Tag Archives: before

Sussex health trust apologises for failings before death of student

A health trust has apologised “unreservedly” for failings in the case of a 21-year-old student whose body was found in a burnt-out car after she absconded from a mental health ward.

How Janet Müller, a German national in her final year at Brighton University, ended up in the boot of a torched Volkswagen Jetta is a mystery. She died from inhalation of fire fumes within hours of going missing. Christopher Jeffrey-Shaw, 27, was convicted of manslaughter and imprisoned for 17 years.

Speaking publicly about the young woman’s death for the first time, her mother, Ramona Müller, 47, said she blamed Sussex Partnership NHS foundation trust for errors that led to her “bright, intelligent and beautiful” twin daughter being able to abscond from Mill View hospital in Hove, twice in one day before her death.

It was not the first time a patient had climbed over an 8ft garden wall and it was a known awol risk, her mother said. “It’s just the first time it ended that badly,” said Müller, who raised Janet and twin sister, Selina, in Berlin.

She had allowed her daughters to come to the UK “because I thought it was safe there. They wanted to do it for their education. So, I tried my best to make it possible for them. I raised them on my own. And then, finally, someone just comes along and takes her life.”

Müller, who was studying international event management, had no previous mental illness but became unwell ahead of her final exams in March 2015, and was admitted to the hospital 10 days before her death.

Her twin, who was studying at Kent University, visited her there and reported her to be agitated and desperate to leave. Her mother said she begged staff to allow Janet home to Germany, or allow her to visit or speak to her. “I tried to call a million times, I tried to speak to Janet.” But, she says she was always reassured: “Janet is fine, she is safe, don’t worry,” and was told her daughter could soon be transferred to a hospital near home in Germany. She never managed to speak to her before her death.

Janet first absconded from the female-only ward on the morning of 12 March 2015, and was found by a farmer in a field and returned by police.

She absconded again later that night and is thought to have gone over the wall, the inquest heard. CCTV footage showed her walking in the early hours of 13 March in Brighton. Her body was found in the car near Ifield golf club near Horsham in West Sussex.

When she learned her daughter was missing, Müller, a paramedic and teacher at a school in Berlin, flew to the UK to search for her. She was met at Eastbourne station by Selina. “I told her: ‘Don’t worry. We will find her.’ And she said to me: ‘Mama. They’ve found her. She’s dead.’”

The family have no idea how she came to be in the car. She had been severely beaten before being burned alive. An inquest found she died from fire fumes inhalation. She had no known connections to Jeffrey-Shaw. “There are so many unanswered questions. Why did she end up with him, not knowing him at all?” said her mother.

Jeffrey-Shaw, who has previous convictions for blackmail and harassment, was charged and convicted of manslaughter at Guildford crown court, but his trial yielded no answers. He admitted setting the car alight, but claimed he did not know the student was in the boot. He told the court he had been involved with drug dealers who borrowed his hire car for a robbery which went wrong and who ordered him to torch it.

The judge, rejecting his account, said the only reason he was not guilty of murder, “is because you did not have the human decency to check if the person in the boot of your car was dead or alive”.

An inquest jury, which agreed a verdict of unlawful killing, found lack of communication between healthcare staff, insufficient records and inadequate risk assessment were contributory, with no extra measures taken after she first absconded, and staff shortages and building works also factors.

Janet’s mother and sister have settled with the trust after issuing a civil claim under the Human Rights Act.

Sam Allen, the trust’s chief executive, admitted: “We failed in our duty of care to Janet, for which I am truly sorry.”

In a public apology, she said: “I want to give my personal assurance that we have worked hard to address the shortcomings identified following Janet’s tragic, untimely death.

“Words of apology from me cannot bring Janet back. The awful events that happened after she absconded from our care will forever be borne by her family.”

Janet’s mother said it had been “a long, hard fight” to get the trust to admit its mistakes, but she had been determined “to get justice for Janet, to force them to make changes, to speak out. Janet’s voice has to be heard, and things should not and must not happen again.”

The family had been devastated by Janet’s death, her mother said. Janet’s sister had abandoned her studies in UK. Once part of a close threesome, both feel responsible for not having done enough to save Janet, she said.

She hoped now the same mistakes could not be repeated. “For us it is too late. Nothing can change what happened to us. Janet will not come back. No apology, nothing, can do that. It’s all too late,” she said.

Some children reach brink of suicide before getting help with mental health, charity warns

Britain is confronting a mental health crisis because resources for children are so stretched that some only receive help if they seriously self-harm or attempt suicide, Barnardo’s has warned.

Javed Khan, chief executive of Britain’s largest children’s charity, said that young people’s mental health had never been worse in the organisation’s 152-year history. Radical action was needed, he said, because funding cuts had forced charities to abandon vital services.

“It’s never been as bad, and in another five years’ time it’s going to be even more complex,” Khan told the Observer. “This mental health crisis is getting more severe and more difficult by the day. The numbers keep going up. Educational psychologists are pulling their hair out – they haven’t got the resources. They can’t respond as fast as they need to.

“We are going to regret this period if this goes on for too long. We are going to rue the day when we took our eye off the ball.”

Neera Sharma, assistant director of policy at Barnardo’s, said that in some parts of the country the pressure on resources was so severe that only the most extreme cases received help. “The threshold is suicidal in some cases; the child would have had to have attempted suicide or committed serious self-harm to get a response,” Sharma said.

Speaking before Barnardo’s annual lecture this Wednesday, where representatives of Jeremy Hunt, the health secretary, will be among the audience, Khan urged the government to adopt a dramatic new approach.

The lack of resources has forced the charity to walk away from 1,033 contracts during the past year because the money available to local authorities meant it could not offer a sufficient service, Khan said. “They are tightening their belt to a point they cannot tighten it any more. They are asking for more to be delivered for far less resources than ever before, and there is a tipping point where you just can’t deliver a safe, high-quality service,” said Khan, who is also a member of the advisory board for the children’s commissioner for England.

One way the government could save money would be to scrap the traditional tendering process in favour of a more collaborative approach between the state and charities: “I don’t think the tendering model is sustainable – there aren’t enough resources in the system,” said Khan.

The latest on the UK’s mental health problem emerged on Thursday when statistics showed that almost one in five children could be at risk of having mental health issues later in life, according to the study of more than 850,000 seven-to-14-year-olds.

Figures from NHS trusts in England in November revealed that 60% of children and young people referred for specialist care by their GP were not receiving treatment. In December the government published a green paper on mental health problems but Khan said that the plans lacked ambition, falling significantly short of what he felt was required.

“If you analyse it, then three-quarters of children are going to get no support,” he said. “The response is insufficient, it’s not broad enough, there is limited financial detail. It talks about rolling out a number of initiatives in a number of areas but funding is only secured to these areas until 2023. The prime minister has talked about this issue as a burning injustice but we don’t think the action is matching the rhetoric.”

Last month Hunt intervened in the debate to condemn social media companies for “turning a blind eye” to mental health damage suffered by children who have uncontrolled access to their online platform.

Khan said social media was an issue – comparing new technology to “allowing a film crew into the bedroom” – and that they were also liaising directly with companies such as Google and Facebook to limit potential harm to young people.

In the UK, Samaritans can be contacted on 116 123. In the US, the National Suicide Prevention Lifeline is 1-800-273-8255. In Australia, the crisis support service Lifeline is 13 11 14. Other international suicide helplines can be found at befrienders.org

Doctors knew my son was suicidal. I should have been told before he died

Three years back I joined a club no one wants to be a member of. I became a parent who lost their child to suicide. He was 20. I didn’t think it was possible. I trusted his doctors to take good care of him. I trusted they would tell me if there was a real risk of him dying, given I was his mother and prime carer. I thought they had the expertise to identify and address a crisis when they saw it. Suicide was not in the script.

I turn the events around his sudden death over and over in my head, and it makes no sense. He had been diagnosed with bipolar disorder 10 weeks before he died. Initially his response to medication was good but then he plunged into a deep dark depression, which I thought was being managed by his GP. All this time, he lived at home with me. None of the medical staff mentioned the word “suicide” at any stage.

When the coroner’s inquest was a couple of months away, a big brown envelope of medical and other documents arrived in the post. I was afraid to open it for fear of the poison that might spill out. After a few days of preparing myself, I sat down with the envelope on a groundsheet in the sun.

Sagaar Mahajan


‘Three years ago, I became a parent who lost their child (Sagaar pictured) to suicide.’ Photograph: Sangeeta Mahajan

One of the many white A4 sheets was a photocopy of a health questionnaire, filled out and signed by my son two weeks before his death. It was designed to evaluate his state of mind over the two preceding weeks.

It showed that his depression was the worst it could be, his score was the highest it could be.

My brain froze. He had been feeling severely depressed and suicidal for at least a month before he could take it no more. He wrote it down, but couldn’t talk about it.

My son had been on antidepressants for two weeks at that point. We were told they would start working after three to four weeks. He was given a slip of paper advising him to go to A&E or call the Samaritans in case of crisis. It was like sending someone with crushing chest pain home with paracetamol.


A father was told by the GP: ‘Now that your son’s dead, I can tell you this wasn’t his first attempt at ending his life.

The shock of this revelation paralysed me. I took a deep breath before collapsing into a puddle on the floor, mourning the unnecessary loss of my son who asked for help but didn’t get it; who suffered silently while waiting for someone to understand him; who died alone on a cold day feeling worthless and hopeless. He didn’t deserve this.

