Willingness of Dutch general practitioners to grant and perform Euthanasia and Assisted Suicide: A mixed methods study comparing psychiatric and somatic cases and the factors guiding their decisions

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Jenniskens, Nils Mevenkamp This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7165404/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 25 Nov, 2025 Read the published version in BMC Medical Ethics → Version 1 posted 10 You are reading this latest preprint version Abstract Background The Netherlands legalized euthanasia and assisted suicide (EAS) in 2002, permitting requests from both somatic and psychiatric patients under strict conditions. However, physicians are not obligated to comply. General practitioners (GPs), who receive most EAS requests, play a central role in this process. Although EAS for somatic conditions is common in the Netherlands, psychiatric EAS remains relatively rare and controversial, despite a growing number of requests. This study explores how Dutch eneral practitioners willingness to grant and perform EAS requests differs between psychiatric and somatic patients and compares the underlying decision-making processes. Methods A concurrent mixed-methods design was employed, combining a quantitative survey and qualitative interviews. The survey included sociodemographic and attitudinal questions, experience with EAS, and six randomized vignettes varying by somatic and psychiatric diagnosis (cancer, depression) and method (euthanasia or assisted suicide) to examine willingness to perform EAS. Semi-structured interviews explored GPs reasoning and experiences in more depth. Results GPs were significantly less likely to grant psychiatric than somatic EAS requests (OR = 0.02, 95% CI [0.009–0.04]). Religious GPs were less likely to approve EAS (OR = 0.31, 95% CI [0.11–0.85]), and euthanasia was favored over assisted suicide (OR = 2.3, 95% CI [1.31–4.03]). Psychiatric diagnosis type and prior experience receiving psychiatric requests showed no significant effect. Willingness to perform EAS was higher for somatic (95.1%) than psychiatric cases (45.6%). Prior experience performing psychiatric EAS was associated with a lower likelihood of restricting their willingness to somatic cases alone (OR = 0.15, 95% CI [0.02–0.73]). Interviews underscored the greater complexity of psychiatric EAS, citing challenges in assessing due care criteria, empathizing with requests, ethical dilemmas, extended processes, and lack of confidence. Psychiatric cases were more often referred to specialists. Conclusions Dutch GPs are less willing to grant and perform EAS for psychiatric patients compared to somatic ones. This may reflect difficulties assessing due care criteria, clinical uncertainty, difficulties empathizing, prolonged processes and ethical complexity, highlighting the need for clearer guidelines, targeted training, and stronger support for GPs involved in psychiatric EAS. Euthanasia Assisted Suicide General Practitioners Psychiatric Patients Somatic Patients Decision-Making Mixed-Methods Study Netherlands Figures Figure 1 Background The Netherlands was the first country to legalize euthanasia and physician-assisted suicide (EAS) under the 2002 Termination of Life on Request and Assisted Suicide Act [ 1 ]. Euthanasia refers to a physician administering a lethal drug, while assisted suicide involves the physician providing but not administering the drug [ 2 ]. Although EAS remains a criminal offense under Dutch law, it is permitted if six due care criteria are met: (1) the request must be voluntary and well-considered, (2) the patient must be experiencing unbearable suffering with no prospect of improvement, (3) the patient must be fully informed about their situation and prognosis, (4) no reasonable alternative may exist to relieve the suffering, (5) an independent physician must be consulted, and (6) the procedure must be carried out with due medical care and attention [ 3 ]. Both somatic and psychiatric patients are legally eligible to request EAS. However, psychiatric EAS remains rare and controversial, with only a few countries besides the Netherlands, such as Belgium, Luxembourg, Switzerland (for assisted suicide only), and recently Spain allowing it [ 4 – 5 ]. In the Netherlands, psychiatric EAS cases rose from 2 in 2008 to 219 in 2024, yet they accounted for only 2.2% of all reported EAS cases [ 6 – 7 ]. Data from the Dutch Euthanasia Expertise Center show that only 10% of psychiatric requests are granted, with most being declined due to failure to meet the due care criteria particularly regarding treatment exhaustion and unbearable suffering [ 8 ]. Dutch physicians have long reported that psychiatric EAS cases are especially complex and difficult to assess. This is partly due to the greater challenge of applying the due care criteria in psychiatric contexts, and partly because of limited clinical experience with such requests [ 9 – 10 ]. Importantly, Dutch physicians are never obligated to grant or perform EAS and may decline for personal or professional reasons [ 2 ]. These beliefs and limitations may influence how somatic versus psychiatric requests are handled. Physicians generally find it easier to assess unbearable suffering, prognosis, and decision-making capacity in somatic cases due to visible physical symptoms and more predictable disease courses. In contrast, psychiatric suffering is often existential, may fluctuate over time, and is frequently accompanied by suicidal ideation or cognitive distortions. These features complicate the evaluation of whether suffering is truly unbearable and without hope of improvement. The ongoing availability of psychiatric treatments further raises doubts about whether the suffering is truly irremediable [ 11 – 14 ]. Beyond clinical challenges, ethical concerns, family involvement, patient attitude, legal criteria, the physician–patient relationship, and external pressures have all been found to influence EAS decision-making. However, little is known about how these factors differ between psychiatric and somatic EAS cases [ 13 , 15 – 18 ]. Previous research has shown that physicians are generally more accepting of somatic EAS than psychiatric EAS. Physician characteristics such as religious beliefs, gender, and medical specialization are associated with lower acceptance of psychiatric EAS [ 10 , 12 , 14 ]. Among all medical specialties, general practitioners (GPs) are the most open to psychiatric EAS, with 47% indicating a willingness to perform it [ 14 ]. GPs receive the majority of EAS requests in the Netherlands and, unlike most specialists, often handle both somatic and psychiatric cases [ 6 , 13 ]. Their central role makes it especially relevant to examine how they approach different types of EAS requests. For example, Pronk et al. found that 86 out of 101 GPs found EAS conceivable for somatic patients, compared to 51 out of 104 for psychiatric patients. GPs cited values such as compassion, fairness, and respect for autonomy in support of psychiatric EAS but also expressed hesitation due to perceived medical boundaries, lack of experience, and difficulty applying the due care criteria [ 10 ]. However, this data was collected in 2018–2019 and may no longer reflect current views, particularly given that the number of psychiatric EAS cases has doubled in recent years [ 6 ]. The incidence of psychiatric EAS continues to grow in the Netherlands, leading to public debate and policy discussions [ 6 ]. As global interest in EAS rises, Dutch insights are increasingly relevant [ 19 ]. While previous studies have explored physician attitudes and the factors influencing EAS decision-making, most have focused on general conceivability rather than actual willingness to grant or perform requests. Moreover, although previous studies based on interviews with Dutch physicians particularly psychiatrists have shown that psychiatric EAS is generally perceived as more difficult to evaluate, little is known about how GP navigate between evaluating psychiatric and somatic requests and how their decision-making process differs between the two. This study addresses that gap by examining current attitudes among Dutch GPs, comparing their willingness to grant and perform EAS across psychiatric and somatic cases. It also investigates how factors such as the type of psychiatric condition, form of EAS, physician experience, and sociodemographic characteristics shape their decisions, and explores differences in the underlying decision-making processes through qualitative analysis. Method Study design A concurrent mixed methods design was used to combine the strengths of quantitative and qualitative approaches [ 20 ]. A survey was sent to gather numerical data and identify broad patterns, while semi-structured interviews were conducted around the same period to gain deeper insights into the decision-making process. The survey collected data on sociodemographic, attitudes, EAS-related experience, and included case examples to examine how specific factors (e.g., condition type, EAS method) influenced GPs’ decisions to grant or deny requests. Survey data collection took place in February and March 2025. For the qualitative component, 13 online interviews were conducted with Dutch GPs between March and April 2025. These interviews explored GPs reasoning in both psychiatric and somatic EAS cases. Study population and sampling The study population consisted of 103 general practitioners (GPs) who fully completed the questionnaire. These respondents were selected from a larger pool of 609 GP practices that were initially invited to participate in the study. In total, 111 GPs responded. Since GP practices rather than individual GPs were contacted directly, an exact response rate cannot be calculated. However, the sample represents approximately 17% of the approached practices. Interview participants were purposely recruited through survey responses, personal and professional contacts, and snowball sampling, with the goal of capturing variation in gender, region, and experience. Recruitment continued until thematic saturation was achieved, no new themes emerged in the final interviews. The final qualitative sample comprised 13 GPs (11 female, 2 male), including two SCEN physicians, all actively practicing in various regions of the Netherlands. Data collection For the quantitative component the online survey provided in additional file 1 was designed using LimeSurvey and distributed via email to Dutch GP offices in February and March 2025. It included closed questions assessing experience, attitudes toward euthanasia and assisted suicide (EAS) for both somatic and psychiatric patients, willingness to perform EAS, and sociodemographic characteristics. Survey questions were either directly taken from the fourth evaluation of the Dutch Euthanasia Act or were partly self-developed, based on questions from the evaluation but adapted to fit the specific aims of this study [ 13 ]. An overview of the variables targeted by the survey questions is presented in Table 1 , and a summary of the attitude-related items is provided in Table 5 . Table 1 Overview of the variables included in the regression analyses, along with their coding schemes Variable Description Variable coding Regression models used Dependent Combined willingness Willingness of GPs to perform EAS themselves. 0 = Willing for both somatic and psychiatric request 1 = Only willing for somatic requests Binary logistic (Willingness to perform) Grant requests Whether the GP would grant the requests for the case studies. 1 = yes 0 = No Multilevel (Case studies) Independent Age Age group of the respondents. Categorical: 50 Binary logistic & Multilevel Religion Religious affiliation. 1 = Religious 0 = Non-religious Binary logistic & Multilevel Years of practice Years of practice as a GP. 1 = > 10 0 = 2–10 Binary logistic & Multilevel Practice area Area of practice of GP. 1 = Rural 0 = Urban Binary logistic & Multilevel Received Psychiatric-only EAS request Experience receiving psychiatric EAS requests. 1 = Yes 0 = No Binary logistic Performed EAS – Psychiatric basis only Experience performing psychiatric euthanasia. 1 = Yes 0 = No Binary logistic (Only willingness to perform model) Request type Indicates whether the condition is psychiatric or somatic. 1 = Psychiatric, 0 = Somatic Multilevel EAS type Type of EAS request. 1 = Euthanasia, 0 = Assisted suicide. Multilevel Condition type Type of psychiatric condition. Categorical: Autism (reference) depression, schizophrenia and PTSS Binary logistic ( Model 4 & 5 Case studies) Note: Gender was excluded from analysis due to a high rate of missing responses. Ethnicity, experience with somatic EAS requests, and performing somatic EAS were excluded from analysis due to insufficient variability in the data. The variable for performing psychiatric EAS was excluded from the case example analysis due to instability in estimates. The survey also employed a case example approach to explore GPs willingness to grant requests. Twelve case examples were developed, with each GP completing six randomly selected cases (Table 2 ) that varied by request type (psychiatric or somatic), EAS method (euthanasia or assisted suicide), and psychiatric condition (autism, depression, schizophrenia, PTSD). The cases were developed based on examples from the fourth evaluations of the Dutch Euthanasia Act and were further inspired by the work of Kouwenhoven et al. [ 21 ]. Table 2 Illustrative set of randomly assigned case examples completed by GPs Case examples 1. Mr. Van de Berg suffers from ALS. He has lost nearly all motor functions, including the ability to walk, speak, and swallow independently. Despite receiving supportive care, he is completely dependent on others for all daily activities. His condition will inevitably lead to respiratory failure. He finds his current and future situation unbearable and submits a request for euthanasia. 2. Ms. De Jong has metastatic breast cancer. She has undergone several treatments, but her disease is no longer curable. She experiences severe, hard-to-manage pain and feels she is losing control over her life, a sense of control she valued deeply during her working life. She states she cannot go on like this and requests euthanasia. 3. Ms. De Jong has metastatic breast cancer. After various treatments, her illness has become incurable. She suffers from intense pain and feels a loss of control over her life, which is deeply distressing for her. She says she can no longer cope and asks her GP for a life-ending drug that she can take herself. 4. Mr. Jansen has lived with schizophrenia for many years. Despite consistent treatment with medication and therapy, he continues to experience severe hallucinations and delusions that significantly impair his quality of life. These symptoms cause him immense suffering, and he sees no hope for improvement. After careful consideration, he requests euthanasia from his GP. 5. Ms. Langezaal is physically healthy but suffers from severe, long-term depression. Psychiatric treatments have failed to relieve her symptoms. She frequently tells her doctors she wants to die and has previously attempted suicide, unsuccessfully. She asks her GP for euthanasia to end her suffering. 