FC28: Medical Assistance in Dying and assessment of decisional capacity in dementia: the Dutch Perspective!

Abstract

Background: The Netherlands allows Medical Assistance in Dying (MAID) based on a diagnosis of dementia under strict legal conditions. The number of dementia MAID cases gradually increase every year up to 288 cases in 2022; 282 were decisionally competent and 6 were decisionally incompetent. In decisionally incompetent patients MAID has been granted based on a written advance directive. To assess decisional competence the Dutch euthanasia review committees, refer to criteria of Appelbaum and Grisso.

Objectives: To examine which factors, and how, influence the judgment of decisional competence for MAID requests of patients with dementia.

Methods: A qualitative analysis was performed of 60 dementia MAID case summaries as published online by the Dutch euthanasia review committees between 2012 and 2021: 20 cases had an advance directive and were decisionally compromised at time of MAID, 40 patients were decisionally competent at time of MAID, of which 20 also had an advance directive (purposive sampling). Two researchers independently coded all text related to decisional competence (thematic analysis). A theoretical framework about the assessment of decisional competence was developed.

Results: The four cognitive criteria of Appelbaum and Grisso were dimensional, and cut-off points were influenced by six factors that also directly impacted on competence assessment, i.e. level of communication, psychiatric comorbidity, personality, presence of an advance directive, consistency of the request, and the patient-physician relationship.

Conclusions: The framework illustrates the complex multidimensional nature of assessment of decisional competence in dementia patients requesting MAID. Subjectivity of the final judgement poses ethical and legal issues and argues for continuous quality improvement processes.