There are hundreds of distraught and bewildered families like mine in this club whose stories have a common thread. A father told by the family doctor, “Now that your son is dead, I can tell you this was not his first attempt at ending his life.” Another parent said: “The GP knew our child wanted to end his life but they didn’t discuss that with us even though he was a minor.” Before ending his life, one young man had asked a mental health nurse to let his mother know that he was suicidal. She didn’t.

The first step in reducing risk is to ask about suicidal thoughts. Responses, however minor, require a compassionate, competent and timely response from clinicians. Safety planning comes next and is a collaborative process where patient and medical professional devise strategies for what to do when the ideas of suicide take hold. Then it is a matter of establishing a network of support with friends, family and the community as an essential part of keeping people safe for now and the future.

I was denied the chance to be there for my son when he needed me the most. My son’s answers to medical experts were largely ignored. I have found that suicide is a taboo subject not only in our society but also within the medical profession.

The doctor declared “suicides are not predictable or preventable” at the coroner’s inquest. His other argument was professional obligation of patient confidentiality.

Is confidentiality more important than helping someone at risk to stay alive?

“First do no harm” is a basic principle of medical practice. The Department of Health published a statement entitled Information sharing and suicide prevention in 2014. It states that practitioners should disclose relevant confidential information to an appropriate person – including family or friends – or authority to protect a vulnerable person from risk of death or serious harm.

Four years on, information is still not being shared with those best placed to help a suicidal person. Now, when there is a huge emphasis on care in the community, this is more important than ever before. The inadequacy of mental health services to cope with increased demand is worsened by a huge shortage of funds, psychiatrists and inpatient beds. A report published in 2015 said that unpaid carers save the government £132bn a year. They are a valuable resource if acknowledged as such.

The world of medicine is conservative and defensive. The GMC, Royal Colleges and NHS trusts should reassure practitioners that their decision to share information appropriately will be supported by them.

As a consultant anaesthetist working at a leading teaching hospital in central London, every day I am part of the extreme measures taken to save lives of patients with physical illnesses. Yet, healthy young people are allowed to die in the community from preventable causes in dire circumstances.

Confidentiality versus life. It’s a no-brainer.

  • In the UK the Samaritans can be contacted on 116 123. In the US, the National Suicide Prevention Lifeline is 1-800-273-8255. In Australia, the crisis support service Lifeline is 13 11 14. Other international suicide helplines can be found at www.befrienders.org.

Join the Healthcare Professionals Network to read more pieces like this. And follow us on Twitter (@GdnHealthcare) to keep up with the latest healthcare news and views

If you’re looking for a healthcare job or need to recruit staff, visit Guardian Jobs

Doctors knew my son was suicidal. I should have been told before he died

Three years back I joined a club no one wants to be a member of. I became a parent who lost their child to suicide. He was 20. I didn’t think it was possible. I trusted his doctors to take good care of him. I trusted they would tell me if there was a real risk of him dying, given I was his mother and prime carer. I thought they had the expertise to identify and address a crisis when they saw it. Suicide was not in the script.

I turn the events around his sudden death over and over in my head, and it makes no sense. He had been diagnosed with bipolar disorder 10 weeks before he died. Initially his response to medication was good but then he plunged into a deep dark depression, which I thought was being managed by his GP. All this time, he lived at home with me. None of the medical staff mentioned the word “suicide” at any stage.

When the coroner’s inquest was a couple of months away, a big brown envelope of medical and other documents arrived in the post. I was afraid to open it for fear of the poison that might spill out. After a few days of preparing myself, I sat down with the envelope on a groundsheet in the sun.

Sagaar Mahajan


‘Three years ago, I became a parent who lost their child (Sagaar pictured) to suicide.’ Photograph: Sangeeta Mahajan

One of the many white A4 sheets was a photocopy of a health questionnaire, filled out and signed by my son two weeks before his death. It was designed to evaluate his state of mind over the two preceding weeks.

It showed that his depression was the worst it could be, his score was the highest it could be.

My brain froze. He had been feeling severely depressed and suicidal for at least a month before he could take it no more. He wrote it down, but couldn’t talk about it.

My son had been on antidepressants for two weeks at that point. We were told they would start working after three to four weeks. He was given a slip of paper advising him to go to A&E or call the Samaritans in case of crisis. It was like sending someone with crushing chest pain home with paracetamol.


A father was told by the GP: ‘Now that your son’s dead, I can tell you this wasn’t his first attempt at ending his life.

The shock of this revelation paralysed me. I took a deep breath before collapsing into a puddle on the floor, mourning the unnecessary loss of my son who asked for help but didn’t get it; who suffered silently while waiting for someone to understand him; who died alone on a cold day feeling worthless and hopeless. He didn’t deserve this.

There are hundreds of distraught and bewildered families like mine in this club whose stories have a common thread. A father told by the family doctor, “Now that your son is dead, I can tell you this was not his first attempt at ending his life.” Another parent said: “The GP knew our child wanted to end his life but they didn’t discuss that with us even though he was a minor.” Before ending his life, one young man had asked a mental health nurse to let his mother know that he was suicidal. She didn’t.

The first step in reducing risk is to ask about suicidal thoughts. Responses, however minor, require a compassionate, competent and timely response from clinicians. Safety planning comes next and is a collaborative process where patient and medical professional devise strategies for what to do when the ideas of suicide take hold. Then it is a matter of establishing a network of support with friends, family and the community as an essential part of keeping people safe for now and the future.

I was denied the chance to be there for my son when he needed me the most. My son’s answers to medical experts were largely ignored. I have found that suicide is a taboo subject not only in our society but also within the medical profession.

The doctor declared “suicides are not predictable or preventable” at the coroner’s inquest. His other argument was professional obligation of patient confidentiality.

Is confidentiality more important than helping someone at risk to stay alive?

“First do no harm” is a basic principle of medical practice. The Department of Health published a statement entitled Information sharing and suicide prevention in 2014. It states that practitioners should disclose relevant confidential information to an appropriate person – including family or friends – or authority to protect a vulnerable person from risk of death or serious harm.

Four years on, information is still not being shared with those best placed to help a suicidal person. Now, when there is a huge emphasis on care in the community, this is more important than ever before. The inadequacy of mental health services to cope with increased demand is worsened by a huge shortage of funds, psychiatrists and inpatient beds. A report published in 2015 said that unpaid carers save the government £132bn a year. They are a valuable resource if acknowledged as such.

The world of medicine is conservative and defensive. The GMC, Royal Colleges and NHS trusts should reassure practitioners that their decision to share information appropriately will be supported by them.

As a consultant anaesthetist working at a leading teaching hospital in central London, every day I am part of the extreme measures taken to save lives of patients with physical illnesses. Yet, healthy young people are allowed to die in the community from preventable causes in dire circumstances.

Confidentiality versus life. It’s a no-brainer.

  • In the UK the Samaritans can be contacted on 116 123. In the US, the National Suicide Prevention Lifeline is 1-800-273-8255. In Australia, the crisis support service Lifeline is 13 11 14. Other international suicide helplines can be found at www.befrienders.org.

Join the Healthcare Professionals Network to read more pieces like this. And follow us on Twitter (@GdnHealthcare) to keep up with the latest healthcare news and views

If you’re looking for a healthcare job or need to recruit staff, visit Guardian Jobs

A woman’s final Facebook message before euthanasia: ‘I’m ready for my trip now…’

At 2pm on 26 January, Aurelia Brouwers lay down on her bed to die. Clutching a toy pink dinosaur and listening to her favourite music, the 29-year-old drank her prescribed medication as close friends gathered round. “She asked me to lie next to her. She had a smile on her face, and then she went softly into sleep,” Sjoukje Willering told the Observer. “It was very serene and calm. It was beautiful.”

Four hours earlier, Brouwers had posted her last message on Facebook. “I’m getting ready for my trip now. Thank you so much for everything. I’m no longer available from now on.” Brouwers died at home in the small Netherlands town of Deventer less than a month after being declared eligible for euthanasia under the country’s 2002 Termination of Life on Request and Assisted Suicide Act, which permits the ending of lives where there is “unbearable suffering” without hope of relief. Her death has triggered a fierce debate in a country that has one of the most permissive euthanasia laws in the world.

For not only was Brouwers young, she did not have a terminal disease such as cancer. She suffered from psychiatric illnesses, including severe anxiety, depression, eating disorders and psychosis. She self-harmed and had attempted suicide numerous times. She had spent nearly three years as an inpatient at a psychiatric hospital, and had served time in prison for arson.

Some say Brouwers’s death is a terrible illustration of the “slippery slope” inevitably associated with euthanasia legislation. Others who supported legalisation now also fear it has gone too far. Her supporters see her case as an important precedent, an escape to those in hopeless situations. “Every day was so hard. She was in a deep black hole,” said Willering. “She said it felt like a hundred knives being stabbed into her head. She never had a moment of doubt that she wanted it to end.” Her death was inevitable, one way or another, she added. “But she wanted the right to die with dignity, and she wanted other psychiatric patients to know that they also have a choice. This was her message to the world.”

This month, annual figures from the bodies that review euthanasia cases in the Netherlands showed an 8.1% increase in assisted deaths in 2017, taking the total to nearly 6,600 people. It came on top of a 10% annual increase the previous year. The vast majority had cancer, heart and arterial disease, or diseases of the nervous system, such as Parkinson’s and multiple sclerosis. But 169 had dementia, up from 141 the previous year. And 83 had severe psychiatric illnesses – up from 64 in 2016. “Supply has created demand,” said Professor Theo Boer, who supported the 2002 legislation but resigned from a regulatory body in 2014 amid concern about rising numbers. “We’re getting used to euthanasia, that is exactly what should not happen. We’re no longer speaking about the exceptional situations that the law was created for, but a gradual process towards organised death.”