6. Ms. Smit suffers from severe ASD, which has led to lifelong unbearable suffering. She endures continuous sensory overload, isolation, and unrelieved emotional distress. Years of treatment have failed to help her. She is unable to engage in everyday life or social contact and finds the overstimulation unbearable. She asks for a life-ending drug she can take herself to end her suffering. To further explore decision-making processes, 13 semi-structured interviews were conducted using an interview guide. The interview guide (additional file 2) was developed based on a literature search using Google Scholar and PubMed, including previous studies on EAS and the decision-making processes of Dutch physicians. Interviews were held online via Zoom, except for two conducted by phone due to scheduling constraints. The interviews explored GPs’ experiences, external influences, and perceived barriers in evaluating both somatic and psychiatric EAS requests. Each session lasted approximately 30 minutes and provided qualitative insights into the factors shaping GPs’ decisions across request types. Data analysis Survey data were analysed using IBM SPSS Statistics 28 and R version 4.4.1. Descriptive statistics (frequencies and percentages) were used to assess GPs demographics, attitudes, and experiences. Case example responses were analysed using multilevel and binary logistic regression in R, with the dependent variable being whether the request was granted (yes/no). Five models were constructed. Since each GP assessed six randomly selected case examples, multiple responses were nested within individual participants, introducing potential clustering. Responses from the same GP may be more similar than those from other GPs. The intraclass correlation coefficient (ICC = 0.162) confirmed that 16.2% of the variance in willingness was attributable to between-GP differences, exceeding the commonly used 10% threshold [ 22 ]. Therefore, multilevel modelling was applied in Models 1–3. Model 1 included demographic variables; Model 2 added request type (psychiatric or somatic); Model 3 added EAS method (euthanasia or assisted suicide) and used the bobyqa optimizer (15,000 iterations) to address convergence issues. Due to convergence issues problems and unstable estimates for condition type and psychiatric experience in Models 4 and 5, binary logistic regression was used instead. Odds ratios (ORs) and confidence intervals (CIs) for other predictors remained stable across models, so this shift did not affect interpretation. Some variables were excluded due to missing data (gender), low variability (ethnicity, somatic EAS experience), or estimation instability (performing psychiatric requests). Religion and years of practice were recoded into binary variables due to low category frequencies. Analyses were conducted using the following R libraries: readr, tidyverse, broom, lme4, and performance. A significance level of 0.05 was used to report the results. Additionally, a separate binary logistic regression analyzed GPs’ willingness to perform EAS. The original three-category outcome (willing to perform both somatic and psychiatric EAS / willing to perform somatic only / unwilling for both) was reduced to a binary variable by excluding the small 'unwilling' group. This resulted in a comparison between GPs willing to perform somatic EAS only and those willing to perform both somatic and psychiatric EAS. The same variable exclusions applied as in previous models, except that experience performing psychiatric EAS was included in this analysis, as convergence issues did not arise for this variable. For the qualitative part, interviews were transcribed using the qualitative data analysis software MAXQDA 24. Transcripts were then analyzed in MAXQDA using content analysis, focusing on organizing the text into meaningful codes and identifying recurring themes. Coding was conducted by the researcher. Initial codes were based on topics from the interview guideline, see additional file 3 for the coding scheme. As analysis progressed, new codes were added to capture unexpected themes emerging from the interviews. This approach combined predefined and emergent codes, enabling a detailed exploration of factors affecting Dutch GPs’ decision-making on EAS requests [ 23 ]. To improve precision, subcodes distinguished somatic from psychiatric requests, enabling comparison of GPs’ decision-making. Results Survey respondents characteristics Table 3 represents the demographic characteristics of the GPs who filled in the survey. Important to note is that not all participants provided complete demographic data, resulting in missing values in the table for some variables. Of the respondents who filled in the questions 38.8% were female, and 24.3% were male. The majority (56.3%) were aged between 40 and 54, with 28.2% over 55, and 15.5% under 40. Most of the participants identified as non-religious (69.9%) and had more than 10 years working experience (84.5%) as a GP. The vast majority of the GPs are of Dutch ethnicity (98.1%). Table 3: Demographic and background characteristics of survey respondents Background characteristics (n=103) N % Gender Female Male 40 25 38.8 24.3 Age 55 16 58 29 15.5 56.3 28.2 Religion Religious Non-religious 30 72 29.1 69.9 Years of practice 2-10 >10 14 87 13.6 84.5 Practice area Urban Rural 34 67 33 65 Ethnicity Dutch Non Dutch 101 2 98.1 1.9 Note: Some participants did not provide complete demographic data, leading to different totals in the table. GPs experience and attitudes regarding EAS Most GPs who participated in the survey had experience in receiving an EAS requests based on a somatic condition only (98.1%) . When asked about performing EAS for somatic patients, 94.2% of the GPs filled in they have performed it before, while 5% had not. For psychiatric requests 69.6% of the GPs had received a request on psychiatric basis only before, with 10.7% of the questioned GPs having experience on performing EAS for patients with a psychiatric condition only. (Table 4). Table 4: Respondents experience with receiving and performing EAS requests Experience N % Received somatic-only EAS request Yes No 101 - 98.1 Performed EAS – somatic basis only Yes No 97 5 4.9 94.2 Received Psychiatric-only EAS request Yes No 72 31 69.6 30.1 Performed EAS – Psychiatric basis only Yes No 11 92 10.7 89.3 Note: Only" refers to the fact that the EAS request or performance stemmed solely from either a somatic or psychiatric condition, without influence from a combination of conditions or other contributing factors. GPs attitudes toward EAS were measured (Table 5) for both general and specific patient types (somatic and psychiatric). Most GPs expressed the highest agreement with feeling less confident when assessing EAS requests from psychiatric patients, with 70 strongly agreeing. Support for EAS eligibility was strongest for somatic conditions (39 strongly agree, 50 agree), while responses for psychiatric cases had a higher variation (17 strongly agree, 52 agree). Still, most GPs agreed that psychiatric patients should have the same opportunity to request EAS as those with somatic conditions. Statements suggesting it is impossible to assess unbearable suffering or the decision-making capacity of psychiatric patients were largely disagreed with. Confidence in current guidelines was low, with 35 GPs disagreeing that they provide sufficient clarity for psychiatric EAS cases. Most GPs also did not favour assisted suicide over euthanasia for either patient group. Table 5: GPs attitudes toward psychiatric and somatic EAS requests Attitudes Dutch GPs towards EAS Strongly disagree (1) Disagree (2) Neutral (3) Agree (4) Strongly agree (5) Mean score I feel less confident when assessing EAS requests from psychiatric patients compared to patients with somatic conditions. 3 2 5 21 70 4.51 I believe that patients with somatic conditions should be eligible for EAS if they request it. 3 2 8 50 39 4.18 I believe that patients with psychiatric conditions should be eligible for EAS if they request it. 3 7 22 52 17 3.72 Everyone has the right to decide about their own life and death. 4 17 21 39 20 3.53 Psychiatric patients should have the same opportunity to request EAS as patients with somatic conditions. 5 14 28 37 16 3.45 It is impossible to determine whether a psychiatric patient’s wish to die stems from psychopathology. 1 40 39 17 4 2.83 The current guidelines provide sufficient clarity to help me assess EAS requests from psychiatric patients. 6 35 29 24 1 2.78 It is impossible to assess whether a psychiatric patient is suffering unbearably and without prospect. 6 43 35 10 5 2.65 It is impossible to determine whether a psychiatric patient’s wish to die is well-considered. 8 47 32 11 3 2.54 I would be more willing to provide assisted suicide than euthanasia to psychiatric patients. 26 33 11 30 2 2.50 I would be more willing to provide assisted suicide than euthanasia to somatic patients. 31 33 17 17 4 2.31 Note: The mean scores reflect the average level of agreement with each statement on a 5-point Likert scale. Higher scores indicate stronger agreement. GPs willingness to grant EAS requests and influencing factors Table 6 shows the results from the multilevel regression models (Models 1–3) and binary logistic regression models (Models 4–5) examining factors related to GPs willingness to grant EAS requests. Model 1 only included sociodemographic variables. Religion was the only significant factor, with religious GPs being less likely to grant EAS requests than non-religious GPs. Age, years of practice, and practice area showed no significant effects. Model 2 added request type and showed that psychiatric requests were significantly less likely to be granted than somatic ones, while religion remained significant. Model 3, the most comprehensive model, included all prior variables and added EAS method. In Model 3, three variables were significantly associated with the likelihood of granting EAS requests. The odds ratio of granting a psychiatric EAS request versus a somatic request was 0.02 (OR = 0.02, 95% CI [0.009–0.04]), indicating that psychiatric requests were substantially less likely to be approved. The odds ratio of granting a euthanasia request vs. an assisted suicide request was 2.3 (OR = 2.3, 95% CI [1.31–4.03]), showing a preference for euthanasia. The odds ratio of religious vs. non-religious GPs granting an EAS request was 0.31 (OR = 0.31, 95% CI [0.11–0.85), reflecting lower approval rates among religious physicians. Models 4 and 5 focused specifically on psychiatric EAS requests, examining whether the psychiatric condition (model 4) or prior experience with receiving such requests (model 5) influenced willingness to grant. Neither model showed statistically significant effects. Table 6: Overview of the results from the case examples analyses using multilevel and binary logistic regression Model 1 Demographics (Multilevel) Model 2 Somatic vs psychiatric (Multilevel) Model 3 Euthanasia vs assisted suicide (Multilevel) Model 4 Condition type (Binary) Model 5: Psychiatric experience (Binary) OR CI (95%) OR CI (95%) OR CI (95%) OR CI OR CI (95%) Intercept 2.7 [1.27-5.83] 32.1 [7.75-132.8] 23 [5.23-101.3] 0.88 [0.32 - 2.30] 1.08 [0.38-3.06] Age 55 1 0.95 1.1 1 [0.35-2.57] [0.41-3.10] 1 0.74 1.1 1 [0.13-4.10] [0.20-6.47] 1 0.84 1.28 1 [0.14-5.03] [0.21-7.90] 1 0.40 0.84 1 [0.14-1.15] [0.30-2.35] 1 0.40 0.87 1 [0.14-1.14] [0.31-2.44] Religion Non-Religious Religious 1 0.46* 1 [0.26-0.80] 1 0.32* 1 [0.12-0.84] 1 0.31* 1 [0.11-0.85] 1 0.62 1 [0.32-1.14] 1 0.59 1 [0.39-1.10] Years of practice 10 1 0.77 1 [0.28-2.17] 1 0.78 1 [0.13-4.58] 1 0.71 1 [0.11-4.57] 1 1.09 1 [0.37-3.24] 1 1.15 1 [0.39-3.44] Practice area Rural Uban 1 0.87 1 [0.51-1.50] 1 0.77 1 [0.30-1.95] 1 0.77 1 [0.29-2.05] 1 0.88 1 [0.47-1.61] 1 0.90 1 [0.48-1.66] Request type Somatic Psychiatric 1 0.02* 1 [0.01-0.04] 1 0.02* 1 [0.009-0.04] 1 - 1 - 1 - 1 - EAS type Assisted suicide Euthanasia 1 2.3* 1 [1.31-4.03] 1 0.62 1 [0.36-1.09] 1 0.63 1 [0.36-1.10] Condition type Autism Depression PTSS Schizophrenia 1 0.82 1.75 1.19 1 [0.34-1.92] [0.83-3.78] [0.55-2.56] 1 0.82 1.74 1.15 1 [0.34-1.92] [0.82-3.76] [0.54-2.49] Received psychiatric only EAS request No experience Experience 1 0.69 1 [0.37-1.28] * significant results 1= reference category Note: Multilevel logistic regressions used for model 1-3 and binary logistic regressions for model 4 & 5 Willingness to perform EAS psychiatric versus somatic requests When asked directly about their willingness to perform EAS, 98 GPs (95.1%) were willing to do so for somatic patients, while 5 were unwilling (Figure 1). For psychiatric patients, 41 GPs (45.6%) were willing, whereas the majority of 49 GPs were unwilling. Results of the binary logistic regressions comparing willingness to perform only somatic EAS to willingness to perform both somatic and psychiatric EAS are shown in Table 7. The only significant predictor was prior experience performing psychiatric EAS (OR = 0.15, 95% CI [0.02–0.73]), indicating that GPs with such experience were more likely to be willing to perform EAS for psychiatric patients. Other variables, including age, religion, years of practice, practice area, and experience receiving psychiatric requests, were not statistically significant. Variables on somatic EAS experience and ethnicity were excluded due to lack of variability; gender was excluded due to insufficient responses. However, results from the subgroup that reported gender aligned with the overall model, suggesting no gender effect. Table 7: Results of the binary logistic regression analysis on GPs willingness to perform Binary Logistic Regression Model OR CI (95%) Intercept 0.53 [0.08, 3.42] Age 55 1 1.57 1.54 1 [0.24, 10.42] [0.23, 10.52] Religion Non-religious Religious 1 1.17 1 [0.41, 3.41] Years of practice >10 2-10 1 0.56 1 [0.07, 4.30] Practice area Rural Urban 1 0.67 1 [0.23, 1.91] Received psychiatric-only EAS request No Yes 1 2.47 1 [0.85, 7.53] Performed EAS-Psychiatric base only No Yes 1 0.15* 1 [0.02, 0.73] *significant result 1= reference category The process of decision-making: Dutch GPs and euthanasia requests A total of 13 Dutch physicians, all qualified as GPs and with multiple years of experience in general practice, participated in the interviews. Eleven were still working as GPs at the time of the interview, while two were currently working as SCEN physicians (table 8). All 13 GPs interviewed stated they have experience only with euthanasia requests, not assisted suicide. Therefore, their decision-making process is relevant solely to euthanasia and not assisted suicide. Table 8: Demographic and professional characteristics of the interview participants Participant Gender Practice area GP in current practice 1 Female Urban Trained as GP, currently practicing as SCEN physician 2 Female Rural Yes 3 Female Rural Yes 4 Male Urban Yes 5 Female Rural Yes 6 Female Urban Yes 7 Female Urban Yes 8 Female Urban Yes 9 Female Urban Yes 10 Female Urban Yes 11 Female Urban Yes 12 Female Urban Trained as GP, currently practicing as SCEN physician 13 Male Urban Yes Note: Trained as GP” refers to the fact that the participant completed formal education and training required to become a GP. All GPs were open to discussing euthanasia, and 12 expressed general willingness to perform it. Their decision-making was nuanced and influenced by multiple factors. Most reported that euthanasia consultations often begin preventively, with patients expressing interest in exploring it as a future option: [“So that first conversation is more of a hedging than really a direct question of 'I want it to happen.’”] (P4) These early conversations aim to inform and clarify patient wishes, not to initiate the formal process. When patients with serious conditions make a direct request, GPs begin deliberating on the best course of action. A recurring theme was the importance of a long-term patient relationship. Many GPs stressed that decisions unfold over time, not in a single consultation: [“That is not a decision made over one night, but during the course of someone’s illness.” ] (P7). Initially, GPs focus on supporting and informing the patient, often explaining end-of-life care options like palliative sedation. If a patient remains certain about euthanasia, GPs assess the legal criteria, such as suffering and decision-making capacity: [“I want to be clear about what unbearable suffering consists of, so I really let someone articulate themselves.”] (P6). In addition to supporting, informing, and evaluating whether the request meets the criteria set by law, the interviews made it clear that GPs navigate through the moral implications of ending someone’s life, even when suffering. One GP expressed that they could not perform euthanasia at all, regardless of the case, due to personal beliefs: [“I couldn’t even kill a mosquito when I was younger, so I’m certainly not going to kill a person. I will do everything to alleviate suffering and help during the final stage, but I won’t do that.”] (P2). When discussing different cases and GPs' personal boundaries, many GPs expressed that if they are unable to perform euthanasia themselves, they are relieved that the Euthanasia Center exists, allowing them to refer their patients there. Even for those who do perform euthanasia, GPs reported engaging in significant moral reflection before making a final decision. As several GPs explained: [“You must be able to justify it to yourself.”] (P1) and [“Does it feel right to do this for this patient? Because I have to live with the knowledge that I will do this and have done it at some point. And I have to live with the absolute certainty.”] (P13). Many cited the relief of unbearable suffering and providing a dignified death as central to their moral justification : [“If someone suffers unbearably, hopelessly, and I cannot relieve it in any other way, then I see euthanasia as the last therapy.”] (P6). Autonomy was another prominent theme. GPs stated that they deeply respect patients' right to decide how and when to die: [“I believe that everyone has the free choice, and my conviction should not be an obstacle to that. Everyone has the right to freely choose how they live and end their life.”] (P2). As they value patient autonomy, GPs also assess throughout the process whether the request is well-considered and voluntary, and not influenced by family or friends : [“And then I always find it important for myself that I speak to the patient alone. Because often there are family members present to make sure that it is indeed the person's own wish and not something imposed by the surroundings.”] (P6). Trust-building and empathy were also cited as essential. GPs use consultations not only to assess criteria but to determine whether they can empathize with the patient’s wish. This was articulated clearly by multiple GPs: [“But I personally feel that I must also be able to empathize with it in order to do it. It's not nothing to do.”] (P7) and [“And then the request comes very late, and I can't fully empathize with it in just three days.” ] (P3). GPs emphasized that the process behind a euthanasia request is complex and must not be underestimated. One GP detailed the process from start to finish: [“This is something you really have to be fully