• Marianne C Snijdewind, Donald G van Tol, Bregje D Onwuteaka-Philipsen, and Dick L Willems.
• Section of Medical Ethics, Department of General Practice, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands. Electronic address: m.c.snijdewind@amc.uva.nl.
• J Pain Symptom Manage. 2014 Dec 1;48(6):1125-34.

ContextThe practice of euthanasia and physician-assisted suicide (EAS) is always complex, but some cases are more complex than others. The nature of these unusually complex cases is not known.ObjectivesTo identify and categorize the characteristics of EAS requests that are more complex than others.MethodsWe held in-depth interviews with 28 Dutch physicians about their perception of complex cases of EAS requests. We also interviewed 26 relatives of patients who had died by EAS. We used open coding and inductive analysis to identify various different aspects of the complexities described by the participants.ResultsComplexities can be categorized into relational difficulties-such as miscommunication, invisible suffering, and the absence of a process of growth toward EAS-and complexities that arise from unexpected situations, such as the capricious progress of a disease or the obligation to move the patient. The interviews showed that relatives of the patient influence the process toward EAS.ConclusionFirst, the process toward EAS may be disrupted, causing a complex situation. Second, the course of the process toward EAS is influenced not only by the patient and his/her attending physician but also by the relatives who are involved. Communicating and clarifying expectations throughout the process may help to prevent the occurrence of unusually complex situations.Copyright © 2014 American Academy of Hospice and Palliative Medicine. Published by Elsevier Inc. All rights reserved.

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