning at the end of life. Patients are told to talk to family and their GP about why they want euthanasia and all participants are encouraged to weigh in on how they feel about the request. Most non-institutionalized Dutch patients do not die alone. They die surrounded by home care, GPs making house calls, and in the case of those still living at home, often surrounded by family.
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Conclusion |
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Our observations reveal that euthanasia in The Netherlands most often occurs in the context of talk-based practice, as an interchange between physicians, patients and their families, the outcome of which is not fixed in advance. It is a dynamic emergent process based in cultural norms of deliberation that emphasizes, even in the face of terminal illness and the option for euthanasia, maintenance of social bonds and sustaining of Dutch life. Opponents and proponents of euthanasia who suggest that euthanasia practices can be condensed and understood in terms of the ‘explicitness’ of the request or by the intention of a physician are missing critical nuances and patterns revealed in the day-to-day practice of euthanasia. This study focused on the contexts and interactions that structure daily practices around euthanasia, using a small sample of patients, families and GPs in the greater Amsterdam region. A study of this type cannot disprove the presence of abuse related to euthanasia practices in The Netherlands, but it does offer evidence that the day-to-day practice of euthanasia discussions is much more conducive to maintaining life than previously understood.
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Declarations |
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Funding: University of California-San Francisco; University of California-Berkeley; American Association of Netherlandic Studies.
Ethical approval: The proposal for research was reviewed and approved by the Committee on Human Research at the University of California-San Francisco and by the Wetenschapscommissie at the Free University in Amsterdam. Participants met through observation gave their verbal consent prior to observation activities and all taped interviews with patients, families, GPs and other health care employees were conducted only after both verbal and written consent were obtained.
Conflict of interest: No funders had any role in the design and conduct of the study; collection, management, analysis, and interpretation of the data or preparation, review and approval of the manuscript. There is no financial conflict of interest to report.
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Acknowledgments |
We thank all the GPs and families who opened their homes and lives during one of the most intimate times in life. Thank you to Anne Mei The, PhD; Gerrit van der Wal, MD, PhD; and the Advisory Committee at the Vrije Universiteit (Anne Mei The, PhD; Gerrit van der Wal, MD, PhD; Dick Willems, MD, PhD; and Sjaak van der Geest, PhD) for their professional support and advice. Thank you to Sharon Kaufman, PhD, for her ongoing support.
Contributors: FN participated in collecting all data for this article, in conceptualizing and drafting the initial version of the article and by incorporating changes from my co-authors in the final version of the article. FN had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. GK and MPB participated in conceptualizing the article and in making revisions to this article.
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Notes |
Norwooda F, Kimsma G and Battin M P. Vulnerability and the ‘slippery slope’ at the end-of-life: a qualitative study of euthanasia, general practice and home death in The Netherlands. Family Practice 2009; 26: 472–480.
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References |
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24 Miles MG, Huberman AM. Qualitative Data Analysis: A Sourcebook of New Methods (1994) Thousand Oaks, CA: Sage Publications. 262–80.
25 Jordan I. Hospizbewegung in Deutschland und den Niederlanden: Palliativversorgung und Selbstbestimmung am Lebensende [Hospice Movement in Germany and The Netherlands: Palliative Care and Decision-Making Around End-Of-Life] (2007) Frankfurt, Germany: Campus. 197.
26 Onwuteaka-Philipsen BD, Gevers JKM, van der Heide A, et al. Wet Toetsing Levensbeëindiging op Verzoek en Hulp bij Zelfdoding [Evaluation of the Termination of Life on Request and Assisted Suicide (Review Procedure) Act of 2002] (2007) The Hague, The Netherlands: ZonMw. 100, 108. These figures are based on findings from the van der Wal and van der Maas prevalence studies of Dutch euthanasia and the wording was agreed upon in direct correspondence, Norwood with G van der Wal, 2006.
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