behind yourself, but it’s a process that I handle very carefully. You have multiple conversations until you decide to bring in a second doctor because you feel ready to proceed with the euthanasia. Then the SCEN doctor comes, and they give the green light. And that is indeed a situation of hopeless, unbearable suffering. Then the protocol actually begins. The protocol that you will follow, the date that is scheduled, the medications that need to be ordered from the pharmacy, the reports that have to be filled out in advance. It’s a whole process leading up to it.”] (P9). Other GPs described the process as “intense” and “energy-consuming.” Beyond conversations and decision-making, the administrative burden was also noted, especially the documentation required by the RTE (Regional Euthanasia Review Committee), with one GP stating: [“I always say that euthanasia is a legal process, not a medical process.”] (P2). Besides practical complexities, GPs reported significant emotional strain. One GP stated: [“I find it hard. The conversations you have are intense and take a long time. So, it places a significant burden on your daily practice, which is already busy enough, and then these kinds of conversations are added on top.”] (P6). The emotional weight increases in the final stages. GPs reported sleepless nights, lingering stress, and emotional recovery time: [“The week leading up to the euthanasia is difficult for me. In the sense that it occupies my mind a lot and I sleep poorly.”] (P8) and [“You have to take an afternoon off to do it, and then you need some time to recover in the evening. And it still lingers in your mind for a week afterward.”] (P2). While the patient’s wish is central, most GPs said they also consider the views of family members. As one GP put it : [“It mainly concerns the patient, but it does help if the family is also supportive.”] (P6). In cases where family support is absent or conflicting, GPs respond differently. Some are troubled by family disagreement, while others prefer the patient and family resolve it themselves. A few GPs stated that family opinions do not influence their decision at all. To cope with the emotional and procedural burden, GPs often seek support. Many described working in pairs with colleagues or trainees for mutual support: [“I never do it alone, there's always a colleague or my buddy with me. And I’ve also joined others on their routes. I’m really not going to do it by myself if it doesn’t feel right or anything, it’s all just terrifying.”] (P10). GPs also consult other professionals, such as palliative care nurses and SCEN doctors, for guidance and emotional reinforcement. Comparing Decision-Making Processes: Psychiatric versus Somatic The decision-making process surrounding euthanasia requests differs significantly between somatic and psychiatric cases, as revealed through interviews with GPs (Table 9). While some GPs expressed openness to evaluating both somatic and psychiatric requests [“It doesn't matter to me whether someone has metastatic lung cancer or indeed an incurable depression”] (P13), others viewed psychiatric requests as outside their professional scope [“I don't believe that it falls within the GP's role”] (P4). Opinions varied: some had experience with psychiatric cases, some were open to them, while others excluded themselves entirely. However, all agreed that psychiatric requests are generally more complex. A key challenge in psychiatric euthanasia is determining whether the patient’s suffering is genuinely "unbearable" and "hopeless." In somatic cases like terminal cancer, GPs described that suffering is more clearly defined and supported by medical evidence such as terminal diagnoses and physical decline. As one GP remarked : [“People also come back from a specialist, like the pulmonologist or cardiologist, and are out of treatment options. Somehow, I feel that’s different from psychiatry. It’s not as objective because you can't measure it in the same way. With tumors, you can measure it”] (P11). GPs indicated that psychiatric suffering is less tangible, leading to more subjective interpretation and uncertainty: [“Psychiatric suffering is difficult in that sense, because compared to most somatic conditions, it’s harder to determine. When can we all be certain that this condition is a hopeless problem that we can no longer do anything about medically?”] (P13). Treatment exhaustion was also described as more straightforward in somatic cases, as it is usually backed by specialist documentation: [“You just have a letter from an oncologist that says this is the prognosis, and the patient is out of treatment options. And that’s very black and white”] (P3). In psychiatric cases, the absence of fixed protocols and the unpredictability of outcomes created more uncertainty: As one GP expressed: [“What I find difficult is that the judgment of whether something is treatable or hopeless is sometimes harder to objectify in psychiatry”] (P13). This reflects broader concerns about the stability of psychiatric conditions, as the same GP questioned:: [“How sure can you be that these complaints really can’t improve in any way?”] (P13). The fluctuating nature of conditions like depression or schizophrenia added further complexity. GPs described how inconsistent symptoms can make it difficult to assess whether a request is stable and well-considered. Additionally, the disease itself can cause psychopathology, where the condition influences the patient’s decision-making capacity. As one GP explained: [“Because it’s hard to distinguish between what is the illness and what is not the illness, does a death wish stem from their illness, or from their unbearable suffering?”] (P6). This makes capacity assessment more difficult than in somatic cases, where wishes are usually clearer. While GPs acknowledged this complexity, most agreed psychiatric suffering can be hopeless and unbearable, though harder to assess. Besides the challenges in assessing psychiatric patients' suffering and decision-making capacity, many GPs expressed hesitation due to limited psychiatric expertise. Even those willing to proceed emphasized the need for specialist support. When asked about assessing psychiatric requests, one GP stated: [“No, I can't do that on my own, so I ultimately need the support of specialists in that area, much more than with somatic conditions”] (P13). The need for psychiatric input was a common theme: [“In that case, I really need the expertise of a psychiatrist to look into it as well. To determine what comes from the illness and what comes from the wish to die, to no longer have this life, and what is still treatable in that?”] (P5). In contrast, most GPs were more confident in evaluating somatic requests: [“For somatic patients, I can handle the entire process; I am capable of that”] (P3). Furthermore, the interviews indicated that while EAS requests generally involve moral reflection, psychiatric requests tend to raise additional ethical challenges. Some GPs questioned whether societal or healthcare shortcomings contributed to patients' suffering. One GP reflected: [“Aren’t we, as a care system or society, failing them? The home care comes by twice a day, and they’re alone the rest of the time. The same goes for someone with a psychiatric illness who isn’t accepted enough”] (P5). Others felt personal discomfort: [“When it comes to psychiatric disorders or dementia, I find the ethical part difficult. It’s something I have to come to terms with personally. I’m also religious, and even though I do support euthanasia, I do so with certain boundaries”] (P4). Moreover, GPs indicated throughout the interviews that they value empathizing with requests. Several GPs noted they had more difficulty personally “feeling” the request for psychiatric cases compared to somatic ones: [“I find psychiatric issues difficult to empathize with, even though I know it’s real and untreatable”] (P5). Despite its complexities, many believed psychiatric requests can be responsibly assessed, but most said this requires more time and collaboration: [“And there are situations where it’s possible to say, 'Well, we’ve really tried everything. No one else thinks differently about this.' And we draw a line now, and we can indeed proceed with euthanasia. But again, it takes more time, it requires more consultation”] (P13). For some, the extra time and complexity were reasons not to engage in psychiatric cases. Others stressed that time constraints should not interfere. Given the added difficulty, referrals to the Euthanasia Expertise Center were more commonly discussed for psychiatric than somatic cases: : [“I also had a few people with mental health issues. I couldn’t do it myself or didn’t want to, so I referred them to the Euthanasia Expertise Center”] (P7) and [“I once had a young woman who requested it from me, but she consistently declined psychiatric care and wasn’t clearly suicidal either. I referred a case like that to the End-of-Life Clinic.”] (P4). For GPs who considered evaluating psychiatric requests or had done so in the past, patient characteristics, especially age played an important role. Psychiatric euthanasia requests from younger patients were often met with hesitation. Some GPs felt uncomfortable deciding on such irreversible matters for younger individuals. One GP shared: [“I do have difficulty with euthanasia in cases of psychological suffering, especially in young people, because I wonder if someone's brain has fully developed”] (P8). Another said : [“That was also the case with psychological suffering in patients of mine from practice. One was a 43-year-old woman and the other was a 65-year-old woman. I felt that the 43-year-old woman was really too young, so I couldn’t justify doing that for myself”] (P6). Lastly, GPs expressed appreciation for the existing legal framework and professional guidelines that help navigate complex euthanasia cases. Several emphasized that Dutch euthanasia law is well established and provides a clear foundation. As one GP stated: [“In the Netherlands, we have had a good law for quite some time now, and we are trained accordingly. So yes, as general practitioners, we know what we need to do, so to speak. We have good guidelines for that.” (P10). Another remarked : [“I think the laws and regulations are clear about what is and isn't acceptable.” ] (P11). Most GPs said they relied primarily on the KNMG guidelines: [“The rules we follow are from the KNMG. And indeed, the Dutch Association for Psychiatry also has separate guidelines. But as general practitioners, we follow the KNMG guidelines.”] (P6). However, some were unfamiliar with the Dutch Association for Psychiatry’s guidelines. SCEN-trained GPs or those with more experience knew of the psychiatric guidelines but sometimes found them too strict: [“What I find difficult is that the Dutch Association for Psychiatry imposes additional requirements. For example, the SCEN specialist must also be a psychiatrist”] (P1). Some GPs mentioned legal concerns specifically in psychiatric cases: [“I find psychiatry more difficult because it maybe that even if you have done it correctly, you may have to stand in court.”] (P7) Still, most did not cite fear of prosecution as a major barrier when evaluating psychiatric requests. Table 9: Comparison of the decision-making process of Dutch GPs for psychiatric versus somatic requests for EAS Comparison Decision making process of Dutch GPs (n=13) Somatic Requests Psychiatric Requests Openness to evaluate requests All GPs (except 1) were open to evaluating somatic EAS requests. More divergent opinions. Some GPs excluded psychiatric EAS from their scope. Complexity in assessing suffering Suffering perceived as clearer and supported by medical evidence. More subjective; less measurable; difficulty in determining hopelessness. Treatment exhaustion Often confirmed with clear documentation from specialists. Harder to verify; lacks objective markers. GPs struggle to assess when all treatments have truly failed. Decision-making capacity Generally perceived as more stable and straightforward. Greater doubts about whether the wish to die stems from autonomous choice or the psychiatric disorder. Knowledge and expertise needs GPs felt more capable and confident. GPs emphasized need for psychiatric expertise or external input. Referral behavior Referral to Euthanasia Centre mentioned less frequently. Referral to Euthanasia Centre or need for consultation was more common. Ethical reflection General moral reflection noted. Additional ethical concerns raised, e.g. societal failure, professional boundaries. Empathy GPs often able to empathize with somatic suffering. Some struggled to emotionally connect despite recognizing real suffering. Process time Seen as faster and more straightforward. Perceived as more time-intensive and requiring more consultation. Fear of legal prosecution Rarely mentioned; low concern. Some indication of fear but rarely mentioned Guidelines and law clarity KNMG guidelines widely used and understood. Psychiatric guidelines less known or seen as restrictive. Influence of patient characteristics Younger patients with families raised some concern. Youth often seen as a barrier; more hesitation reported. Discussion Study Results in the Context of Existing Evidence This study offers new insights into Dutch GPs willingness to grant and perform EAS for psychiatric versus somatic patients, and highlights key differences in their decision-making processes. Quantitative results showed that psychiatric requests were significantly less likely to be granted, religious GPs were less likely to grant EAS requests, and euthanasia was more likely to be granted than assisted suicide. The lower odds of granting psychiatric requests aligns with findings by Bolt et al., who reported that Dutch physicians found EAS more conceivable for physical conditions (82%) than for psychiatric ones (34%) [ 12 ]. The influence of religion supports previous findings that it can act as a barrier, with religious physicians being more likely to oppose EAS [ 10 , 13 , 24 ]. In contrast to a prior study reporting no significant difference between euthanasia and assisted suicide [ 25 ], this study observed a clear preference for euthanasia, matching attitudes found in Table 5 . Differences may stem from sample composition, as the earlier study included elderly care physicians and specialists, while this one focused solely on GPs. When directly asked about willingness to perform EAS, most GPs were open to doing so for somatic patients, but fewer than half of the GPs were willing to perform psychiatric EAS, which is consistent with earlier studies by Pronk et al. and Evenblij et al., who similarly found that less than half of the GPs find performing psychiatric EAS conceivable [ 10 , 14 ]. The results also demonstrated that prior experience performing psychiatric EAS significantly increased willingness to do so again, aligning with research suggesting experience reduces hesitation [ 24 ]. However, while Evenblij et al. found that experience receiving psychiatric EAS requests increased openness to performing it, this study found no significant effect [ 10 ]. A likely explanation is that Evenblij et al. used broader, more general questions about conceivability and included a wider physician sample rather than only GPs. Moreover, while religion significantly influenced willingness to grant EAS, it did not affect willingness to perform it. This may suggest that religious beliefs impact formal approval more than personal action. Another explanation is that the analysis excluded GPs entirely unwilling to perform EAS due to their small number. Strictly religious GPs may have been overrepresented in this group or chose not to answer, as personal willingness may conflict more directly with their beliefs than hypothetical case questions. The interviews provided deeper insight into GPs’ decision-making processes and confirmed a general consensus: evaluating psychiatric EAS requests is more challenging than somatic ones. These findings complement the quantitative results and explain lower willingness towards psychiatric EAS. In general, GPs valued a strong doctor–patient relationship, engaged in moral reflection, and described emotional and organizational strains, in line with prior research [ 17 , 18 , 26 ]. While earlier studies emphasized the importance of understanding patient requests, this study notably found that GPs highlighted the need to empathize with a patient’s wish - a dimension rarely discussed in existing literature [ 18 ]. Furthermore, while some studies suggest that family opinions can significantly influence or even pressure physicians, most participants in this study valued family input without feeling pressured. This aligns with recent findings showing that Dutch physicians often seek relatives’ views, but only 35% actually consider them in their decisions [ 16 , 17 , 27 ]. Comparing psychiatric with somatic requests revealed that psychiatric cases are experienced as more difficult by the GPs, mainly due to challenges in assessing due care criteria. Difficulties included objectifying psychiatric suffering, distinguishing requests from illness symptoms, evaluating decision-making capacity, fearing potential recovery, and determining