The review bodies found that in 99.8% of cases, euthanasia was carried out in line with legal guidelines. However, Dutch prosecutors have recently opened criminal investigations into four cases, and last year an investigation began into a 74-year-old woman with dementia who had requested euthanasia before her illness became severe. Confused and agitated, she had to be restrained by family members to allow a lethal injection to be administered.

The focus of the current review of Brouwers’s death is a large redbrick house in The Hague, close to a clutch of museums in the north of the city. It houses the Levenseindekliniek – End of Life Clinic – a last resort for those who have been refused euthanasia elsewhere. Brouwers came here after failing to convince her own doctors and psychiatrists that she met the criteria for euthanasia. According to Steven Pleiter, the clinic’s avuncular director, a doctor and a nurse assessed Brouwers and built a relationship with her over a long period.

Her case was also reviewed by a multidisciplinary group at the clinic. “Aurelia was known to us for years. She was young but had already been suffering for a long time. Our processes are very careful,” Pleiter said.

The Levenseindekliniek has 62 doctor-nurse teams working part-time, but is on a significant recruitment drive to meet the spiralling demand for euthanasia. In 2012, the first year it was open, the clinic helped 32 people to die. Last year the figure was 750. But, Pleiter pointed out, that was only 30% of 2,500 applicants. One in every four does not meet the legal criteria, another 25% withdraw their request, and 20% die while their cases are being evaluated. Last year 9% of those undergoing euthanasia through the clinic had psychiatric illnesses and 10% had dementia. The costs are covered by the country’s health insurance system.

“Death by euthanasia is 4% of all deaths in the Netherlands. Is that a slippery slope? I don’t think so,” said Pleiter. Much of the demand was coming from the baby-boomer generation, he added. “They are thinking differently about the way life ends. God and religion are less dominant in their lives. They want more autonomy. But every case is unique.”

The decision Brouwers had waited so long for came on New Year’s Eve. It was “the best present I could have”, she wrote. “She was very happy, but she also had some hard moments, knowing she had to say goodbye to friends and family,” said Willering. “She was very open about it. You could ask her at any moment, ‘Aurelia, is this really what you want?’ and she would say, ‘Yes, I want to die.’ ” Another friend, Toon Krijthe, also at her bedside when she died, said: “I was glad for her, because I knew this was her only option – and I knew if it wasn’t a yes, she would find another way.”

Brouwers spent the days until 26 January saying goodbye to friends and working on a television documentary that was broadcast after her death. “She also visited the crematorium to plan and rehearse her funeral,” Krijthe said. “She believed in God, and she prayed, but she didn’t go to church.”

On the appointed day, two doctors from the Levenseindekliniek were present as Brouwers swallowed the liquid medication prescribed for her. “It took about 10 or 15 minutes for her to fall into sleep. She was very ready for it,” Willering said. She was cremated a week later. Within the Netherlands, it was a huge news story. As well as the television documentary, Brouwers’s death was a front-page story in the regional paper, with an additional six pages inside. “Personally I sympathise with her, and I’m happy she got a humane death,” said Boer, who teaches ethics at the Theological University of Kampen. “But culturally, I’m concerned that her death is being portrayed as a brave solution to severe suffering. She had huge support on social media.

“A border is being crossed between individual empathy and societal acceptance. If it becomes a societal norm that a person who has a psychiatric condition can opt to die, that is a problem.”

However, according to Professor Agnes van der Heide, an end-of-life expert at Erasmus University in Rotterdam, public opinion surveys show “a substantial proportion of our population think the law should be even more liberal – especially with regard to dementia”. Many who see their parents or grandparents in the grip of advanced dementia wish to opt out of such a bleak end-of-life scenario for themselves.

Not all doctors agree. Last year a group of 220 took out a newspaper advertisement saying they would refuse to euthanise patients with dementia who were unable to give verbal consent, even if the individual had signed a declaration of wishes in advance. “Our moral abhorrence at ending the life of a defenceless person is too great,” they wrote.

“It’s difficult to see how you can administer a lethal injection to a patient who doesn’t understand what you’re doing. So there is a conflict between doctors and the public,” said Van der Heide.

The End of Life Clinic, on the face of it just another house in the north of The Hague.


The End of Life Clinic, on the face of it just another house in the north of The Hague. Photograph: Judith Jockel for the Guardian

Yet some want to go even further. Pia Dijkstra, an MP and member of the centrist-liberal D66 party, has proposed a law allowing anyone over 75, without a diagnosis of physical or mental illness, to request euthanasia. “There is a growing number of older people who want to decide themselves how their life should end – how, when and where, and in a dignified way. They feel their life has been good but it’s now complete. They want control. The existing euthanasia law doesn’t meet their needs,” she said.

A study is to be carried out before a bill goes to parliament, but Dijkstra said the proposal had the support of 60-70% of the public, with some arguing for no age restriction. “I have had an enormous number of emails and letters from elderly people who want this possibility. But it’s important to have a good debate. And it’s so important to let older people know they are valued by society, and that this should be their choice.”


It is not good for society to have organised death facilitated by the state

Steven Pleiter, clinic director

Euthanasia advocates say people are helped to die regardless of the law. “About 80% of cases are reported to the review committees, which means 20% are not,” said Van der Heide. Some were in the area of so-called mercy killings, carried out by medical staff or family members; some involve palliative sedation, to relieve suffering but which ends in death. Penney Lewis, head of the Centre of Medical Law and Ethics at King’s College London, said: “Underground euthanasia happens in permissive and prohibitive jurisdictions. It happens everywhere.”

Despite the permissiveness of Dutch law, many applicants are refused, she said. “There is a lot of debate among Dutch doctors about what constitutes unbearable and hopeless suffering. But I think a model based on suffering is preferable to one based on a diagnosis.

“I’m not convinced by the ‘slippery slope’ argument. Of course, there’s evidence that the more people understand that this is an option, a greater proportion will avail themselves of it.”

The “normalisation” of euthanasia is of deep concern to Boer. “It is not good for society to have organised death facilitated by the state. A culture of euthanasia undermines our capacity to deal with suffering, and that is very bad for society.”


Not only was Aurelia Brouwers young, she did not have a terminal disease. She suffered from psychiatric illnesses

The Netherlands, Belgium and Luxembourg all have permissive laws on assisted dying and voluntary euthanasia, based on applicants’ suffering, and restricted to citizens of those countries. Switzerland allows assisted dying on compassionate grounds, and some clinics there, such as Dignitas, accept people who are not Swiss residents.

More restrictive laws exist elsewhere: assisted dying is legal in six US states (California, Colorado, Montana, Oregon, Vermont and Washington) plus Washington DC; in Canada; and in the Australian state of Victoria (after a campaign, pictured above). New Zealand is considering legislation. These are based on the “Oregon model”, which permits assisted dying for people with a terminal illness who are mentally competent and have a defined life expectancy.

In 2015, MPs in the UK voted against an assisted dying bill by 330 votes to 118. The campaign group Dignity in Dying advocates a law based on the Oregon model, covering people with less than six months to live. “Aurelia Brouwers made her choice in a very different legal context from the one we are campaigning for,” said Tom Davies of Dignity in Dying. The group is supporting Noel Conway, 68, who has motor neurone disease and has mounted a lawsuit to allow him a “peaceful and dignified death” by taking medication prescribed by a doctor. The court of appeal is expected to hear his case in May.

A woman’s final Facebook message before euthanasia: ‘I’m ready for my trip now…’

At 2pm on 26 January, Aurelia Brouwers lay down on her bed to die. Clutching a toy pink dinosaur and listening to her favourite music, the 29-year-old drank her prescribed medication as close friends gathered round. “She asked me to lie next to her. She had a smile on her face, and then she went softly into sleep,” Sjoukje Willering told the Observer. “It was very serene and calm. It was beautiful.”

Four hours earlier, Brouwers had posted her last message on Facebook. “I’m getting ready for my trip now. Thank you so much for everything. I’m no longer available from now on.” Brouwers died at home in the small Netherlands town of Deventer less than a month after being declared eligible for euthanasia under the country’s 2002 Termination of Life on Request and Assisted Suicide Act, which permits the ending of lives where there is “unbearable suffering” without hope of relief. Her death has triggered a fierce debate in a country that has one of the most permissive euthanasia laws in the world.

For not only was Brouwers young, she did not have a terminal disease such as cancer. She suffered from psychiatric illnesses, including severe anxiety, depression, eating disorders and psychosis. She self-harmed and had attempted suicide numerous times. She had spent nearly three years as an inpatient at a psychiatric hospital, and had served time in prison for arson.

Some say Brouwers’s death is a terrible illustration of the “slippery slope” inevitably associated with euthanasia legislation. Others who supported legalisation now also fear it has gone too far. Her supporters see her case as an important precedent, an escape to those in hopeless situations. “Every day was so hard. She was in a deep black hole,” said Willering. “She said it felt like a hundred knives being stabbed into her head. She never had a moment of doubt that she wanted it to end.” Her death was inevitable, one way or another, she added. “But she wanted the right to die with dignity, and she wanted other psychiatric patients to know that they also have a choice. This was her message to the world.”

