requirement applies. Based on jurisprudence and guidelines, another second opinion must be performed by an appropriate expert. This will usually be a psychiatrist working in an academic setting who specializes in the disorder the patient is suffering from. (Regional Euthanasia Review Committess RTE: Code of Practice, 2015) To support the physician throughout this challenging and long process, a guideline is drawn up by the Dutch Psychiatric Association; the first version was published in 1998, the current version is from 2018. (NVvP, 2018) The guideline distinguishes four phases: the request phase, the assessment phase, the consultation phase, and the implementation phase. The request phase begins when a patient expresses a wish for euthanasia. Important goals at that time are: to create an open and safe atmosphere in which to discuss the death wish, to carry out an assessment of possible acute suicidality, to check whether the relatives of the patient are aware of the request, and to provide information about the extensive euthanasia procedure that may follow. In the assessment phase, the physician assesses all due care criteria and requests the mandatory second opinion from an appropriate expert. In the consultation phase, a second physician is consulted. This is normally a physician, often a general practitioner, that received additional training in assessing PAD-requests (called a SCEN-physician). In the implementation phase, the assisted death takes place. (1) In this guideline, irremediability is conceptualized as follows: “irremediability means that there is no longer any prospect of alleviating, enduring or removing suffering. There is no longer a reasonable treatment perspective. In patients with a psychiatric disorder, irremediability is strongly personal and individually determined.” (page 78). The Euthanasia Act also specifies how the PAD-procedure should be evaluated after the patient’s death. Because it concerns an unnatural death, the body should be examined by a coroner directly. The physician who performed the PAD must report to the regional euthanasia review committee. In practice this means that the physician fills out a standardized form describing how the due diligence demands were followed, accompanied by relevant medical correspondence, the reports of the independent physicians and the coroner’s report. The regional euthanasia review committee exists of three members: a physician, an ethicist and a lawyer. If the review committee is satisfied that all due diligence demands were adequately followed, the physician is discharged from further prosecution. If there are doubts, the physician is sometimes asked to appear before the committee to give further explanation. If there are serious doubts about the legality of the PAD, the review committees can transfer the case to the public prosecutor for further investigation and possibly prosecution. (RTE, Code of Practice, 2015) 16 | CHAPTER 1 1