treatment exhaustion, all of which contributed to a lengthier decision-making process. These challenges, though not often compared directly with somatic cases, are well-documented in psychiatric EAS literature [ 9 – 10 , 14 , 28 ]. Furthermore, the interviews revealed that GPs had additional ethical concerns and greater uncertainty about their own capabilities and knowledge when evaluating psychiatric EAS requests, often expressing a need for support from a psychiatrist. These findings align with previous studies and the attitudinal data in Table 5 , which show that many GPs feel less confident assessing psychiatric cases [ 12 , 14 , 29 ]. This research also identified less-explored contributors to the disparity between psychiatric and somatic EAS, such as patient age. GPs expressed greater personal resistance to psychiatric requests from younger individuals, suggesting that age plays a more decisive role in psychiatric cases. This aligns with findings from a Psychiatry study reporting concerns about future recovery, developmental maturity, and long-term prognosis in younger psychiatric patients [ 30 ]. A notable new insight was that GPs felt more emotionally distant from psychiatric requests; they found it harder to relate to or empathize with these cases. This often-overlooked emotional aspect may help explain why they are less willing to handle such requests. In response to these challenges, GPs discussed referring psychiatric cases to the Euthanasia Expertise Center more or sought their support, echoing national data from the Center [ 31 ]. Lastly, although most GPs reported using KNMG guidelines, few were familiar with the NVvP’s specific psychiatric guideline. This aligns with findings that even psychiatrists sometimes lack awareness or application of this standard [ 32 ]. While not required by the RTE, the NVvP guideline offers valuable support, for instance on treatment refusal, and could strengthen GP confidence and provide additional support, as GPs now indicated a lack of support from existing guidelines (Table 5 ). Strengths and limitations This study used a concurrent mixed-methods approach, combining quantitative and qualitative data to strengthen validity. While the survey identified broad patterns in GPs willingness toward EAS, interviews provided deeper insight into the reasoning behind their decisions, enhancing the study’s comprehensiveness and interpretative depth. The research is particularly timely given the rise in psychiatric EAS cases in the Netherlands and the growing international debate surrounding such practices. Insights from the Dutch context may serve as a useful reference for countries navigating similar legal and ethical considerations [ 6 , 19 ]. Nevertheless, this study has some limitations. The relatively small sample size (n = 103) may limit the generalizability of the findings, although most results are in line with prior research. Some GPs indicated that the survey answer options did not fully reflect their views particularly regarding the lack of an option to refer a patient’s request. Furthermore, due to convergence issues, multilevel modelling was not used for Models 4 and 5. Although binary logistic regression without hierarchical structure was used. Odds ratios (ORs) and confidence intervals (CIs) for most predictors remained consistent with those in the hierarchical models indicating that this modeling approach did not impact the interpretation of the results. Recommendations for future research As psychiatric EAS cases rise in the Netherlands, ongoing research remains critical. This study highlights the need to explore empathy in greater depth, particularly how they affect physicians willingness to engage with psychiatric requests. Future qualitative research should further examine how patient characteristics, especially younger age, shape GPs’ decisions, as youth often provokes stronger ethical hesitation. Additionally, larger-scale quantitative studies are recommended to assess how physician traits such as experience, religion, and psychiatric EAS exposure influence clinical decisions. These insights can inform more tailored training, support structures, and policies to better equip GPs for complex EAS requests. Conclusion These findings highlight the need to strengthen support measures by improving and increasing awareness of existing guidelines, facilitating access to psychiatric or SCEN consultations, encouraging collaboration with the Euthanasia Expertise Center, and enhancing training to better support GPs in evaluating due care criteria in psychiatric EAS cases. Abbreviations AI Artificial Intelligence CI Confidence Interval DSM-5 Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition EAS Euthanasia and Assisted Suicide GP General Practitioner KNMG Royal Dutch Medical Association KNMP Royal Dutch Pharmacists Association MAiD Medical Assistance in Dying (Canadian term) MAXQDA Software for qualitative and mixed methods data analysis NVvP Dutch Association of Psychiatrists (Nederlandse Vereniging voor Psychiatrie) OR Odds Ratio PAD Physician-Assisted Dying PAS Physician-Assisted Suicide RTE Regional Euthanasia Review Committees SCEN Support and Consultation on Euthanasia in the Netherlands SPSS Statistical Package for the Social Sciences Declarations Ethics approval and consent to participate This study was conducted in compliance with the Declaration of Helsinki. Ethical approval for this study was obtained from the Ethics Committee of the Management Center Innsbruck (MCI). All participants received information about the study’s aims. Informed consent was obtained prior to participation in both the survey and the interviews. Interviews were recorded with permission, and all data were securely stored and accessible only to the researcher. Anonymity and confidentiality were strictly maintained throughout the research process. Given the sensitivity of the topic, special attention was paid to participants comfort and the voluntary nature of their involvement. Consent for publication Not applicable Funding Declaration Not applicable. Clinical Trial Number Not applicable. Corresponding author MSc Esmee PGM Jenniskens Email: [email protected] Author Contribution EJ conceived the study, designed the methodology, developed the survey and interview instruments, coordinated and conducted all data collection (including survey distribution and interviews), and performed the full quantitative and qualitative analyses. EJ also created all tables and figures, drafted the manuscript, and ensured the overall integrity, structure, and coherence of the project from inception to completion.NM served as the academic supervisor, providing conceptual input, methodological guidance, and critical feedback throughout the study. NM reviewed and commented on multiple drafts of the manuscript and contributed to improving its clarity.Both authors read and approved the final manuscript. Acknowledgement I sincerely thank the general practitioners who generously shared their time and experiences through the survey and interviews, providing invaluable perspectives on their willingness to grant and perform EAS for somatic versus psychiatric patients and their decision making process. Data Availability The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request. References Termination of Life on Request and Assisted Suicide (Review Procedures) Act. 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Supplementary Files JenniskensAdditionalFile1Survey.docx JenniskensAdditionalFile2InterviewGuide.docx JenniskensAdditionalFile3CodingScheme.docx Cite Share Download PDF Status: Published Journal Publication published 25 Nov, 2025 Read the published version in BMC Medical Ethics → Version 1 posted Editorial decision: Revision requested 25 Aug, 2025 Reviews received at journal 21 Aug, 2025 Reviews received at journal 21 Aug, 2025 Reviewers agreed at journal 13 Aug, 2025 Reviewers agreed at journal 29 Jul, 2025 Reviewers invited by journal 29 Jul, 2025 Editor invited by journal 29 Jul, 2025 Editor assigned by journal 28 Jul, 2025 Submission checks completed at journal 28 Jul, 2025 First submitted to journal 19 Jul, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Jenniskens","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABFUlEQVRIiWNgGAWjYNACHiBmBkIQkx9EJhSQoEVGsgGkxYA4u8BabAwOgCg8Wvj5Tyc++CBjk2fOzv7Y4OOOOh7j86sTPzwwYJDnFzuAVYvkjNzNhjN40ootm3mME2eeOcxjduPtZgmgwwxnzk7AqsXgBu82aR6ew4kbDvMwH+ZtOwDUcnYDSEuCwW3sWuzPn93++w/Pf6AW9seH/7YBHTbj7OYf+LQYMORuY2bgOQDUwmCczNjGzGPA37sNry0SN3I3S/bwJIMcZmzY23aYRwLoVIsEAwmcfuHvP7vxw88eu8QN548/lvjZVmcPFNl880eFjTy/NHYtYMDYg2IxWKUEbuVg8APF4gMEVI+CUTAKRsFIAwBawGB12WUDXAAAAABJRU5ErkJggg==","orcid":"","institution":"","correspondingAuthor":true,"prefix":"","firstName":"Esmee","middleName":"P.G.M.","lastName":"Jenniskens","suffix":""},{"id":493271189,"identity":"bd04a1a5-ff82-4e41-9ee1-5baff1c73c31","order_by":1,"name":"Nils Mevenkamp","email":"","orcid":"","institution":"Management center Innsbruck","correspondingAuthor":false,"prefix":"","firstName":"Nils","middleName":"","lastName":"Mevenkamp","suffix":""}],"badges":[],"createdAt":"2025-07-19 15:38:08","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-7165404/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-7165404/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12910-025-01333-y","type":"published","date":"2025-11-25T15:57:31+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":88098572,"identity":"baee6282-6d79-4289-8298-67350ce8da06","added_by":"auto","created_at":"2025-08-01 11:09:58","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":146322,"visible":true,"origin":"","legend":"\u003cp\u003eWillingness to perform EAS: somatic versus psychiatric patients.\u003c/p\u003e","description":"","filename":"JenniskensFigure1Willingnesstoperform.jpg","url":"https://assets-eu.researchsquare.com/files/rs-7165404/v1/48ee3dc7e13d8d250ae9bef8.jpg"},{"id":97178658,"identity":"ab282c62-cb9f-42b3-a518-b7f8bf3b0244","added_by":"auto","created_at":"2025-12-01 16:12:20","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1748285,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7165404/v1/26503bc3-f844-4b61-b8d0-5f42cff67c9c.pdf"},{"id":88096800,"identity":"cff569ff-ccef-4697-b8f7-22bd669a0c11","added_by":"auto","created_at":"2025-08-01 11:01:58","extension":"docx","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":19659,"visible":true,"origin":"","legend":"","description":"","filename":"JenniskensAdditionalFile1Survey.docx","url":"https://assets-eu.researchsquare.com/files/rs-7165404/v1/2b8069b8c05a7c117fd00b67.docx"},{"id":88096802,"identity":"0e24c6a7-a4ea-4fae-bd10-8530f4f87273","added_by":"auto","created_at":"2025-08-01 11:01:58","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":16163,"visible":true,"origin":"","legend":"","description":"","filename":"JenniskensAdditionalFile2InterviewGuide.docx","url":"https://assets-eu.researchsquare.com/files/rs-7165404/v1/46ca4775071774d0828fed6c.docx"},{"id":88098574,"identity":"281fbe0e-70a3-4d54-9a09-76ba9488cfd7","added_by":"auto","created_at":"2025-08-01 11:09:58","extension":"docx","order_by":2,"title":"","display":"","copyAsset":false,"role":"supplement","size":22099,"visible":true,"origin":"","legend":"","description":"","filename":"JenniskensAdditionalFile3CodingScheme.docx","url":"https://assets-eu.researchsquare.com/files/rs-7165404/v1/5a980d289d85d163f5288b25.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Willingness of Dutch general practitioners to grant and perform Euthanasia and Assisted Suicide: A mixed methods study comparing psychiatric and somatic cases and the factors guiding their decisions","fulltext":[{"header":"Background","content":"\u003cp\u003eThe Netherlands was the first country to legalize euthanasia and physician-assisted suicide (EAS) under the 2002 Termination of Life on Request and Assisted Suicide Act [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Euthanasia refers to a physician administering a lethal drug, while assisted suicide involves the physician providing but not administering the drug [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Although EAS remains a criminal offense under Dutch law, it is permitted if six due care criteria are met: (1) the request must be voluntary and well-considered, (2) the patient must be experiencing unbearable suffering with no prospect of improvement, (3) the patient must be fully informed about their situation and prognosis, (4) no reasonable alternative may exist to relieve the suffering, (5) an independent physician must be consulted, and (6) the procedure must be carried out with due medical care and attention [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eBoth somatic and psychiatric patients are legally eligible to request EAS. However, psychiatric EAS remains rare and controversial, with only a few countries besides the Netherlands, such as Belgium, Luxembourg, Switzerland (for assisted suicide only), and recently Spain allowing it [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e–\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. In the Netherlands, psychiatric EAS cases rose from 2 in 2008 to 219 in 2024, yet they accounted for only 2.2% of all reported EAS cases [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e–\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Data from the Dutch Euthanasia Expertise Center show that only 10% of psychiatric requests are granted, with most being declined due to failure to meet the due care criteria particularly regarding treatment exhaustion and unbearable suffering [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eDutch physicians have long reported that psychiatric EAS cases are especially complex and difficult to assess. This is partly due to the greater challenge of applying the due care criteria in psychiatric contexts, and partly because of limited clinical experience with such requests [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e–\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. Importantly, Dutch physicians are never obligated to grant or perform EAS and may decline for personal or professional reasons [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. These beliefs and limitations may influence how somatic versus psychiatric requests are handled. Physicians generally find it easier to assess unbearable suffering, prognosis, and decision-making capacity in somatic cases due to visible physical symptoms and more predictable disease courses. In contrast, psychiatric suffering is often existential, may fluctuate over time, and is frequently accompanied by suicidal ideation or cognitive distortions. These features complicate the evaluation of whether suffering is truly unbearable and without hope of improvement. The ongoing availability of psychiatric treatments further raises doubts about whether the suffering is truly irremediable [\u003cspan additionalcitationids=\"CR12 CR13\" citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e–\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. Beyond clinical challenges, ethical concerns, family involvement, patient attitude, legal criteria, the physician–patient relationship, and external pressures have all been found to influence EAS decision-making. However, little is known about how these factors differ between psychiatric and somatic EAS cases [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan additionalcitationids=\"CR16 CR17\" citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e–\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e].\u003c/p\u003e\u003cp\u003ePrevious research has shown that physicians are generally more accepting of somatic EAS than psychiatric EAS. Physician characteristics such as religious beliefs, gender, and medical specialization are associated with lower acceptance of psychiatric EAS [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. Among all medical specialties, general practitioners (GPs) are the most open to psychiatric EAS, with 47% indicating a willingness to perform it [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. GPs receive the majority of EAS requests in the Netherlands and, unlike most specialists, often handle both somatic and psychiatric cases [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. Their central role makes it especially relevant to examine how they approach different types of EAS requests. For example, Pronk et al. found that 86 out of 101 GPs found EAS conceivable for somatic patients, compared to 51 out of 104 for psychiatric patients. GPs cited values such as compassion, fairness, and respect for autonomy in support of psychiatric EAS but also expressed hesitation due to perceived medical boundaries, lack of experience, and difficulty applying the due care criteria [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. However, this data was collected in 2018–2019 and may no longer reflect current views, particularly given that the number of psychiatric EAS cases has doubled in recent years [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eThe incidence of psychiatric EAS continues to grow in the Netherlands, leading to public debate and policy discussions [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. As global interest in EAS rises, Dutch insights are increasingly relevant [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. While previous studies have explored physician attitudes and the factors influencing EAS decision-making, most have focused on general conceivability rather than actual willingness to grant or perform requests. Moreover, although previous studies based on interviews with Dutch physicians particularly psychiatrists have shown that psychiatric EAS is generally perceived as more difficult to evaluate, little is known about how GP navigate between evaluating psychiatric and somatic requests and how their decision-making process differs between the two. This study addresses that gap by examining current attitudes among Dutch GPs, comparing their willingness to grant and perform EAS across psychiatric and somatic cases. It also investigates how factors such as the type of psychiatric condition, form of EAS, physician experience, and sociodemographic characteristics shape their decisions, and explores differences in the underlying decision-making processes through qualitative analysis.