This month, annual figures from the bodies that review euthanasia cases in the Netherlands showed an 8.1% increase in assisted deaths in 2017, taking the total to nearly 6,600 people. It came on top of a 10% annual increase the previous year. The vast majority had cancer, heart and arterial disease, or diseases of the nervous system, such as Parkinson’s and multiple sclerosis. But 169 had dementia, up from 141 the previous year. And 83 had severe psychiatric illnesses – up from 64 in 2016. “Supply has created demand,” said Professor Theo Boer, who supported the 2002 legislation but resigned from a regulatory body in 2014 amid concern about rising numbers. “We’re getting used to euthanasia, that is exactly what should not happen. We’re no longer speaking about the exceptional situations that the law was created for, but a gradual process towards organised death.”

The review bodies found that in 99.8% of cases, euthanasia was carried out in line with legal guidelines. However, Dutch prosecutors have recently opened criminal investigations into four cases, and last year an investigation began into a 74-year-old woman with dementia who had requested euthanasia before her illness became severe. Confused and agitated, she had to be restrained by family members to allow a lethal injection to be administered.

The focus of the current review of Brouwers’s death is a large redbrick house in The Hague, close to a clutch of museums in the north of the city. It houses the Levenseindekliniek – End of Life Clinic – a last resort for those who have been refused euthanasia elsewhere. Brouwers came here after failing to convince her own doctors and psychiatrists that she met the criteria for euthanasia. According to Steven Pleiter, the clinic’s avuncular director, a doctor and a nurse assessed Brouwers and built a relationship with her over a long period.

Her case was also reviewed by a multidisciplinary group at the clinic. “Aurelia was known to us for years. She was young but had already been suffering for a long time. Our processes are very careful,” Pleiter said.

The Levenseindekliniek has 62 doctor-nurse teams working part-time, but is on a significant recruitment drive to meet the spiralling demand for euthanasia. In 2012, the first year it was open, the clinic helped 32 people to die. Last year the figure was 750. But, Pleiter pointed out, that was only 30% of 2,500 applicants. One in every four does not meet the legal criteria, another 25% withdraw their request, and 20% die while their cases are being evaluated. Last year 9% of those undergoing euthanasia through the clinic had psychiatric illnesses and 10% had dementia. The costs are covered by the country’s health insurance system.

“Death by euthanasia is 4% of all deaths in the Netherlands. Is that a slippery slope? I don’t think so,” said Pleiter. Much of the demand was coming from the baby-boomer generation, he added. “They are thinking differently about the way life ends. God and religion are less dominant in their lives. They want more autonomy. But every case is unique.”

The decision Brouwers had waited so long for came on New Year’s Eve. It was “the best present I could have”, she wrote. “She was very happy, but she also had some hard moments, knowing she had to say goodbye to friends and family,” said Willering. “She was very open about it. You could ask her at any moment, ‘Aurelia, is this really what you want?’ and she would say, ‘Yes, I want to die.’ ” Another friend, Toon Krijthe, also at her bedside when she died, said: “I was glad for her, because I knew this was her only option – and I knew if it wasn’t a yes, she would find another way.”

Brouwers spent the days until 26 January saying goodbye to friends and working on a television documentary that was broadcast after her death. “She also visited the crematorium to plan and rehearse her funeral,” Krijthe said. “She believed in God, and she prayed, but she didn’t go to church.”

On the appointed day, two doctors from the Levenseindekliniek were present as Brouwers swallowed the liquid medication prescribed for her. “It took about 10 or 15 minutes for her to fall into sleep. She was very ready for it,” Willering said. She was cremated a week later. Within the Netherlands, it was a huge news story. As well as the television documentary, Brouwers’s death was a front-page story in the regional paper, with an additional six pages inside. “Personally I sympathise with her, and I’m happy she got a humane death,” said Boer, who teaches ethics at the Theological University of Kampen. “But culturally, I’m concerned that her death is being portrayed as a brave solution to severe suffering. She had huge support on social media.

“A border is being crossed between individual empathy and societal acceptance. If it becomes a societal norm that a person who has a psychiatric condition can opt to die, that is a problem.”

However, according to Professor Agnes van der Heide, an end-of-life expert at Erasmus University in Rotterdam, public opinion surveys show “a substantial proportion of our population think the law should be even more liberal – especially with regard to dementia”. Many who see their parents or grandparents in the grip of advanced dementia wish to opt out of such a bleak end-of-life scenario for themselves.

Not all doctors agree. Last year a group of 220 took out a newspaper advertisement saying they would refuse to euthanise patients with dementia who were unable to give verbal consent, even if the individual had signed a declaration of wishes in advance. “Our moral abhorrence at ending the life of a defenceless person is too great,” they wrote.

“It’s difficult to see how you can administer a lethal injection to a patient who doesn’t understand what you’re doing. So there is a conflict between doctors and the public,” said Van der Heide.

The End of Life Clinic, on the face of it just another house in the north of The Hague.


The End of Life Clinic, on the face of it just another house in the north of The Hague. Photograph: Judith Jockel for the Guardian

Yet some want to go even further. Pia Dijkstra, an MP and member of the centrist-liberal D66 party, has proposed a law allowing anyone over 75, without a diagnosis of physical or mental illness, to request euthanasia. “There is a growing number of older people who want to decide themselves how their life should end – how, when and where, and in a dignified way. They feel their life has been good but it’s now complete. They want control. The existing euthanasia law doesn’t meet their needs,” she said.

A study is to be carried out before a bill goes to parliament, but Dijkstra said the proposal had the support of 60-70% of the public, with some arguing for no age restriction. “I have had an enormous number of emails and letters from elderly people who want this possibility. But it’s important to have a good debate. And it’s so important to let older people know they are valued by society, and that this should be their choice.”


It is not good for society to have organised death facilitated by the state

Steven Pleiter, clinic director

Euthanasia advocates say people are helped to die regardless of the law. “About 80% of cases are reported to the review committees, which means 20% are not,” said Van der Heide. Some were in the area of so-called mercy killings, carried out by medical staff or family members; some involve palliative sedation, to relieve suffering but which ends in death. Penney Lewis, head of the Centre of Medical Law and Ethics at King’s College London, said: “Underground euthanasia happens in permissive and prohibitive jurisdictions. It happens everywhere.”

Despite the permissiveness of Dutch law, many applicants are refused, she said. “There is a lot of debate among Dutch doctors about what constitutes unbearable and hopeless suffering. But I think a model based on suffering is preferable to one based on a diagnosis.

“I’m not convinced by the ‘slippery slope’ argument. Of course, there’s evidence that the more people understand that this is an option, a greater proportion will avail themselves of it.”

The “normalisation” of euthanasia is of deep concern to Boer. “It is not good for society to have organised death facilitated by the state. A culture of euthanasia undermines our capacity to deal with suffering, and that is very bad for society.”


Not only was Aurelia Brouwers young, she did not have a terminal disease. She suffered from psychiatric illnesses

The Netherlands, Belgium and Luxembourg all have permissive laws on assisted dying and voluntary euthanasia, based on applicants’ suffering, and restricted to citizens of those countries. Switzerland allows assisted dying on compassionate grounds, and some clinics there, such as Dignitas, accept people who are not Swiss residents.

More restrictive laws exist elsewhere: assisted dying is legal in six US states (California, Colorado, Montana, Oregon, Vermont and Washington) plus Washington DC; in Canada; and in the Australian state of Victoria (after a campaign, pictured above). New Zealand is considering legislation. These are based on the “Oregon model”, which permits assisted dying for people with a terminal illness who are mentally competent and have a defined life expectancy.

In 2015, MPs in the UK voted against an assisted dying bill by 330 votes to 118. The campaign group Dignity in Dying advocates a law based on the Oregon model, covering people with less than six months to live. “Aurelia Brouwers made her choice in a very different legal context from the one we are campaigning for,” said Tom Davies of Dignity in Dying. The group is supporting Noel Conway, 68, who has motor neurone disease and has mounted a lawsuit to allow him a “peaceful and dignified death” by taking medication prescribed by a doctor. The court of appeal is expected to hear his case in May.

A woman’s final Facebook message before euthanasia: ‘I’m ready for my trip now…’

At 2pm on 26 January, Aurelia Brouwers lay down on her bed to die. Clutching a toy pink dinosaur and listening to her favourite music, the 29-year-old drank her prescribed medication as close friends gathered round. “She asked me to lie next to her. She had a smile on her face, and then she went softly into sleep,” Sjoukje Willering told the Observer. “It was very serene and calm. It was beautiful.”

Four hours earlier, Brouwers had posted her last message on Facebook. “I’m getting ready for my trip now. Thank you so much for everything. I’m no longer available from now on.” Brouwers died at home in the small Netherlands town of Deventer less than a month after being declared eligible for euthanasia under the country’s 2002 Termination of Life on Request and Assisted Suicide Act, which permits the ending of lives where there is “unbearable suffering” without hope of relief. Her death has triggered a fierce debate in a country that has one of the most permissive euthanasia laws in the world.

For not only was Brouwers young, she did not have a terminal disease such as cancer. She suffered from psychiatric illnesses, including severe anxiety, depression, eating disorders and psychosis. She self-harmed and had attempted suicide numerous times. She had spent nearly three years as an inpatient at a psychiatric hospital, and had served time in prison for arson.

