In November 2007, a 55-year-old female patient with end-stage chronic obstructive pulmonary disease (COPD) was admitted to the nursing home. She was diagnosed with COPD in 1997 and underwent 7 pulmonary rehabilitation sessions (1998, 2000, 2001, 2002, 2 in 2005, 2006). 2000 she underwent pulmonary decompression surgery and in the same year she had a stroke which resulted in paralysis of the left arm and pain in the left side of her body. 2006 she was recommended to receive long-term oxygen therapy. In February 2007, the patient was admitted to the nursing home for individualized and comprehensive treatment, after which her health status and ability to perform daily activities improved. She was discharged from the hospital in April of the same year, however, she was readmitted several times after her discharge due to acute exacerbations and received non-invasive positive pressure mechanical ventilation several times due to the development of progressive respiratory failure. When the patient was admitted to the nursing home for the second time in November 2007, she hoped that the intensive combination of therapy and physical training would again improve her ability to care for herself on a daily basis and eventually discharge her home. However, despite 2 months of comprehensive individualized treatment aimed at improving her health and daily living skills, the patient’s condition continued to deteriorate and she could not be discharged. Due to the progressive deterioration and increasing symptoms, the patient had to receive both palliative care and conventional treatment, including symptom control and daily care, and to discuss prognosis and later treatment. The patient had decided not to be resuscitated and refused to be transferred to the intensive care unit. At that time, she also refused hospitalization in case of an acute exacerbation. For the first time, 2 months after her second admission to the nursing home, the patient expressed her wish for euthanasia to the competent physician in the presence of her relatives. In her will, she wrote: “I was diagnosed with COPD in 1997 and had a stroke in 2000. Since 1997, I have been hospitalized repeatedly without interruption. Every 3 weeks, I develop an infection and struggle with the disease, which is getting worse and worse. I was too tired to fight the disease anymore. My breathing difficulties were getting worse, I had to take a half hour break every time I went to the bathroom before I could leave, and now I was terrified of going to the bathroom. At the same time the pain in my body was getting worse and worse. I always thought that my disease would not progress to an unbearable level. But now that it has progressed to this stage, all I have left in my life is my illness, and I want to end it all; my greatest wish is not to suffer from it anymore.” Due to progressively increasing pain and breathing difficulties, measures to control the patient’s symptoms were intensified day by day at the patient’s strong request, and the doctors also gave the patient psychosocial and spiritual help in the end-of-life stage. Thirteen days after the patient’s wish for euthanasia, the patient was euthanized in the presence of his relatives after a consultation with a psychiatrist and an independent physician. Medical Perspective In the Netherlands, euthanasia is defined as a life-ending operation performed by a clinician in the presence of a patient who has clearly expressed a wish to die. After all targeted treatment and palliative care, euthanasia allows the patient to end his or her life with dignity. Euthanasia is legal only when the patient’s condition is so severe that it is unbearable and there is no hope of medical treatment, and the following legal criteria are fully met I. The patient has explicitly requested it Doctors must be sure that the patient has made the request for euthanasia voluntarily and after full and careful consideration. The patient in this case had made an explicit request for euthanasia to her chest physician and general practitioner many years earlier. Since that time, she had repeatedly expressed her desire to be euthanized when her disease had progressed to an unbearable level with no hope of medical treatment. 2 weeks before her death, she again requested euthanasia. Her decision was made without any external pressure or influence from, for example, family and friends. She made her wish for euthanasia clear in front of her spouse, mother, sisters and daughter, and her family respected her wishes. She completed a written will expressly requesting euthanasia to end her life because she could not bear the pain of her illness. She saw a psychiatrist 1 week after making her will to rule out that her request for euthanasia was due to depression. The psychiatrist made the diagnosis that the patient did not have any psychiatric symptoms that would have led to her decision to euthanize. In addition, the psychiatrist asserted that her decision was entirely voluntary and carefully considered. During the 13 days between the time she made her will and her death, she expressed her desire for euthanasia and discussed what was most important in her life with her physician almost daily. II. Suffering