\u003c/p\u003e"},{"header":"Method","content":"\u003cp\u003e\u003cb\u003eStudy design\u003c/b\u003e\u003c/p\u003e\u003cp\u003eA concurrent mixed methods design was used to combine the strengths of quantitative and qualitative approaches [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. A survey was sent to gather numerical data and identify broad patterns, while semi-structured interviews were conducted around the same period to gain deeper insights into the decision-making process. The survey collected data on sociodemographic, attitudes, EAS-related experience, and included case examples to examine how specific factors (e.g., condition type, EAS method) influenced GPs’ decisions to grant or deny requests. Survey data collection took place in February and March 2025. For the qualitative component, 13 online interviews were conducted with Dutch GPs between March and April 2025. These interviews explored GPs reasoning in both psychiatric and somatic EAS cases.\u003c/p\u003e\u003cp\u003e\u003cb\u003eStudy population and sampling\u003c/b\u003e\u003c/p\u003e\u003cp\u003eThe study population consisted of 103 general practitioners (GPs) who fully completed the questionnaire. These respondents were selected from a larger pool of 609 GP practices that were initially invited to participate in the study. In total, 111 GPs responded. Since GP practices rather than individual GPs were contacted directly, an exact response rate cannot be calculated. However, the sample represents approximately 17% of the approached practices. Interview participants were purposely recruited through survey responses, personal and professional contacts, and snowball sampling, with the goal of capturing variation in gender, region, and experience. Recruitment continued until thematic saturation was achieved, no new themes emerged in the final interviews. The final qualitative sample comprised 13 GPs (11 female, 2 male), including two SCEN physicians, all actively practicing in various regions of the Netherlands.\u003c/p\u003e\u003cp\u003e\u003cb\u003eData collection\u003c/b\u003e\u003c/p\u003e\u003cp\u003eFor the quantitative component the online survey provided in additional file 1 was designed using LimeSurvey and distributed via email to Dutch GP offices in February and March 2025. It included closed questions assessing experience, attitudes toward euthanasia and assisted suicide (EAS) for both somatic and psychiatric patients, willingness to perform EAS, and sociodemographic characteristics. Survey questions were either directly taken from the fourth evaluation of the Dutch Euthanasia Act or were partly self-developed, based on questions from the evaluation but adapted to fit the specific aims of this study [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. An overview of the variables targeted by the survey questions is presented in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e, and a summary of the attitude-related items is provided in Table\u0026nbsp;\u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e5\u003c/span\u003e.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cdiv class=\"gridtable\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eOverview of the variables included in the regression analyses, along with their coding schemes\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"4\"\u003e\u003c/colgroup\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eVariable\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eDescription\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eVariable coding\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eRegression models used\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e\u003cp\u003e\u003cem\u003eDependent\u003c/em\u003e\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCombined willingness\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eWillingness of GPs to perform EAS themselves.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0 = Willing for both somatic and psychiatric request 1 = Only willing for somatic requests\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eBinary logistic (Willingness to perform)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eGrant requests\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eWhether the GP would grant the requests for the case studies.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1 = yes 0 = No\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eMultilevel (Case studies)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"4\" nameend=\"c4\" namest=\"c1\"\u003e\u003cp\u003e\u003cb\u003eIndependent\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAge\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eAge group of the respondents.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eCategorical: \u0026lt;40 (reference) 40–54 and \u0026gt; 50\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eBinary logistic \u0026amp; Multilevel\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eReligion\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eReligious affiliation.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1 = Religious 0 = Non-religious\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eBinary logistic \u0026amp; Multilevel\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eYears of practice\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eYears of practice as a GP.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1 = \u0026gt; 10 0 = 2–10\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eBinary logistic \u0026amp; Multilevel\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePractice area\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eArea of practice of GP.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1 = Rural 0 = Urban\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eBinary logistic \u0026amp; Multilevel\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eReceived Psychiatric-only EAS request\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eExperience receiving psychiatric EAS requests.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1 = Yes 0 = No\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eBinary logistic\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePerformed EAS – Psychiatric basis only\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eExperience performing psychiatric euthanasia.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1 = Yes 0 = No\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eBinary logistic (Only willingness to perform model)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eRequest type\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eIndicates whether the condition is psychiatric or somatic.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1 = Psychiatric, 0 = Somatic\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eMultilevel\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eEAS type\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eType of EAS request.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1 = Euthanasia, 0 = Assisted suicide.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eMultilevel\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCondition type\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eType of psychiatric condition.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eCategorical: Autism (reference) depression, schizophrenia and PTSS\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eBinary logistic ( Model 4 \u0026amp; 5 Case studies)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"4\"\u003e\u003cem\u003eNote: Gender was excluded from analysis due to a high rate of missing responses. Ethnicity, experience with somatic EAS requests, and performing somatic EAS were excluded from analysis due to insufficient variability in the data. The variable for performing psychiatric EAS was excluded from the case example analysis due to instability in estimates.\u003c/em\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003eThe survey also employed a case example approach to explore GPs willingness to grant requests. Twelve case examples were developed, with each GP completing six randomly selected cases (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e) that varied by request type (psychiatric or somatic), EAS method (euthanasia or assisted suicide), and psychiatric condition (autism, depression, schizophrenia, PTSD). The cases were developed based on examples from the fourth evaluations of the Dutch Euthanasia Act and were further inspired by the work of Kouwenhoven et al. [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e].\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cdiv class=\"gridtable\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eIllustrative set of randomly assigned case examples completed by GPs\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"1\"\u003e\u003c/colgroup\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCase examples\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e1. Mr. Van de Berg suffers from ALS. He has lost nearly all motor functions, including the ability to walk, speak, and swallow independently. Despite receiving supportive care, he is completely dependent on others for all daily activities. His condition will inevitably lead to respiratory failure. He finds his current and future situation unbearable and submits a request for euthanasia.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e2. Ms. De Jong has metastatic breast cancer. She has undergone several treatments, but her disease is no longer curable. She experiences severe, hard-to-manage pain and feels she is losing control over her life, a sense of control she valued deeply during her working life. She states she cannot go on like this and requests euthanasia.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e3. Ms. De Jong has metastatic breast cancer. After various treatments, her illness has become incurable. She suffers from intense pain and feels a loss of control over her life, which is deeply distressing for her. She says she can no longer cope and asks her GP for a life-ending drug that she can take herself.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e4. Mr. Jansen has lived with schizophrenia for many years. Despite consistent treatment with medication and therapy, he continues to experience severe hallucinations and delusions that significantly impair his quality of life. These symptoms cause him immense suffering, and he sees no hope for improvement. After careful consideration, he requests euthanasia from his GP.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e5. Ms. Langezaal is physically healthy but suffers from severe, long-term depression. Psychiatric treatments have failed to relieve her symptoms. She frequently tells her doctors she wants to die and has previously attempted suicide, unsuccessfully. She asks her GP for euthanasia to end her suffering.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e6. Ms. Smit suffers from severe ASD, which has led to lifelong unbearable suffering. She endures continuous sensory overload, isolation, and unrelieved emotional distress. Years of treatment have failed to help her. She is unable to engage in everyday life or social contact and finds the overstimulation unbearable. She asks for a life-ending drug she can take herself to end her suffering.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/table\u003e\u003c/div\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003eTo further explore decision-making processes, 13 semi-structured interviews were conducted using an interview guide. The interview guide (additional file 2) was developed based on a literature search using Google Scholar and PubMed, including previous studies on EAS and the decision-making processes of Dutch physicians. Interviews were held online via Zoom, except for two conducted by phone due to scheduling constraints. The interviews explored GPs’ experiences, external influences, and perceived barriers in evaluating both somatic and psychiatric EAS requests. Each session lasted approximately 30 minutes and provided qualitative insights into the factors shaping GPs’ decisions across request types.\u003c/p\u003e\u003ch2\u003eData analysis\u003c/h2\u003e\u003cp\u003eSurvey data were analysed using IBM SPSS Statistics 28 and R version 4.4.1. Descriptive statistics (frequencies and percentages) were used to assess GPs demographics, attitudes, and experiences. Case example responses were analysed using multilevel and binary logistic regression in R, with the dependent variable being whether the request was granted (yes/no). Five models were constructed. Since each GP assessed six randomly selected case examples, multiple responses were nested within individual participants, introducing potential clustering. Responses from the same GP may be more similar than those from other GPs. The intraclass correlation coefficient (ICC = 0.162) confirmed that 16.2% of the variance in willingness was attributable to between-GP differences, exceeding the commonly used 10% threshold [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. Therefore, multilevel modelling was applied in Models 1–3.\u003c/p\u003e\u003cp\u003eModel 1 included demographic variables; Model 2 added request type (psychiatric or somatic); Model 3 added EAS method (euthanasia or assisted suicide) and used the bobyqa optimizer (15,000 iterations) to address convergence issues. Due to convergence issues problems and unstable estimates for condition type and psychiatric experience in Models 4 and 5, binary logistic regression was used instead. Odds ratios (ORs) and confidence intervals (CIs) for other predictors remained stable across models, so this shift did not affect interpretation. Some variables were excluded due to missing data (gender), low variability (ethnicity, somatic EAS experience), or estimation instability (performing psychiatric requests). Religion and years of practice were recoded into binary variables due to low category frequencies. Analyses were conducted using the following R libraries: readr, tidyverse, broom, lme4, and performance. A significance level of 0.05 was used to report the results.\u003c/p\u003e\u003cp\u003eAdditionally, a separate binary logistic regression analyzed GPs’ willingness to perform EAS. The original three-category outcome (willing to perform both somatic and psychiatric EAS / willing to perform somatic only / unwilling for both) was reduced to a binary variable by excluding the small 'unwilling' group. This resulted in a comparison between GPs willing to perform somatic EAS only and those willing to perform both somatic and psychiatric EAS. The same variable exclusions applied as in previous models, except that experience performing psychiatric EAS was included in this analysis, as convergence issues did not arise for this variable.\u003c/p\u003e\u003cp\u003eFor the qualitative part, interviews were transcribed using the qualitative data analysis software MAXQDA 24. Transcripts were then analyzed in MAXQDA using content analysis, focusing on organizing the text into meaningful codes and identifying recurring themes. Coding was conducted by the researcher. Initial codes were based on topics from the interview guideline, see additional file 3 for the coding scheme. As analysis progressed, new codes were added to capture unexpected themes emerging from the interviews. This approach combined predefined and emergent codes, enabling a detailed exploration of factors affecting Dutch GPs’ decision-making on EAS requests [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. To improve precision, subcodes distinguished somatic from psychiatric requests, enabling comparison of GPs’ decision-making.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003e\u003cstrong\u003eSurvey respondents characteristics\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTable 3 represents the demographic characteristics of the GPs who filled in the survey. Important to note is that not all participants provided complete demographic data, resulting in missing values in the table for some variables. Of the respondents who filled in the questions 38.8% were female, and 24.3% were male. The majority (56.3%) were aged between 40 and 54, with 28.2% over 55, and 15.5% under 40. Most of the participants identified as non-religious (69.9%) and had more than 10 years working experience (84.5%) as a GP. The vast majority of the GPs are of Dutch ethnicity (98.1%).