Some say Brouwers’s death is a terrible illustration of the “slippery slope” inevitably associated with euthanasia legislation. Others who supported legalisation now also fear it has gone too far. Her supporters see her case as an important precedent, an escape to those in hopeless situations. “Every day was so hard. She was in a deep black hole,” said Willering. “She said it felt like a hundred knives being stabbed into her head. She never had a moment of doubt that she wanted it to end.” Her death was inevitable, one way or another, she added. “But she wanted the right to die with dignity, and she wanted other psychiatric patients to know that they also have a choice. This was her message to the world.”

This month, annual figures from the bodies that review euthanasia cases in the Netherlands showed an 8.1% increase in assisted deaths in 2017, taking the total to nearly 6,600 people. It came on top of a 10% annual increase the previous year. The vast majority had cancer, heart and arterial disease, or diseases of the nervous system, such as Parkinson’s and multiple sclerosis. But 169 had dementia, up from 141 the previous year. And 83 had severe psychiatric illnesses – up from 64 in 2016. “Supply has created demand,” said Professor Theo Boer, who supported the 2002 legislation but resigned from a regulatory body in 2014 amid concern about rising numbers. “We’re getting used to euthanasia, that is exactly what should not happen. We’re no longer speaking about the exceptional situations that the law was created for, but a gradual process towards organised death.”

The review bodies found that in 99.8% of cases, euthanasia was carried out in line with legal guidelines. However, Dutch prosecutors have recently opened criminal investigations into four cases, and last year an investigation began into a 74-year-old woman with dementia who had requested euthanasia before her illness became severe. Confused and agitated, she had to be restrained by family members to allow a lethal injection to be administered.

The focus of the current review of Brouwers’s death is a large redbrick house in The Hague, close to a clutch of museums in the north of the city. It houses the Levenseindekliniek – End of Life Clinic – a last resort for those who have been refused euthanasia elsewhere. Brouwers came here after failing to convince her own doctors and psychiatrists that she met the criteria for euthanasia. According to Steven Pleiter, the clinic’s avuncular director, a doctor and a nurse assessed Brouwers and built a relationship with her over a long period.

Her case was also reviewed by a multidisciplinary group at the clinic. “Aurelia was known to us for years. She was young but had already been suffering for a long time. Our processes are very careful,” Pleiter said.

The Levenseindekliniek has 62 doctor-nurse teams working part-time, but is on a significant recruitment drive to meet the spiralling demand for euthanasia. In 2012, the first year it was open, the clinic helped 32 people to die. Last year the figure was 750. But, Pleiter pointed out, that was only 30% of 2,500 applicants. One in every four does not meet the legal criteria, another 25% withdraw their request, and 20% die while their cases are being evaluated. Last year 9% of those undergoing euthanasia through the clinic had psychiatric illnesses and 10% had dementia. The costs are covered by the country’s health insurance system.

“Death by euthanasia is 4% of all deaths in the Netherlands. Is that a slippery slope? I don’t think so,” said Pleiter. Much of the demand was coming from the baby-boomer generation, he added. “They are thinking differently about the way life ends. God and religion are less dominant in their lives. They want more autonomy. But every case is unique.”

The decision Brouwers had waited so long for came on New Year’s Eve. It was “the best present I could have”, she wrote. “She was very happy, but she also had some hard moments, knowing she had to say goodbye to friends and family,” said Willering. “She was very open about it. You could ask her at any moment, ‘Aurelia, is this really what you want?’ and she would say, ‘Yes, I want to die.’ ” Another friend, Toon Krijthe, also at her bedside when she died, said: “I was glad for her, because I knew this was her only option – and I knew if it wasn’t a yes, she would find another way.”

Brouwers spent the days until 26 January saying goodbye to friends and working on a television documentary that was broadcast after her death. “She also visited the crematorium to plan and rehearse her funeral,” Krijthe said. “She believed in God, and she prayed, but she didn’t go to church.”

On the appointed day, two doctors from the Levenseindekliniek were present as Brouwers swallowed the liquid medication prescribed for her. “It took about 10 or 15 minutes for her to fall into sleep. She was very ready for it,” Willering said. She was cremated a week later. Within the Netherlands, it was a huge news story. As well as the television documentary, Brouwers’s death was a front-page story in the regional paper, with an additional six pages inside. “Personally I sympathise with her, and I’m happy she got a humane death,” said Boer, who teaches ethics at the Theological University of Kampen. “But culturally, I’m concerned that her death is being portrayed as a brave solution to severe suffering. She had huge support on social media.

“A border is being crossed between individual empathy and societal acceptance. If it becomes a societal norm that a person who has a psychiatric condition can opt to die, that is a problem.”

However, according to Professor Agnes van der Heide, an end-of-life expert at Erasmus University in Rotterdam, public opinion surveys show “a substantial proportion of our population think the law should be even more liberal – especially with regard to dementia”. Many who see their parents or grandparents in the grip of advanced dementia wish to opt out of such a bleak end-of-life scenario for themselves.

Not all doctors agree. Last year a group of 220 took out a newspaper advertisement saying they would refuse to euthanise patients with dementia who were unable to give verbal consent, even if the individual had signed a declaration of wishes in advance. “Our moral abhorrence at ending the life of a defenceless person is too great,” they wrote.

“It’s difficult to see how you can administer a lethal injection to a patient who doesn’t understand what you’re doing. So there is a conflict between doctors and the public,” said Van der Heide.

The End of Life Clinic, on the face of it just another house in the north of The Hague.


The End of Life Clinic, on the face of it just another house in the north of The Hague. Photograph: Judith Jockel for the Guardian

Yet some want to go even further. Pia Dijkstra, an MP and member of the centrist-liberal D66 party, has proposed a law allowing anyone over 75, without a diagnosis of physical or mental illness, to request euthanasia. “There is a growing number of older people who want to decide themselves how their life should end – how, when and where, and in a dignified way. They feel their life has been good but it’s now complete. They want control. The existing euthanasia law doesn’t meet their needs,” she said.

A study is to be carried out before a bill goes to parliament, but Dijkstra said the proposal had the support of 60-70% of the public, with some arguing for no age restriction. “I have had an enormous number of emails and letters from elderly people who want this possibility. But it’s important to have a good debate. And it’s so important to let older people know they are valued by society, and that this should be their choice.”


It is not good for society to have organised death facilitated by the state

Steven Pleiter, clinic director

Euthanasia advocates say people are helped to die regardless of the law. “About 80% of cases are reported to the review committees, which means 20% are not,” said Van der Heide. Some were in the area of so-called mercy killings, carried out by medical staff or family members; some involve palliative sedation, to relieve suffering but which ends in death. Penney Lewis, head of the Centre of Medical Law and Ethics at King’s College London, said: “Underground euthanasia happens in permissive and prohibitive jurisdictions. It happens everywhere.”

Despite the permissiveness of Dutch law, many applicants are refused, she said. “There is a lot of debate among Dutch doctors about what constitutes unbearable and hopeless suffering. But I think a model based on suffering is preferable to one based on a diagnosis.

“I’m not convinced by the ‘slippery slope’ argument. Of course, there’s evidence that the more people understand that this is an option, a greater proportion will avail themselves of it.”

The “normalisation” of euthanasia is of deep concern to Boer. “It is not good for society to have organised death facilitated by the state. A culture of euthanasia undermines our capacity to deal with suffering, and that is very bad for society.”


Not only was Aurelia Brouwers young, she did not have a terminal disease. She suffered from psychiatric illnesses

The Netherlands, Belgium and Luxembourg all have permissive laws on assisted dying and voluntary euthanasia, based on applicants’ suffering, and restricted to citizens of those countries. Switzerland allows assisted dying on compassionate grounds, and some clinics there, such as Dignitas, accept people who are not Swiss residents.

More restrictive laws exist elsewhere: assisted dying is legal in six US states (California, Colorado, Montana, Oregon, Vermont and Washington) plus Washington DC; in Canada; and in the Australian state of Victoria (after a campaign, pictured above). New Zealand is considering legislation. These are based on the “Oregon model”, which permits assisted dying for people with a terminal illness who are mentally competent and have a defined life expectancy.

In 2015, MPs in the UK voted against an assisted dying bill by 330 votes to 118. The campaign group Dignity in Dying advocates a law based on the Oregon model, covering people with less than six months to live. “Aurelia Brouwers made her choice in a very different legal context from the one we are campaigning for,” said Tom Davies of Dignity in Dying. The group is supporting Noel Conway, 68, who has motor neurone disease and has mounted a lawsuit to allow him a “peaceful and dignified death” by taking medication prescribed by a doctor. The court of appeal is expected to hear his case in May.

A woman’s final Facebook message before euthanasia: ‘I’m ready for my trip now…’

At 2pm on 26 January, Aurelia Brouwers lay down on her bed to die. Clutching a toy pink dinosaur and listening to her favourite music, the 29-year-old drank her prescribed medication as close friends gathered round. “She asked me to lie next to her. She had a smile on her face, and then she went softly into sleep,” Sjoukje Willering told the Observer. “It was very serene and calm. It was beautiful.”

Four hours earlier, Brouwers had posted her last message on Facebook. “I’m getting ready for my trip now. Thank you so much for everything. I’m no longer available from now on.” Brouwers died at home in the small Netherlands town of Deventer less than a month after being declared eligible for euthanasia under the country’s 2002 Termination of Life on Request and Assisted Suicide Act, which permits the ending of lives where there is “unbearable suffering” without hope of relief. Her death has triggered a fierce debate in a country that has one of the most permissive euthanasia laws in the world.

For not only was Brouwers young, she did not have a terminal disease such as cancer. She suffered from psychiatric illnesses, including severe anxiety, depression, eating disorders and psychosis. She self-harmed and had attempted suicide numerous times. She had spent nearly three years as an inpatient at a psychiatric hospital, and had served time in prison for arson.

