Legal regulation of physician-assisted death--the latest report cards.

1911 I 2002, the government of the Netherlands explicitly legalized euthanasia and physician-assisted suicide. These controversial endof-life practices had been openly tolerated and studied for many years before legalization, and Dutch physicians were expected to voluntarily report their participation in these acts, trusting that they would be acquitted of any legal wrongdoing provided that they had met the accepted criteria for “careful practice.” Not surprisingly, the reporting rates have increased since the law was passed — from 18% in 1990 to approximately 80% in 2005, as reported by van der Heide and colleagues in this issue of the Journal (pages 1957–1965). According to the authors, the majority of unreported cases now involve the use of opioids, or sedatives with uncertain lethal effects, making the physician’s intent more ambiguous. What is most interesting in this report is a small decrease in the number of cases of euthanasia, physician-assisted suicide, and “life-ending acts without explicit request” and a concomitant increase in acts of continuous deep sedation (also called terminal sedation or sedation to unconsciousness for treatment-intractable symptoms). The first two Dutch studies, conducted in 1990 and 1995, did not have a category for terminal sedation, in which the clinician primarily intends to relieve severe suffering without necessarily intending to hasten death, though the patient may hope that the intervention will accelerate death. In the past, such cases were probably recorded as euthanasia if the patient had decision-making capacity and as a “life-ending act without explicit