title: Complexities in euthanasia or physician-assisted suicide as perceived by Dutch physicians and patients' relatives.
abstract: BACKGROUND
  The practice of euthanasia and physician-assisted suicide (EAS) is always complex, but some cases are more complex than others. The nature of these unusually complex cases is not known.
  
  
  OBJECTIVE
  To identify and categorize the characteristics of EAS requests that are more complex than others.
  
  
  METHODS
  We held in-depth interviews with 28 Dutch physicians about their perception of complex cases of EAS requests. We also interviewed 26 relatives of patients who had died by EAS. We used open coding and inductive analysis to identify various different aspects of the complexities described by the participants.
  
  
  RESULTS
  Complexities can be categorized into relational difficulties-such as miscommunication, invisible suffering, and the absence of a process of growth toward EAS-and complexities that arise from unexpected situations, such as the capricious progress of a disease or the obligation to move the patient. The interviews showed that relatives of the patient influence the process toward EAS.
  
  
  CONCLUSIONS
  First, the process toward EAS may be disrupted, causing a complex situation. Second, the course of the process toward EAS is influenced not only by the patient and his/her attending physician but also by the relatives who are involved. Communicating and clarifying expectations throughout the process may help to prevent the occurrence of unusually complex situations.
authors.affiliation: Section of Medical Ethics, Department of General Practice, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands. Electronic address: m.c.snijdewind@amc.uva.nl.
authors.forename: Marianne C
authors.initials: MC
authors.lastname: Snijdewind
authors.affiliation: Department of General Practice, University of Groningen, Groningen, The Netherlands.
authors.forename: Donald G
authors.initials: DG
authors.lastname: van Tol
authors.affiliation: EMGO Institute for Health and Care Research, Department of Public and Occupational Health, Expertise Center for Palliative Care, VU University Medical Center Amsterdam, The Netherlands.
authors.forename: Bregje D
authors.initials: BD
authors.lastname: Onwuteaka-Philipsen
authors.affiliation: Section of Medical Ethics, Department of General Practice, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands.
authors.forename: Dick L
authors.initials: DL
authors.lastname: Willems
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D003142:Communication; D033101:Euthanasia, Active, Voluntary / Q000523:psychology*; D005190:Family / Q000523:psychology*; D005260:Female; D006801:Humans; D007407:Interviews as Topic; D008297:Male; D008875:Middle Aged; D009426:Netherlands; D010465:Perception; D010820:Physicians / Q000523:psychology*; D017236:Suicide, Assisted / Q000523:psychology*
keywords: Euthanasia; complexities; patient-physician relation; physician-assisted suicide; qualitative research