Some say Brouwers’s death is a terrible illustration of the “slippery slope” inevitably associated with euthanasia legislation. Others who supported legalisation now also fear it has gone too far. Her supporters see her case as an important precedent, an escape to those in hopeless situations. “Every day was so hard. She was in a deep black hole,” said Willering. “She said it felt like a hundred knives being stabbed into her head. She never had a moment of doubt that she wanted it to end.” Her death was inevitable, one way or another, she added. “But she wanted the right to die with dignity, and she wanted other psychiatric patients to know that they also have a choice. This was her message to the world.”

This month, annual figures from the bodies that review euthanasia cases in the Netherlands showed an 8.1% increase in assisted deaths in 2017, taking the total to nearly 6,600 people. It came on top of a 10% annual increase the previous year. The vast majority had cancer, heart and arterial disease, or diseases of the nervous system, such as Parkinson’s and multiple sclerosis. But 169 had dementia, up from 141 the previous year. And 83 had severe psychiatric illnesses – up from 64 in 2016. “Supply has created demand,” said Professor Theo Boer, who supported the 2002 legislation but resigned from a regulatory body in 2014 amid concern about rising numbers. “We’re getting used to euthanasia, that is exactly what should not happen. We’re no longer speaking about the exceptional situations that the law was created for, but a gradual process towards organised death.”

The review bodies found that in 99.8% of cases, euthanasia was carried out in line with legal guidelines. However, Dutch prosecutors have recently opened criminal investigations into four cases, and last year an investigation began into a 74-year-old woman with dementia who had requested euthanasia before her illness became severe. Confused and agitated, she had to be restrained by family members to allow a lethal injection to be administered.

The focus of the current review of Brouwers’s death is a large redbrick house in The Hague, close to a clutch of museums in the north of the city. It houses the Levenseindekliniek – End of Life Clinic – a last resort for those who have been refused euthanasia elsewhere. Brouwers came here after failing to convince her own doctors and psychiatrists that she met the criteria for euthanasia. According to Steven Pleiter, the clinic’s avuncular director, a doctor and a nurse assessed Brouwers and built a relationship with her over a long period.

Her case was also reviewed by a multidisciplinary group at the clinic. “Aurelia was known to us for years. She was young but had already been suffering for a long time. Our processes are very careful,” Pleiter said.

The Levenseindekliniek has 62 doctor-nurse teams working part-time, but is on a significant recruitment drive to meet the spiralling demand for euthanasia. In 2012, the first year it was open, the clinic helped 32 people to die. Last year the figure was 750. But, Pleiter pointed out, that was only 30% of 2,500 applicants. One in every four does not meet the legal criteria, another 25% withdraw their request, and 20% die while their cases are being evaluated. Last year 9% of those undergoing euthanasia through the clinic had psychiatric illnesses and 10% had dementia. The costs are covered by the country’s health insurance system.

“Death by euthanasia is 4% of all deaths in the Netherlands. Is that a slippery slope? I don’t think so,” said Pleiter. Much of the demand was coming from the baby-boomer generation, he added. “They are thinking differently about the way life ends. God and religion are less dominant in their lives. They want more autonomy. But every case is unique.”

The decision Brouwers had waited so long for came on New Year’s Eve. It was “the best present I could have”, she wrote. “She was very happy, but she also had some hard moments, knowing she had to say goodbye to friends and family,” said Willering. “She was very open about it. You could ask her at any moment, ‘Aurelia, is this really what you want?’ and she would say, ‘Yes, I want to die.’ ” Another friend, Toon Krijthe, also at her bedside when she died, said: “I was glad for her, because I knew this was her only option – and I knew if it wasn’t a yes, she would find another way.”

Brouwers spent the days until 26 January saying goodbye to friends and working on a television documentary that was broadcast after her death. “She also visited the crematorium to plan and rehearse her funeral,” Krijthe said. “She believed in God, and she prayed, but she didn’t go to church.”

On the appointed day, two doctors from the Levenseindekliniek were present as Brouwers swallowed the liquid medication prescribed for her. “It took about 10 or 15 minutes for her to fall into sleep. She was very ready for it,” Willering said. She was cremated a week later. Within the Netherlands, it was a huge news story. As well as the television documentary, Brouwers’s death was a front-page story in the regional paper, with an additional six pages inside. “Personally I sympathise with her, and I’m happy she got a humane death,” said Boer, who teaches ethics at the Theological University of Kampen. “But culturally, I’m concerned that her death is being portrayed as a brave solution to severe suffering. She had huge support on social media.

“A border is being crossed between individual empathy and societal acceptance. If it becomes a societal norm that a person who has a psychiatric condition can opt to die, that is a problem.”

However, according to Professor Agnes van der Heide, an end-of-life expert at Erasmus University in Rotterdam, public opinion surveys show “a substantial proportion of our population think the law should be even more liberal – especially with regard to dementia”. Many who see their parents or grandparents in the grip of advanced dementia wish to opt out of such a bleak end-of-life scenario for themselves.

Not all doctors agree. Last year a group of 220 took out a newspaper advertisement saying they would refuse to euthanise patients with dementia who were unable to give verbal consent, even if the individual had signed a declaration of wishes in advance. “Our moral abhorrence at ending the life of a defenceless person is too great,” they wrote.

“It’s difficult to see how you can administer a lethal injection to a patient who doesn’t understand what you’re doing. So there is a conflict between doctors and the public,” said Van der Heide.

The End of Life Clinic, on the face of it just another house in the north of The Hague.


The End of Life Clinic, on the face of it just another house in the north of The Hague. Photograph: Judith Jockel for the Guardian

Yet some want to go even further. Pia Dijkstra, an MP and member of the centrist-liberal D66 party, has proposed a law allowing anyone over 75, without a diagnosis of physical or mental illness, to request euthanasia. “There is a growing number of older people who want to decide themselves how their life should end – how, when and where, and in a dignified way. They feel their life has been good but it’s now complete. They want control. The existing euthanasia law doesn’t meet their needs,” she said.

A study is to be carried out before a bill goes to parliament, but Dijkstra said the proposal had the support of 60-70% of the public, with some arguing for no age restriction. “I have had an enormous number of emails and letters from elderly people who want this possibility. But it’s important to have a good debate. And it’s so important to let older people know they are valued by society, and that this should be their choice.”


It is not good for society to have organised death facilitated by the state

Steven Pleiter, clinic director

Euthanasia advocates say people are helped to die regardless of the law. “About 80% of cases are reported to the review committees, which means 20% are not,” said Van der Heide. Some were in the area of so-called mercy killings, carried out by medical staff or family members; some involve palliative sedation, to relieve suffering but which ends in death. Penney Lewis, head of the Centre of Medical Law and Ethics at King’s College London, said: “Underground euthanasia happens in permissive and prohibitive jurisdictions. It happens everywhere.”

Despite the permissiveness of Dutch law, many applicants are refused, she said. “There is a lot of debate among Dutch doctors about what constitutes unbearable and hopeless suffering. But I think a model based on suffering is preferable to one based on a diagnosis.

“I’m not convinced by the ‘slippery slope’ argument. Of course, there’s evidence that the more people understand that this is an option, a greater proportion will avail themselves of it.”

The “normalisation” of euthanasia is of deep concern to Boer. “It is not good for society to have organised death facilitated by the state. A culture of euthanasia undermines our capacity to deal with suffering, and that is very bad for society.”


Not only was Aurelia Brouwers young, she did not have a terminal disease. She suffered from psychiatric illnesses

The Netherlands, Belgium and Luxembourg all have permissive laws on assisted dying and voluntary euthanasia, based on applicants’ suffering, and restricted to citizens of those countries. Switzerland allows assisted dying on compassionate grounds, and some clinics there, such as Dignitas, accept people who are not Swiss residents.

More restrictive laws exist elsewhere: assisted dying is legal in six US states (California, Colorado, Montana, Oregon, Vermont and Washington) plus Washington DC; in Canada; and in the Australian state of Victoria (after a campaign, pictured above). New Zealand is considering legislation. These are based on the “Oregon model”, which permits assisted dying for people with a terminal illness who are mentally competent and have a defined life expectancy.

In 2015, MPs in the UK voted against an assisted dying bill by 330 votes to 118. The campaign group Dignity in Dying advocates a law based on the Oregon model, covering people with less than six months to live. “Aurelia Brouwers made her choice in a very different legal context from the one we are campaigning for,” said Tom Davies of Dignity in Dying. The group is supporting Noel Conway, 68, who has motor neurone disease and has mounted a lawsuit to allow him a “peaceful and dignified death” by taking medication prescribed by a doctor. The court of appeal is expected to hear his case in May.

A woman’s final Facebook message before euthanasia: ‘I’m ready for my trip now…’

At 2pm on 26 January, Aurelia Brouwers lay down on her bed to die. Clutching a toy pink dinosaur and listening to her favourite music, the 29-year-old drank her prescribed medication as close friends gathered round. “She asked me to lie next to her. She had a smile on her face, and then she went softly into sleep,” Sjoukje Willering told the Observer. “It was very serene and calm. It was beautiful.”

Four hours earlier, Brouwers had posted her last message on Facebook. “I’m getting ready for my trip now. Thank you so much for everything. I’m no longer available from now on.” Brouwers died at home in the small Netherlands town of Deventer less than a month after being declared eligible for euthanasia under the country’s 2002 Termination of Life on Request and Assisted Suicide Act, which permits the ending of lives where there is “unbearable suffering” without hope of relief. Her death has triggered a fierce debate in a country that has one of the most permissive euthanasia laws in the world.