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 3:\u003c/strong\u003e Demographic and background characteristics of survey respondents\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003eBackground characteristics (n=103)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eN\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e%\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"3\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eGender\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003cp\u003eMale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e40\u003c/p\u003e\n \u003cp\u003e25\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e38.8\u003c/p\u003e\n \u003cp\u003e24.3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"3\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eAge\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026lt;40\u003c/p\u003e\n \u003cp\u003e40-54\u003c/p\u003e\n \u003cp\u003e\u0026gt;55\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e16\u003c/p\u003e\n \u003cp\u003e58\u003c/p\u003e\n \u003cp\u003e29\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e15.5\u003c/p\u003e\n \u003cp\u003e56.3\u003c/p\u003e\n \u003cp\u003e28.2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"3\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eReligion\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eReligious\u003c/p\u003e\n \u003cp\u003eNon-religious\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e30\u003c/p\u003e\n \u003cp\u003e72\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e29.1\u003c/p\u003e\n \u003cp\u003e69.9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"3\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eYears of practice\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e2-10\u003c/p\u003e\n \u003cp\u003e\u0026gt;10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e14\u003c/p\u003e\n \u003cp\u003e87\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e13.6\u003c/p\u003e\n \u003cp\u003e84.5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"3\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003ePractice area\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eUrban\u003c/p\u003e\n \u003cp\u003eRural\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e34\u003c/p\u003e\n \u003cp\u003e67\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e33\u003c/p\u003e\n \u003cp\u003e65\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"3\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eEthnicity\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eDutch\u003c/p\u003e\n \u003cp\u003eNon Dutch\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e101\u003c/p\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e98.1\u003c/p\u003e\n \u003cp\u003e1.9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cem\u003eNote: Some participants did not provide complete demographic data, leading to different totals in the table.\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eGPs experience and attitudes regarding EAS\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eMost GPs who participated in the survey had experience in receiving an EAS requests based on a somatic condition only (98.1%) . When asked about performing EAS for somatic patients, 94.2% of the GPs filled in they have performed it before, while 5% had not. For psychiatric requests 69.6% of the GPs had received a request on psychiatric basis only before, with 10.7% of the questioned GPs having experience on performing EAS for patients with a psychiatric condition only. (Table 4).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 4:\u003c/strong\u003e Respondents experience with receiving and performing EAS requests\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003eExperience \u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eN\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e%\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"3\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eReceived somatic-only EAS request\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e101\u003c/p\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e98.1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"3\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003ePerformed EAS \u0026ndash; somatic basis only\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e97\u003c/p\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e4.9\u003c/p\u003e\n \u003cp\u003e94.2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"3\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eReceived Psychiatric-only EAS request\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e72\u003c/p\u003e\n \u003cp\u003e31\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e69.6\u003c/p\u003e\n \u003cp\u003e30.1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"3\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003ePerformed EAS \u0026ndash; Psychiatric basis only\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e11\u003c/p\u003e\n \u003cp\u003e92\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e10.7\u003c/p\u003e\n \u003cp\u003e89.3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cem\u003eNote: Only\u0026quot; refers to the fact that the EAS request or performance stemmed solely from either a somatic or psychiatric condition, without influence from a combination of conditions or other contributing factors.\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eGPs attitudes toward EAS were measured (Table 5) for both general and specific patient types (somatic and psychiatric). Most GPs expressed the highest agreement with feeling less confident when assessing EAS requests from psychiatric patients, with 70 strongly agreeing. Support for EAS eligibility was strongest for somatic conditions (39 strongly agree, 50 agree), while responses for psychiatric cases had a higher variation (17 strongly agree, 52 agree). Still, most GPs agreed that psychiatric patients should have the same opportunity to request EAS as those with somatic conditions. Statements suggesting it is impossible to assess unbearable suffering or the decision-making capacity of psychiatric patients were largely disagreed with. Confidence in current guidelines was low, with 35 GPs disagreeing that they provide sufficient clarity for psychiatric EAS cases. Most GPs also did not favour assisted suicide over euthanasia for either patient group.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 5:\u003c/strong\u003e GPs attitudes toward psychiatric and somatic EAS requests\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003eAttitudes Dutch GPs towards EAS\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eStrongly disagree (1)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eDisagree (2)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eNeutral (3)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eAgree (4)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eStrongly agree (5)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eMean score\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eI feel less confident when assessing EAS requests from psychiatric patients compared to patients with somatic conditions.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e21\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e70\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e4.51\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eI believe that patients with somatic conditions should be eligible for EAS if they request it.\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e50\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e39\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e4.18\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eI believe that patients with psychiatric conditions should be eligible for EAS if they request it.\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e22\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e52\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e17\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e3.72\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eEveryone has the right to decide about their own life and death.\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e17\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e21\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e39\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e3.53\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003ePsychiatric patients should have the same opportunity to request EAS as patients with somatic conditions.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e14\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e28\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e37\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e16\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e3.45\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eIt is impossible to determine whether a psychiatric patient\u0026rsquo;s wish to die stems from psychopathology.\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e40\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e39\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e17\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e2.83\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eThe current guidelines provide sufficient clarity to help me assess EAS requests from psychiatric patients.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e35\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e29\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e24\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e2.78\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eIt is impossible to assess whether a psychiatric patient is suffering unbearably and without prospect.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e43\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e35\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e2.65\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eIt is impossible to determine whether a psychiatric patient\u0026rsquo;s wish to die is well-considered.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e47\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e32\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e2.54\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eI would be more willing to provide assisted suicide than euthanasia to psychiatric patients.\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e26\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e33\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e30\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e2.50\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eI would be more willing to provide assisted suicide than euthanasia to somatic patients.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e31\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e33\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e17\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e17\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e2.31\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cem\u003eNote: The mean scores reflect the average level of agreement with each statement on a 5-point Likert scale.\u0026nbsp;\u003c/em\u003e\u003cem\u003eHigher scores indicate stronger agreement.\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eGPs willingness to grant EAS requests and influencing factors\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTable 6 shows the results from the multilevel regression models (Models 1\u0026ndash;3) and binary logistic regression models (Models 4\u0026ndash;5) examining factors related to GPs willingness to grant EAS requests. \u0026nbsp;Model 1 only \u0026nbsp;included sociodemographic variables. Religion was the only significant factor, with religious GPs being \u0026nbsp;less likely to grant EAS requests than non-religious GPs. Age, years of practice, and practice area showed no significant effects. Model 2 added request type and showed that psychiatric requests were significantly less likely to be granted than somatic ones, while religion remained significant. Model 3, the most comprehensive model, included all prior variables and added EAS method. In Model 3, three variables were significantly associated with the likelihood of granting EAS requests. The odds ratio of granting a psychiatric EAS request versus a somatic request was 0.02 (OR = 0.02, 95% CI [0.009\u0026ndash;0.04]), indicating that psychiatric requests were substantially less likely to be approved. The odds ratio of granting a euthanasia request vs. an assisted suicide request was 2.3 (OR = 2.3, 95% CI [1.31\u0026ndash;4.03]), showing a preference for euthanasia. The odds ratio of religious vs. non-religious GPs granting an EAS request was 0.31 (OR = 0.31, 95% CI [0.11\u0026ndash;0.85), reflecting lower approval rates among religious physicians. Models 4 and 5 focused specifically on psychiatric EAS requests, examining whether the psychiatric condition (model 4) or prior experience with receiving such requests (model 5) influenced willingness to grant. Neither model showed statistically significant effects.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 6:\u0026nbsp;\u003c/strong\u003e Overview of the results from the case examples analyses using multilevel and binary logistic regression\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eModel 1 Demographics (Multilevel)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eModel 2 Somatic vs psychiatric\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e(Multilevel)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eModel 3 \u0026nbsp;Euthanasia vs assisted suicide\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e(Multilevel)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eModel 4 Condition type\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e(Binary)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eModel 5: Psychiatric experience\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e(Binary)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eOR\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eCI (95%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eOR\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eCI (95%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eOR\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eCI (95%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eOR\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eCI\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eOR\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eCI (95%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eIntercept\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e2.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e[1.27-5.83]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e32.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e[7.75-132.8]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e23\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e[5.23-101.3]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.88\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e[0.32 - 2.30]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1.08\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e[0.38-3.06]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"11\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eAge\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026lt;40 \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;40-55 \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026gt;55\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003cp\u003e0.95\u003c/p\u003e\n \u003cp\u003e1.