without hope of cure The physician in charge must determine that the patient’s illness has reached an unbearable level and that there is no hope of cure. In this case, it was clear that the patient’s condition had no chance of improvement. This was evident from her deteriorating condition and increasing dependence on health care providers and relatives. She could barely perform any of her daily activities without the help of others, and had severe breathing difficulties with the slightest activity or even at rest. Since her stroke in 2000, she has had neuropathic pain on the left side of her body that has not healed. Her chest pain lasted for several months. Third, the patient is informed The physician must keep the patient fully informed about his or her condition and prognosis. In the nursing home, the patient spoke with her physician about her condition and prognosis and learned that her disease was likely to worsen and that an acute exacerbation of her condition would severely impair her health status and ability to live. The patient was fully aware of her condition, prognosis, and possible treatment measures. The physician must determine that there are no effective treatment options for the patient’s condition. This requirement is clearly met by the patient’s deteriorating condition and her increasing dependence on health care providers and relatives. At the same time, the likelihood of this patient showing improvement in her ability to live is zero. Her lung function had declined significantly over the past few years. One year before requesting euthanasia, her exertional expiratory volume in one second was only 26% of the expected value. For her COPD, her physicians administered the most rational treatment according to current international guidelines, including long-term oxygen therapy and noninvasive positive pressure mechanical ventilation. She underwent seven hospitalizations for comprehensive pulmonary rehabilitation, and in 2000 she underwent pulmonary decompression surgery. Recently, her condition has deteriorated and has not resolved despite intensive and comprehensive individualized treatment. The patient was unable to undergo lung transplantation because of smoking. She complained of severe respiratory distress and pain. After her request for euthanasia, the doctor increased the dose of opioids to effectively control her dyspnea and pain, but her desire for euthanasia grew stronger. The doctors used the most reasonable treatment plan to control the symptoms, but the results were poor. In the period before her death, her condition deteriorated rapidly and it became more difficult to even get out of bed each day. V. Independent opinion The supervising physician must ask at least 1 independent physician to consult to view the patient and give a written consultation opinion based on the euthanasia criteria above. Twelve days after the patient requested euthanasia, an independent physician (consulting euthanasia physician) came to consult on her condition and concluded that the patient met the four euthanasia criteria above. VI. End-of-life treatment The physician in charge must end the patient’s life with adequate treatment and care. The day after the independent physician consultation, the physician prepared the patient for euthanasia. When the patient was informed of the euthanasia plan, she was calm. She said she had done everything she wanted to do and fully accepted the plan. On the day of her death, her family came to say goodbye to her. In the presence of her mother, sister, daughter, and spouse, the physician administered intravenous barbiturates to cause her coma, followed by neuromuscular relaxants, in accordance with protocol, and she died quickly and quietly. VII. Results After the patient’s death, the supervising physician completed the medical record and informed the city’s pathologist that the patient died an unnatural death. After examining the deceased, the pathologist informed the public prosecutor to grant burial. The pathologist then submits his or her own report, the report of the supervising physician, the report of the independent physician, and the patient’s will to the regional review board. This committee (composed of legal experts, medical experts, and ethicists) reviews this information to determine whether the euthanasia was performed in accordance with the relevant regulations. Three weeks after the euthanasia was performed, the committee informed the physician in charge that the euthanasia had been performed in accordance with the regulations and would not be prosecuted. A few weeks later, the physician spoke with the family about the deceased’s life, illness, and relationship with the family, and the family expressed their gratitude to the physician for fulfilling the deceased’s last wishes. What was learned from this euthanasia case? In the Netherlands in 2002, euthanasia was legal only for patients with unbearable pain and no hope of cure, and only under conditions that fully comply with legal standards. Euthanasia is usually used for cancer patients. However, euthanasia can also be used for patients with end-stage COPD after all targeted and palliative treatments have been administered.