For not only was Brouwers young, she did not have a terminal disease such as cancer. She suffered from psychiatric illnesses, including severe anxiety, depression, eating disorders and psychosis. She self-harmed and had attempted suicide numerous times. She had spent nearly three years as an inpatient at a psychiatric hospital, and had served time in prison for arson.

Some say Brouwers’s death is a terrible illustration of the “slippery slope” inevitably associated with euthanasia legislation. Others who supported legalisation now also fear it has gone too far. Her supporters see her case as an important precedent, an escape to those in hopeless situations. “Every day was so hard. She was in a deep black hole,” said Willering. “She said it felt like a hundred knives being stabbed into her head. She never had a moment of doubt that she wanted it to end.” Her death was inevitable, one way or another, she added. “But she wanted the right to die with dignity, and she wanted other psychiatric patients to know that they also have a choice. This was her message to the world.”

This month, annual figures from the bodies that review euthanasia cases in the Netherlands showed an 8.1% increase in assisted deaths in 2017, taking the total to nearly 6,600 people. It came on top of a 10% annual increase the previous year. The vast majority had cancer, heart and arterial disease, or diseases of the nervous system, such as Parkinson’s and multiple sclerosis. But 169 had dementia, up from 141 the previous year. And 83 had severe psychiatric illnesses – up from 64 in 2016. “Supply has created demand,” said Professor Theo Boer, who supported the 2002 legislation but resigned from a regulatory body in 2014 amid concern about rising numbers. “We’re getting used to euthanasia, that is exactly what should not happen. We’re no longer speaking about the exceptional situations that the law was created for, but a gradual process towards organised death.”

The review bodies found that in 99.8% of cases, euthanasia was carried out in line with legal guidelines. However, Dutch prosecutors have recently opened criminal investigations into four cases, and last year an investigation began into a 74-year-old woman with dementia who had requested euthanasia before her illness became severe. Confused and agitated, she had to be restrained by family members to allow a lethal injection to be administered.

The focus of the current review of Brouwers’s death is a large redbrick house in The Hague, close to a clutch of museums in the north of the city. It houses the Levenseindekliniek – End of Life Clinic – a last resort for those who have been refused euthanasia elsewhere. Brouwers came here after failing to convince her own doctors and psychiatrists that she met the criteria for euthanasia. According to Steven Pleiter, the clinic’s avuncular director, a doctor and a nurse assessed Brouwers and built a relationship with her over a long period.

Her case was also reviewed by a multidisciplinary group at the clinic. “Aurelia was known to us for years. She was young but had already been suffering for a long time. Our processes are very careful,” Pleiter said.

The Levenseindekliniek has 62 doctor-nurse teams working part-time, but is on a significant recruitment drive to meet the spiralling demand for euthanasia. In 2012, the first year it was open, the clinic helped 32 people to die. Last year the figure was 750. But, Pleiter pointed out, that was only 30% of 2,500 applicants. One in every four does not meet the legal criteria, another 25% withdraw their request, and 20% die while their cases are being evaluated. Last year 9% of those undergoing euthanasia through the clinic had psychiatric illnesses and 10% had dementia. The costs are covered by the country’s health insurance system.

“Death by euthanasia is 4% of all deaths in the Netherlands. Is that a slippery slope? I don’t think so,” said Pleiter. Much of the demand was coming from the baby-boomer generation, he added. “They are thinking differently about the way life ends. God and religion are less dominant in their lives. They want more autonomy. But every case is unique.”

The decision Brouwers had waited so long for came on New Year’s Eve. It was “the best present I could have”, she wrote. “She was very happy, but she also had some hard moments, knowing she had to say goodbye to friends and family,” said Willering. “She was very open about it. You could ask her at any moment, ‘Aurelia, is this really what you want?’ and she would say, ‘Yes, I want to die.’ ” Another friend, Toon Krijthe, also at her bedside when she died, said: “I was glad for her, because I knew this was her only option – and I knew if it wasn’t a yes, she would find another way.”

Brouwers spent the days until 26 January saying goodbye to friends and working on a television documentary that was broadcast after her death. “She also visited the crematorium to plan and rehearse her funeral,” Krijthe said. “She believed in God, and she prayed, but she didn’t go to church.”

On the appointed day, two doctors from the Levenseindekliniek were present as Brouwers swallowed the liquid medication prescribed for her. “It took about 10 or 15 minutes for her to fall into sleep. She was very ready for it,” Willering said. She was cremated a week later. Within the Netherlands, it was a huge news story. As well as the television documentary, Brouwers’s death was a front-page story in the regional paper, with an additional six pages inside. “Personally I sympathise with her, and I’m happy she got a humane death,” said Boer, who teaches ethics at the Theological University of Kampen. “But culturally, I’m concerned that her death is being portrayed as a brave solution to severe suffering. She had huge support on social media.

“A border is being crossed between individual empathy and societal acceptance. If it becomes a societal norm that a person who has a psychiatric condition can opt to die, that is a problem.”

However, according to Professor Agnes van der Heide, an end-of-life expert at Erasmus University in Rotterdam, public opinion surveys show “a substantial proportion of our population think the law should be even more liberal – especially with regard to dementia”. Many who see their parents or grandparents in the grip of advanced dementia wish to opt out of such a bleak end-of-life scenario for themselves.

Not all doctors agree. Last year a group of 220 took out a newspaper advertisement saying they would refuse to euthanise patients with dementia who were unable to give verbal consent, even if the individual had signed a declaration of wishes in advance. “Our moral abhorrence at ending the life of a defenceless person is too great,” they wrote.

“It’s difficult to see how you can administer a lethal injection to a patient who doesn’t understand what you’re doing. So there is a conflict between doctors and the public,” said Van der Heide.

The End of Life Clinic, on the face of it just another house in the north of The Hague.


The End of Life Clinic, on the face of it just another house in the north of The Hague. Photograph: Judith Jockel for the Guardian

Yet some want to go even further. Pia Dijkstra, an MP and member of the centrist-liberal D66 party, has proposed a law allowing anyone over 75, without a diagnosis of physical or mental illness, to request euthanasia. “There is a growing number of older people who want to decide themselves how their life should end – how, when and where, and in a dignified way. They feel their life has been good but it’s now complete. They want control. The existing euthanasia law doesn’t meet their needs,” she said.

A study is to be carried out before a bill goes to parliament, but Dijkstra said the proposal had the support of 60-70% of the public, with some arguing for no age restriction. “I have had an enormous number of emails and letters from elderly people who want this possibility. But it’s important to have a good debate. And it’s so important to let older people know they are valued by society, and that this should be their choice.”


It is not good for society to have organised death facilitated by the state

Steven Pleiter, clinic director

Euthanasia advocates say people are helped to die regardless of the law. “About 80% of cases are reported to the review committees, which means 20% are not,” said Van der Heide. Some were in the area of so-called mercy killings, carried out by medical staff or family members; some involve palliative sedation, to relieve suffering but which ends in death. Penney Lewis, head of the Centre of Medical Law and Ethics at King’s College London, said: “Underground euthanasia happens in permissive and prohibitive jurisdictions. It happens everywhere.”

Despite the permissiveness of Dutch law, many applicants are refused, she said. “There is a lot of debate among Dutch doctors about what constitutes unbearable and hopeless suffering. But I think a model based on suffering is preferable to one based on a diagnosis.

“I’m not convinced by the ‘slippery slope’ argument. Of course, there’s evidence that the more people understand that this is an option, a greater proportion will avail themselves of it.”

The “normalisation” of euthanasia is of deep concern to Boer. “It is not good for society to have organised death facilitated by the state. A culture of euthanasia undermines our capacity to deal with suffering, and that is very bad for society.”


Not only was Aurelia Brouwers young, she did not have a terminal disease. She suffered from psychiatric illnesses

The Netherlands, Belgium and Luxembourg all have permissive laws on assisted dying and voluntary euthanasia, based on applicants’ suffering, and restricted to citizens of those countries. Switzerland allows assisted dying on compassionate grounds, and some clinics there, such as Dignitas, accept people who are not Swiss residents.

More restrictive laws exist elsewhere: assisted dying is legal in six US states (California, Colorado, Montana, Oregon, Vermont and Washington) plus Washington DC; in Canada; and in the Australian state of Victoria (after a campaign, pictured above). New Zealand is considering legislation. These are based on the “Oregon model”, which permits assisted dying for people with a terminal illness who are mentally competent and have a defined life expectancy.

In 2015, MPs in the UK voted against an assisted dying bill by 330 votes to 118. The campaign group Dignity in Dying advocates a law based on the Oregon model, covering people with less than six months to live. “Aurelia Brouwers made her choice in a very different legal context from the one we are campaigning for,” said Tom Davies of Dignity in Dying. The group is supporting Noel Conway, 68, who has motor neurone disease and has mounted a lawsuit to allow him a “peaceful and dignified death” by taking medication prescribed by a doctor. The court of appeal is expected to hear his case in May.

A woman’s final Facebook message before euthanasia: ‘I’m ready for my trip now…’

At 2pm on 26 January, Aurelia Brouwers lay down on her bed to die. Clutching a toy pink dinosaur and listening to her favourite music, the 29-year-old drank her prescribed medication as close friends gathered round. “She asked me to lie next to her. She had a smile on her face, and then she went softly into sleep,” Sjoukje Willering told the Observer. “It was very serene and calm. It was beautiful.”