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;1 \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e[0.35-2.57]\u003c/p\u003e\n \u003cp\u003e[0.41-3.10] \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003cp\u003e0.74\u003c/p\u003e\n \u003cp\u003e1.1\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1 \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e[0.13-4.10]\u003c/p\u003e\n \u003cp\u003e[0.20-6.47] \u0026nbsp; \u0026nbsp; \u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003cp\u003e0.84\u003c/p\u003e\n \u003cp\u003e1.28\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003cp\u003e[0.14-5.03]\u003c/p\u003e\n \u003cp\u003e[0.21-7.90]\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003cp\u003e0.40\u003c/p\u003e\n \u003cp\u003e0.84\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003cp\u003e[0.14-1.15]\u003c/p\u003e\n \u003cp\u003e[0.30-2.35]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003cp\u003e0.40\u003c/p\u003e\n \u003cp\u003e0.87\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003cp\u003e[0.14-1.14]\u003c/p\u003e\n \u003cp\u003e[0.31-2.44]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"11\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eReligion\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eNon-Religious\u003c/p\u003e\n \u003cp\u003eReligious\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003cp\u003e0.46*\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003cp\u003e[0.26-0.80]\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003cp\u003e0.32*\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003cp\u003e[0.12-0.84]\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003cp\u003e0.31*\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003cp\u003e[0.11-0.85]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003cp\u003e0.62\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003cp\u003e[0.32-1.14]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003cp\u003e0.59\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003cp\u003e[0.39-1.10]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"11\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eYears of practice\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026lt;10 \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026gt;10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1 \u0026nbsp; \u0026nbsp; \u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0.77\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1 \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u003c/p\u003e\n \u003cp\u003e[0.28-2.17] \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003cp\u003e0.78 \u0026nbsp;\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1 \u0026nbsp; \u0026nbsp; \u0026nbsp;\u003c/p\u003e\n \u003cp\u003e[0.13-4.58] \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1 \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0.71 \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1 \u0026nbsp; \u0026nbsp; \u0026nbsp;\u003c/p\u003e\n \u003cp\u003e[0.11-4.57] \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003cp\u003e1.09\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003cp\u003e[0.37-3.24]\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003cp\u003e1.15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003cp\u003e[0.39-3.44]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"11\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003ePractice area\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eRural\u003c/p\u003e\n \u003cp\u003eUban\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1 \u0026nbsp; \u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0.87\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1 \u0026nbsp; \u0026nbsp;\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e[0.51-1.50] \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1 \u0026nbsp;\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0.77\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1 \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e[0.30-1.95] \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1 \u0026nbsp; \u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0.77 \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1 \u0026nbsp; \u0026nbsp;\u003c/p\u003e\n \u003cp\u003e[0.29-2.05] \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003cp\u003e0.88\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003cp\u003e[0.47-1.61]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003cp\u003e0.90\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003cp\u003e[0.48-1.66]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"11\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eRequest type\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eSomatic\u003c/p\u003e\n \u003cp\u003ePsychiatric\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003cp\u003e0.02*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003cp\u003e[0.01-0.04]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1 \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0.02* \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1 \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e[0.009-0.04] \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"11\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eEAS type\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eAssisted suicide\u003c/p\u003e\n \u003cp\u003eEuthanasia\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1 \u0026nbsp; \u0026nbsp; \u0026nbsp;\u003c/p\u003e\n \u003cp\u003e2.3* \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1 \u0026nbsp; \u0026nbsp; \u0026nbsp;\u003c/p\u003e\n \u003cp\u003e[1.31-4.03] \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003cp\u003e0.62\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003cp\u003e[0.36-1.09]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003cp\u003e0.63\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003cp\u003e[0.36-1.10]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"11\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eCondition type\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eAutism\u003c/p\u003e\n \u003cp\u003eDepression\u003c/p\u003e\n \u003cp\u003ePTSS\u003c/p\u003e\n \u003cp\u003eSchizophrenia\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003cp\u003e0.82\u003c/p\u003e\n \u003cp\u003e1.75\u003c/p\u003e\n \u003cp\u003e1.19\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003cp\u003e[0.34-1.92]\u003c/p\u003e\n \u003cp\u003e[0.83-3.78]\u003c/p\u003e\n \u003cp\u003e[0.55-2.56]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003cp\u003e0.82\u003c/p\u003e\n \u003cp\u003e1.74\u003c/p\u003e\n \u003cp\u003e1.15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003cp\u003e[0.34-1.92]\u003c/p\u003e\n \u003cp\u003e[0.82-3.76]\u003c/p\u003e\n \u003cp\u003e[0.54-2.49]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"11\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eReceived psychiatric only EAS request\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eNo experience\u003c/p\u003e\n \u003cp\u003eExperience\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003cp\u003e0.69\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003cp\u003e[0.37-1.28]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e* \u0026nbsp;significant results \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; 1= reference category \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eNote: Multilevel logistic regressions used for model 1-3 and binary logistic regressions for model 4 \u0026amp; 5\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eWillingness to perform EAS psychiatric versus somatic requests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWhen asked directly about their willingness to perform EAS, 98 GPs (95.1%) were willing to do so for somatic patients, while 5 were unwilling (Figure 1). For psychiatric patients, 41 GPs (45.6%) were willing, whereas the majority of 49 GPs were unwilling.\u003c/p\u003e\n\u003cp\u003eResults of the binary logistic regressions comparing willingness to perform only somatic EAS to willingness to perform both somatic and psychiatric EAS are shown in Table 7. The only significant predictor was prior experience performing psychiatric EAS (OR = 0.15, 95% CI [0.02\u0026ndash;0.73]), indicating that GPs with such experience were more likely to be willing to perform EAS for psychiatric patients. Other variables, including age, religion, years of practice, practice area, and experience receiving psychiatric requests, were not statistically significant. Variables on somatic EAS experience and ethnicity were excluded due to lack of variability; gender was excluded due to insufficient responses. However, results from the subgroup that reported gender aligned with the overall model, suggesting no gender effect.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 7:\u0026nbsp;\u003c/strong\u003eResults of the binary logistic regression analysis on GPs willingness to perform\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 212px;\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 223px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eBinary Logistic Regression Model\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 212px;\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 87px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eOR\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 135px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCI (95%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"3\" valign=\"top\" style=\"width: 435px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eIntercept\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 212px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 87px;\"\u003e\n \u003cp\u003e0.53 \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 135px;\"\u003e\n \u003cp\u003e[0.08, 3.42]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"3\" valign=\"top\" style=\"width: 435px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAge\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 212px;\"\u003e\n \u003cp\u003e\u0026lt;40 \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;40-55 \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026gt;55\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 87px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003cp\u003e1.57\u003c/p\u003e\n \u003cp\u003e1.54\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 135px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003cp\u003e[0.24, 10.42]\u003c/p\u003e\n \u003cp\u003e[0.23, 10.52]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"3\" valign=\"top\" style=\"width: 435px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eReligion\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 212px;\"\u003e\n \u003cp\u003eNon-religious\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eReligious\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 87px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003cp\u003e1.17\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 135px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003cp\u003e[0.41, 3.41]\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"3\" valign=\"top\" style=\"width: 435px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eYears of practice\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 212px;\"\u003e\n \u003cp\u003e\u0026gt;10\u003c/p\u003e\n \u003cp\u003e2-10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 87px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003cp\u003e0.56\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 135px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003cp\u003e[0.07, 4.30]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"3\" valign=\"top\" style=\"width: 435px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePractice area\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 212px;\"\u003e\n \u003cp\u003eRural\u003c/p\u003e\n \u003cp\u003eUrban\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 87px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003cp\u003e0.67\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 135px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003cp\u003e[0.23, 1.91]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"3\" valign=\"top\" style=\"width: 435px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eReceived psychiatric-only EAS request\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 212px;\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 87px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003cp\u003e2.47\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 135px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003cp\u003e[0.85, 7.53]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"3\" valign=\"top\" style=\"width: 435px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePerformed EAS-Psychiatric base only\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 212px;\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 87px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003cp\u003e0.15*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 135px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003cp\u003e[0.02, 0.73]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cem\u003e*significant result \u0026nbsp; \u0026nbsp; 1= reference category \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eThe process of decision-making: Dutch GPs and euthanasia requests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA total of 13 Dutch physicians, all qualified as GPs and with multiple years of experience in general practice, participated in the interviews. Eleven were still working as GPs at the time of the interview, while two were currently working as SCEN physicians (table 8). All 13 GPs interviewed stated they have experience only with euthanasia requests, not assisted suicide. Therefore, their decision-making process is relevant solely to euthanasia and not assisted suicide.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 8:\u0026nbsp;\u003c/strong\u003eDemographic and professional characteristics of the interview participants\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"561\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eParticipant\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eGender\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003ePractice area\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eGP in current practice\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eUrban\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eTrained as GP, currently practicing as SCEN physician\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eRural\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eRural\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eMale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eUrban\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eRural\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eUrban\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eUrban\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eUrban\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eUrban\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eUrban\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eUrban\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eUrban\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eTrained as GP, currently practicing as SCEN physician\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e13\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eMale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eUrban\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eNote: Trained as GP\u0026rdquo; refers to the fact that the participant completed \u0026nbsp;formal education and training required to become a GP.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAll GPs were open to discussing euthanasia, and 12 expressed general willingness to perform it. Their decision-making was nuanced and influenced by multiple factors. Most reported that euthanasia consultations often begin preventively, with patients expressing interest in exploring it as a future option: \u003cem\u003e[\u0026ldquo;So that first conversation is more of a hedging than really a direct question of \u0026apos;I want it to happen.\u0026rsquo;\u0026rdquo;]\u003c/em\u003e (P4) These early conversations aim to inform and clarify patient wishes, not to initiate the formal process. When patients with serious conditions make a direct request, GPs begin deliberating on the best course of action. \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eA recurring theme was the importance of a long-term patient relationship. Many GPs stressed that decisions unfold over time, not in a single consultation: \u003cem\u003e[\u0026ldquo;That is not a decision made over one night, but during the course of someone\u0026rsquo;s illness.\u0026rdquo;\u003c/em\u003e] (P7). \u0026nbsp;Initially, GPs focus on supporting and informing the patient, often explaining end-of-life care options like palliative sedation. If a patient remains certain about euthanasia, GPs assess the legal criteria, such as suffering and decision-making capacity: \u003cem\u003e[\u0026ldquo;I want to be clear about what unbearable suffering consists of, so I really let someone articulate themselves.\u0026rdquo;]\u003c/em\u003e (P6). In addition to supporting, informing, and evaluating whether the request meets the criteria set by law, the interviews made it clear that GPs navigate through the moral implications of ending someone\u0026rsquo;s life, even when suffering. One GP expressed that they could not perform euthanasia at all, regardless of the case, due to personal beliefs: \u003cem\u003e[\u0026ldquo;I couldn\u0026rsquo;t even kill a mosquito when I was younger, so I\u0026rsquo;m certainly not going to kill a person. I will do everything to alleviate suffering and help during the final stage, but I won\u0026rsquo;t do that.\u0026rdquo;]\u0026nbsp;\u003c/em\u003e(P2).\u003cem\u003e\u0026nbsp;\u003c/em\u003eWhen discussing different cases and GPs\u0026apos; personal boundaries, many GPs expressed that if they are unable to perform euthanasia themselves, they are relieved that the Euthanasia Center exists, allowing them to refer their patients there.