title: Unbearable suffering and requests for euthanasia prospectively studied in end-of-life cancer patients in primary care.
abstract: BACKGROUND
  An international discussion about whether or not to legally permit euthanasia and (or) physician assisted suicide (EAS) is ongoing. Unbearable suffering in patients may result in a request for EAS. In the Netherlands EAS is legally permitted, and unbearable suffering is one of the central compulsory criteria. The majority of EAS is performed in cancer patients in the primary care practice. In around one in every seven end-of-life cancer patients dying in the primary care setting EAS is performed. The prevalence of unbearable symptoms and overall unbearable suffering in relationship to explicit requests for EAS was studied in a cohort of end-of-life cancer patients in primary care.
  
  
  METHODS
  A prospective study in primary care cancer patients estimated to die within six months was performed. Every two months suffering was assessed with the State-of-Suffering V (SOS-V). The SOS-V is a comprehensive instrument for quantitative and qualitative assessment of unbearable suffering related to 69 physical, psychological and social symptoms in five domains.
  
  
  RESULTS
  Out of 148 patients who were asked to participate 76 (51%) entered the study. The studied population were 64 patients who were followed up until death; 27% explicitly requested EAS, which was performed in 8% of the patients. The final interview per patient was analyzed; in four patients the SOS-V was missing. Unbearable symptoms were present in 94% of patients with an explicit request for EAS and in 87% of patients without an explicit request. No differences were found in the prevalence of unbearable suffering for physical, psychological, social and existential symptoms, nor for overall unbearable suffering, between patients who did or who did not explicitly request EAS.
  
  
  CONCLUSIONS
  In a population of end-of-life cancer patients cared for in primary care no differences in unbearable suffering were found between patients with and without explicit requests for EAS. The study raises the question whether unbearable suffering is the dominant motive to request for EAS. Most patients suffered from unbearable symptoms, indicating that the compulsory criterion of unbearable suffering may be met a priori in most end-of-life cancer patients dying at home, whether they request EAS or not.
authors.affiliation: Department of Public and Occupational Health, VU University Medical Center, EMGO+ Institute, Expertise Center for Palliative Care, van der Boechorststraat 7, 1081 BT Amsterdam, The Netherlands ; Primary Care Center De Greev, Grevelingenstraat 10, 3522 PR Utrecht, The Netherlands.
authors.forename: Cees Dm
authors.initials: CD
authors.lastname: Ruijs
authors.affiliation: Department of Public and Occupational Health, VU University Medical Center, EMGO+ Institute, Expertise Center for Palliative Care, van der Boechorststraat 7, 1081 BT Amsterdam, The Netherlands.
authors.forename: Gerrit
authors.initials: G
authors.lastname: van der Wal
authors.affiliation: Department of Clinical Psychology, VU University, EMGO+ Institute, van der Boechorststraat 1, 1081 BT Amsterdam, The Netherlands.
authors.forename: Ad Jfm
authors.initials: AJ
authors.lastname: Kerkhof
authors.affiliation: Department of Public and Occupational Health, VU University Medical Center, EMGO+ Institute, Expertise Center for Palliative Care, van der Boechorststraat 7, 1081 BT Amsterdam, The Netherlands.
authors.forename: Bregje D
authors.initials: BD
authors.lastname: Onwuteaka-Philipsen