Four hours earlier, Brouwers had posted her last message on Facebook. “I’m getting ready for my trip now. Thank you so much for everything. I’m no longer available from now on.” Brouwers died at home in the small Netherlands town of Deventer less than a month after being declared eligible for euthanasia under the country’s 2002 Termination of Life on Request and Assisted Suicide Act, which permits the ending of lives where there is “unbearable suffering” without hope of relief. Her death has triggered a fierce debate in a country that has one of the most permissive euthanasia laws in the world.

For not only was Brouwers young, she did not have a terminal disease such as cancer. She suffered from psychiatric illnesses, including severe anxiety, depression, eating disorders and psychosis. She self-harmed and had attempted suicide numerous times. She had spent nearly three years as an inpatient at a psychiatric hospital, and had served time in prison for arson.

Some say Brouwers’s death is a terrible illustration of the “slippery slope” inevitably associated with euthanasia legislation. Others who supported legalisation now also fear it has gone too far. Her supporters see her case as an important precedent, an escape to those in hopeless situations. “Every day was so hard. She was in a deep black hole,” said Willering. “She said it felt like a hundred knives being stabbed into her head. She never had a moment of doubt that she wanted it to end.” Her death was inevitable, one way or another, she added. “But she wanted the right to die with dignity, and she wanted other psychiatric patients to know that they also have a choice. This was her message to the world.”

This month, annual figures from the bodies that review euthanasia cases in the Netherlands showed an 8.1% increase in assisted deaths in 2017, taking the total to nearly 6,600 people. It came on top of a 10% annual increase the previous year. The vast majority had cancer, heart and arterial disease, or diseases of the nervous system, such as Parkinson’s and multiple sclerosis. But 169 had dementia, up from 141 the previous year. And 83 had severe psychiatric illnesses – up from 64 in 2016. “Supply has created demand,” said Professor Theo Boer, who supported the 2002 legislation but resigned from a regulatory body in 2014 amid concern about rising numbers. “We’re getting used to euthanasia, that is exactly what should not happen. We’re no longer speaking about the exceptional situations that the law was created for, but a gradual process towards organised death.”

The review bodies found that in 99.8% of cases, euthanasia was carried out in line with legal guidelines. However, Dutch prosecutors have recently opened criminal investigations into four cases, and last year an investigation began into a 74-year-old woman with dementia who had requested euthanasia before her illness became severe. Confused and agitated, she had to be restrained by family members to allow a lethal injection to be administered.

The focus of the current review of Brouwers’s death is a large redbrick house in The Hague, close to a clutch of museums in the north of the city. It houses the Levenseindekliniek – End of Life Clinic – a last resort for those who have been refused euthanasia elsewhere. Brouwers came here after failing to convince her own doctors and psychiatrists that she met the criteria for euthanasia. According to Steven Pleiter, the clinic’s avuncular director, a doctor and a nurse assessed Brouwers and built a relationship with her over a long period.

Her case was also reviewed by a multidisciplinary group at the clinic. “Aurelia was known to us for years. She was young but had already been suffering for a long time. Our processes are very careful,” Pleiter said.

The Levenseindekliniek has 62 doctor-nurse teams working part-time, but is on a significant recruitment drive to meet the spiralling demand for euthanasia. In 2012, the first year it was open, the clinic helped 32 people to die. Last year the figure was 750. But, Pleiter pointed out, that was only 30% of 2,500 applicants. One in every four does not meet the legal criteria, another 25% withdraw their request, and 20% die while their cases are being evaluated. Last year 9% of those undergoing euthanasia through the clinic had psychiatric illnesses and 10% had dementia. The costs are covered by the country’s health insurance system.

“Death by euthanasia is 4% of all deaths in the Netherlands. Is that a slippery slope? I don’t think so,” said Pleiter. Much of the demand was coming from the baby-boomer generation, he added. “They are thinking differently about the way life ends. God and religion are less dominant in their lives. They want more autonomy. But every case is unique.”

The decision Brouwers had waited so long for came on New Year’s Eve. It was “the best present I could have”, she wrote. “She was very happy, but she also had some hard moments, knowing she had to say goodbye to friends and family,” said Willering. “She was very open about it. You could ask her at any moment, ‘Aurelia, is this really what you want?’ and she would say, ‘Yes, I want to die.’ ” Another friend, Toon Krijthe, also at her bedside when she died, said: “I was glad for her, because I knew this was her only option – and I knew if it wasn’t a yes, she would find another way.”

Brouwers spent the days until 26 January saying goodbye to friends and working on a television documentary that was broadcast after her death. “She also visited the crematorium to plan and rehearse her funeral,” Krijthe said. “She believed in God, and she prayed, but she didn’t go to church.”

On the appointed day, two doctors from the Levenseindekliniek were present as Brouwers swallowed the liquid medication prescribed for her. “It took about 10 or 15 minutes for her to fall into sleep. She was very ready for it,” Willering said. She was cremated a week later. Within the Netherlands, it was a huge news story. As well as the television documentary, Brouwers’s death was a front-page story in the regional paper, with an additional six pages inside. “Personally I sympathise with her, and I’m happy she got a humane death,” said Boer, who teaches ethics at the Theological University of Kampen. “But culturally, I’m concerned that her death is being portrayed as a brave solution to severe suffering. She had huge support on social media.

“A border is being crossed between individual empathy and societal acceptance. If it becomes a societal norm that a person who has a psychiatric condition can opt to die, that is a problem.”

However, according to Professor Agnes van der Heide, an end-of-life expert at Erasmus University in Rotterdam, public opinion surveys show “a substantial proportion of our population think the law should be even more liberal – especially with regard to dementia”. Many who see their parents or grandparents in the grip of advanced dementia wish to opt out of such a bleak end-of-life scenario for themselves.

Not all doctors agree. Last year a group of 220 took out a newspaper advertisement saying they would refuse to euthanise patients with dementia who were unable to give verbal consent, even if the individual had signed a declaration of wishes in advance. “Our moral abhorrence at ending the life of a defenceless person is too great,” they wrote.

“It’s difficult to see how you can administer a lethal injection to a patient who doesn’t understand what you’re doing. So there is a conflict between doctors and the public,” said Van der Heide.

The End of Life Clinic, on the face of it just another house in the north of The Hague.


The End of Life Clinic, on the face of it just another house in the north of The Hague. Photograph: Judith Jockel for the Guardian

Yet some want to go even further. Pia Dijkstra, an MP and member of the centrist-liberal D66 party, has proposed a law allowing anyone over 75, without a diagnosis of physical or mental illness, to request euthanasia. “There is a growing number of older people who want to decide themselves how their life should end – how, when and where, and in a dignified way. They feel their life has been good but it’s now complete. They want control. The existing euthanasia law doesn’t meet their needs,” she said.

A study is to be carried out before a bill goes to parliament, but Dijkstra said the proposal had the support of 60-70% of the public, with some arguing for no age restriction. “I have had an enormous number of emails and letters from elderly people who want this possibility. But it’s important to have a good debate. And it’s so important to let older people know they are valued by society, and that this should be their choice.”


It is not good for society to have organised death facilitated by the state

Steven Pleiter, clinic director

Euthanasia advocates say people are helped to die regardless of the law. “About 80% of cases are reported to the review committees, which means 20% are not,” said Van der Heide. Some were in the area of so-called mercy killings, carried out by medical staff or family members; some involve palliative sedation, to relieve suffering but which ends in death. Penney Lewis, head of the Centre of Medical Law and Ethics at King’s College London, said: “Underground euthanasia happens in permissive and prohibitive jurisdictions. It happens everywhere.”

Despite the permissiveness of Dutch law, many applicants are refused, she said. “There is a lot of debate among Dutch doctors about what constitutes unbearable and hopeless suffering. But I think a model based on suffering is preferable to one based on a diagnosis.

“I’m not convinced by the ‘slippery slope’ argument. Of course, there’s evidence that the more people understand that this is an option, a greater proportion will avail themselves of it.”

The “normalisation” of euthanasia is of deep concern to Boer. “It is not good for society to have organised death facilitated by the state. A culture of euthanasia undermines our capacity to deal with suffering, and that is very bad for society.”


Not only was Aurelia Brouwers young, she did not have a terminal disease. She suffered from psychiatric illnesses

The Netherlands, Belgium and Luxembourg all have permissive laws on assisted dying and voluntary euthanasia, based on applicants’ suffering, and restricted to citizens of those countries. Switzerland allows assisted dying on compassionate grounds, and some clinics there, such as Dignitas, accept people who are not Swiss residents.

More restrictive laws exist elsewhere: assisted dying is legal in six US states (California, Colorado, Montana, Oregon, Vermont and Washington) plus Washington DC; in Canada; and in the Australian state of Victoria (after a campaign, pictured above). New Zealand is considering legislation. These are based on the “Oregon model”, which permits assisted dying for people with a terminal illness who are mentally competent and have a defined life expectancy.

In 2015, MPs in the UK voted against an assisted dying bill by 330 votes to 118. The campaign group Dignity in Dying advocates a law based on the Oregon model, covering people with less than six months to live. “Aurelia Brouwers made her choice in a very different legal context from the one we are campaigning for,” said Tom Davies of Dignity in Dying. The group is supporting Noel Conway, 68, who has motor neurone disease and has mounted a lawsuit to allow him a “peaceful and dignified death” by taking medication prescribed by a doctor. The court of appeal is expected to hear his case in May.