\u003c/p\u003e\n\u003cp\u003eEven for those who do perform euthanasia, GPs reported engaging in significant moral reflection before making a final decision. As several GPs explained: \u003cem\u003e[\u0026ldquo;You must be able to justify it to yourself.\u0026rdquo;]\u0026nbsp;\u003c/em\u003e(P1)\u003cem\u003e\u0026nbsp;\u003c/em\u003eand \u003cem\u003e[\u0026ldquo;Does it feel right to do this for this patient? Because I have to live with the knowledge that I will do this and have done it at some point. And I have to live with the absolute certainty.\u0026rdquo;]\u0026nbsp;\u003c/em\u003e(P13).\u003cem\u003e\u0026nbsp;\u003c/em\u003eMany cited the relief of unbearable suffering and providing a dignified death as central to their moral justification\u003cem\u003e: [\u0026ldquo;If someone suffers unbearably, hopelessly, and I cannot relieve it in any other way, then I see euthanasia as the last therapy.\u0026rdquo;]\u0026nbsp;\u003c/em\u003e(P6). Autonomy was another prominent theme. GPs stated that they deeply respect patients\u0026apos; right to decide how and when to die: \u003cem\u003e[\u0026ldquo;I believe that everyone has the free choice, and my conviction should not be an obstacle to that. Everyone has the right to freely choose how they live and end their life.\u0026rdquo;]\u0026nbsp;\u003c/em\u003e(P2).\u003cem\u003e\u0026nbsp;\u003c/em\u003eAs they value patient autonomy, GPs also assess throughout the process whether the request is well-considered and voluntary, and not influenced by family or friends\u003cem\u003e: [\u0026ldquo;And then I always find it important for myself that I speak to the patient alone. Because often there are family members present to make sure that it is indeed the person\u0026apos;s own wish and not something imposed by the surroundings.\u0026rdquo;]\u0026nbsp;\u003c/em\u003e(P6).\u003cem\u003e\u0026nbsp;\u003c/em\u003eTrust-building and empathy were also cited as essential. GPs use consultations not only to assess criteria but to determine whether they can empathize with the patient\u0026rsquo;s wish. This was articulated clearly by multiple GPs:\u003cem\u003e\u0026nbsp;[\u0026ldquo;But I personally feel that I must also be able to empathize with it in order to do it. It\u0026apos;s not nothing to do.\u0026rdquo;]\u0026nbsp;\u003c/em\u003e(P7)\u003cem\u003e\u0026nbsp;\u003c/em\u003eand \u003cem\u003e[\u0026ldquo;And then the request comes very late, and I can\u0026apos;t fully empathize with it in just three days.\u0026rdquo; ]\u0026nbsp;\u003c/em\u003e(P3).\u003c/p\u003e\n\u003cp\u003eGPs emphasized that the process behind a euthanasia request is complex and must not be underestimated. One GP detailed the process from start to finish: \u003cem\u003e[\u0026ldquo;This is something you really have to be fully behind yourself, but it\u0026rsquo;s a process that I handle very carefully. You have multiple conversations until you decide to bring in a second doctor because you feel ready to proceed with the euthanasia. Then the SCEN doctor comes, and they give the green light. And that is indeed a situation of hopeless, unbearable suffering. Then the protocol actually begins. The protocol that you will follow, the date that is scheduled, the medications that need to be ordered from the pharmacy, the reports that have to be filled out in advance. It\u0026rsquo;s a whole process leading up to it.\u0026rdquo;]\u0026nbsp;\u003c/em\u003e(P9). Other GPs described the process as \u0026ldquo;intense\u0026rdquo; and \u0026ldquo;energy-consuming.\u0026rdquo; Beyond conversations and decision-making, the administrative burden was also noted, especially the documentation required by the RTE (Regional Euthanasia Review Committee), with one GP stating: \u003cem\u003e[\u0026ldquo;I always say that euthanasia is a legal process, not a medical process.\u0026rdquo;]\u0026nbsp;\u003c/em\u003e(P2). Besides practical complexities, GPs reported significant emotional strain. One GP stated: \u003cem\u003e[\u0026ldquo;I find it hard. The conversations you have are intense and take a long time. So, it places a significant burden on your daily practice, which is already busy enough, and then these kinds of conversations are added on top.\u0026rdquo;]\u003c/em\u003e (P6). The emotional weight increases in the final stages. GPs reported sleepless nights, lingering stress, and emotional recovery time: \u003cem\u003e[\u0026ldquo;The week leading up to the euthanasia is difficult for me. In the sense that it occupies my mind a lot and I sleep poorly.\u0026rdquo;]\u003c/em\u003e (P8) and \u003cem\u003e[\u0026ldquo;You have to take an afternoon off to do it, and then you need some time to recover in the evening. And it still lingers in your mind for a week afterward.\u0026rdquo;]\u003c/em\u003e (P2). \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eWhile the patient\u0026rsquo;s wish is central, most GPs said they also consider the views of family members. As one GP put it\u003cem\u003e: [\u0026ldquo;It mainly concerns the patient, but it does help if the family is also supportive.\u0026rdquo;]\u003c/em\u003e (P6). In cases where family support is absent or conflicting, GPs respond differently. Some are troubled by family disagreement, while others prefer the patient and family resolve it themselves. A few GPs stated that family opinions do not influence their decision at all. To cope with the emotional and procedural burden, GPs often seek support. Many described working in pairs with colleagues or trainees for mutual support: \u003cem\u003e[\u0026ldquo;I never do it alone, there\u0026apos;s always a colleague or my buddy with me. And I\u0026rsquo;ve also joined others on their routes. I\u0026rsquo;m really not going to do it by myself if it doesn\u0026rsquo;t feel right or anything, it\u0026rsquo;s all just terrifying.\u0026rdquo;]\u003c/em\u003e (P10). GPs also consult other professionals, such as palliative care nurses and SCEN doctors, for guidance and emotional reinforcement.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eComparing Decision-Making Processes: Psychiatric versus Somatic\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe decision-making process surrounding euthanasia requests differs significantly between somatic and psychiatric cases, as revealed through interviews with GPs (Table 9). While some GPs expressed openness to evaluating both somatic and psychiatric requests \u003cem\u003e[\u0026ldquo;It doesn\u0026apos;t matter to me whether someone has metastatic lung cancer or indeed an incurable depression\u0026rdquo;]\u0026nbsp;\u003c/em\u003e(P13), others viewed psychiatric requests as outside their professional scope \u003cem\u003e[\u0026ldquo;I don\u0026apos;t believe that it falls within the GP\u0026apos;s role\u0026rdquo;]\u0026nbsp;\u003c/em\u003e(P4). Opinions varied: some had experience with psychiatric cases, some were open to them, while others excluded themselves entirely. However, all agreed that psychiatric requests are generally more complex. \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eA key challenge in psychiatric euthanasia is determining whether the patient\u0026rsquo;s suffering is genuinely \u0026quot;unbearable\u0026quot; and \u0026quot;hopeless.\u0026quot; In somatic cases like terminal cancer, GPs described that suffering is more clearly defined and supported by medical evidence such as terminal diagnoses and physical decline. As one GP remarked\u003cem\u003e: [\u0026ldquo;People also come back from a specialist, like the pulmonologist or cardiologist, and are out of treatment options. Somehow, I feel that\u0026rsquo;s different from psychiatry. It\u0026rsquo;s not as objective because you can\u0026apos;t measure it in the same way. With tumors, you can measure it\u0026rdquo;]\u0026nbsp;\u003c/em\u003e(P11). GPs indicated that psychiatric suffering is less tangible, leading to more subjective interpretation and uncertainty: \u003cem\u003e[\u0026ldquo;Psychiatric suffering is difficult in that sense, because compared to most somatic conditions, it\u0026rsquo;s harder to determine. When can we all be certain that this condition is a hopeless problem that we can no longer do anything about medically?\u0026rdquo;]\u0026nbsp;\u003c/em\u003e(P13).\u003cem\u003e\u0026nbsp;\u003c/em\u003eTreatment exhaustion was also described as more straightforward in somatic cases, as it is usually backed by specialist documentation: \u003cem\u003e[\u0026ldquo;You just have a letter from an oncologist that says this is the prognosis, and the patient is out of treatment options. And that\u0026rsquo;s very black and white\u0026rdquo;]\u0026nbsp;\u003c/em\u003e(P3).\u003cem\u003e\u0026nbsp;\u003c/em\u003eIn psychiatric cases, the absence of fixed protocols and the unpredictability of outcomes created more uncertainty: As one GP expressed: \u003cem\u003e[\u0026ldquo;What I find difficult is that the judgment of whether something is treatable or hopeless is sometimes harder to objectify in psychiatry\u0026rdquo;]\u0026nbsp;\u003c/em\u003e(P13).\u003cem\u003e\u0026nbsp;\u003c/em\u003eThis reflects broader concerns about the stability of psychiatric conditions, as the same GP questioned:: \u003cem\u003e[\u0026ldquo;How sure can you be that these complaints really can\u0026rsquo;t improve in any way?\u0026rdquo;]\u0026nbsp;\u003c/em\u003e(P13). The fluctuating nature of conditions like depression or schizophrenia added further complexity. GPs described how inconsistent symptoms can make it difficult to assess whether a request is stable and well-considered. Additionally, the disease itself can cause psychopathology, where the condition influences the patient\u0026rsquo;s decision-making capacity. As one GP explained: \u003cem\u003e[\u0026ldquo;Because it\u0026rsquo;s hard to distinguish between what is the illness and what is not the illness, does a death wish stem from their illness, or from their unbearable suffering?\u0026rdquo;]\u0026nbsp;\u003c/em\u003e(P6). This makes capacity assessment more difficult than in somatic cases, where wishes are usually clearer. While GPs acknowledged this complexity, most agreed psychiatric suffering can be hopeless and unbearable, though harder to assess.\u003c/p\u003e\n\u003cp\u003eBesides the challenges in assessing psychiatric patients\u0026apos; suffering and decision-making capacity, many GPs expressed hesitation due to limited psychiatric expertise. Even those willing to proceed emphasized the need for specialist support. When asked about assessing psychiatric requests, one GP stated: \u003cem\u003e[\u0026ldquo;No, I can\u0026apos;t do that on my own, so I ultimately need the support of specialists in that area, much more than with somatic conditions\u0026rdquo;]\u0026nbsp;\u003c/em\u003e(P13). The need for psychiatric input was a common theme: \u003cem\u003e[\u0026ldquo;In that case, I really need the expertise of a psychiatrist to look into it as well. To determine what comes from the illness and what comes from the wish to die, to no longer have this life, and what is still treatable in that?\u0026rdquo;]\u0026nbsp;\u003c/em\u003e(P5). In contrast, most GPs were more confident in evaluating somatic requests: \u003cem\u003e[\u0026ldquo;For somatic patients, I can handle the entire process; I am capable of that\u0026rdquo;]\u003c/em\u003e (P3). Furthermore, the interviews indicated that while EAS requests generally involve moral reflection, psychiatric requests tend to raise additional ethical challenges. Some GPs questioned whether societal or healthcare shortcomings contributed to patients\u0026apos; suffering. One GP reflected: \u003cem\u003e[\u0026ldquo;Aren\u0026rsquo;t we, as a care system or society, failing them? The home care comes by twice a day, and they\u0026rsquo;re alone the rest of the time. The same goes for someone with a psychiatric illness who isn\u0026rsquo;t accepted enough\u0026rdquo;]\u0026nbsp;\u003c/em\u003e(P5). Others felt personal discomfort: \u003cem\u003e[\u0026ldquo;When it comes to psychiatric disorders or dementia, I find the ethical part difficult. It\u0026rsquo;s something I have to come to terms with personally. I\u0026rsquo;m also religious, and even though I do support euthanasia, I do so with certain boundaries\u0026rdquo;]\u0026nbsp;\u003c/em\u003e(P4).\u003cem\u003e\u0026nbsp;\u003c/em\u003eMoreover, GPs indicated throughout the interviews that they value empathizing with requests. Several GPs noted they had more difficulty personally \u0026ldquo;feeling\u0026rdquo; the request for psychiatric cases compared to somatic ones: \u003cem\u003e[\u0026ldquo;I find psychiatric issues difficult to empathize with, even though I know it\u0026rsquo;s real and untreatable\u0026rdquo;]\u0026nbsp;\u003c/em\u003e(P5). \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eDespite its complexities, many believed psychiatric requests can be responsibly assessed, but most said this requires more time and collaboration: \u003cem\u003e[\u0026ldquo;And there are situations where it\u0026rsquo;s possible to say, \u0026apos;Well, we\u0026rsquo;ve really tried everything. No one else thinks differently about this.\u0026apos; And we draw a line now, and we can indeed proceed with euthanasia. But again, it takes more time, it requires more consultation\u0026rdquo;]\u0026nbsp;\u003c/em\u003e(P13). For some, the extra time and complexity were reasons not to engage in psychiatric cases. Others stressed that time constraints should not interfere. Given the added difficulty, referrals to the Euthanasia Expertise Center were more commonly discussed for psychiatric than somatic cases: : \u003cem\u003e[\u0026ldquo;I also had a few people with mental health issues. I couldn\u0026rsquo;t do it myself or didn\u0026rsquo;t want to, so I referred them to the Euthanasia Expertise Center\u0026rdquo;]\u0026nbsp;\u003c/em\u003e(P7) and\u003cem\u003e\u0026nbsp;[\u0026ldquo;I once had a young woman who requested it from me, but she consistently declined psychiatric care and wasn\u0026rsquo;t clearly suicidal either. I referred a case like that to the End-of-Life Clinic.\u0026rdquo;]\u0026nbsp;\u003c/em\u003e(P4). For GPs who considered evaluating psychiatric requests or had done so in the past, patient characteristics, especially age played an important role. Psychiatric euthanasia requests from younger patients were often met with hesitation. Some GPs felt uncomfortable deciding on such irreversible matters for younger individuals. One GP shared: \u003cem\u003e[\u0026ldquo;I do have difficulty with euthanasia in cases of psychological suffering, especially in young people, because I wonder if someone\u0026apos;s brain has fully developed\u0026rdquo;]\u0026nbsp;\u003c/em\u003e(P8). Another said\u003cem\u003e: [\u0026ldquo;That was also the case with psychological suffering in patients of mine from practice. One was a 43-year-old woman and the other was a 65-year-old woman. I felt that the 43-year-old woman was really too young, so I couldn\u0026rsquo;t justify doing that for myself\u0026rdquo;]\u0026nbsp;\u003c/em\u003e(P6).\u003c/p\u003e\n\u003cp\u003eLastly, GPs expressed appreciation for the existing legal framework and professional guidelines that help navigate complex euthanasia cases. Several emphasized that Dutch euthanasia law is well established and provides a clear foundation. As one GP stated: \u003cem\u003e[\u0026ldquo;In the Netherlands, we have had a good law for quite some time now, and we are trained accordingly. So yes, as general practitioners, we know what we need to do, so to speak. We have good guidelines for that.\u0026rdquo;\u003c/em\u003e (P10). Another remarked\u003cem\u003e:\u003c/em\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003cem\u003e[\u0026ldquo;I think the laws and regulations are clear about what is and isn\u0026apos;t acceptable.\u0026rdquo; ]\u0026nbsp;\u003c/em\u003e(P11). Most GPs said they relied primarily on the KNMG guidelines: \u003cem\u003e[\u0026ldquo;The rules we follow are from the KNMG. And indeed, the Dutch Association for Psychiatry also has separate guidelines. But as general practitioners, we follow the KNMG guidelines.\u0026rdquo;]\u003c/em\u003e (P6). However, some were unfamiliar with the Dutch Association for Psychiatry\u0026rsquo;s guidelines. SCEN-trained GPs or those with more experience knew of the psychiatric guidelines but sometimes found them too strict: \u003cem\u003e[\u0026ldquo;What I find difficult is that the Dutch Association for Psychiatry imposes additional requirements. For example, the SCEN specialist must also be a psychiatrist\u0026rdquo;]\u0026nbsp;\u003c/em\u003e(P1). Some GPs mentioned legal concerns specifically in psychiatric cases: \u003cem\u003e[\u0026ldquo;I find psychiatry more difficult because it maybe that even if you have done it correctly, you may have to stand in court.\u0026rdquo;]\u003c/em\u003e (P7) Still, most did not cite fear of prosecution as a major barrier when evaluating psychiatric requests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 9:\u003c/strong\u003e Comparison of the decision-making process of Dutch GPs for psychiatric versus somatic requests for EAS\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"605\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003eComparison Decision making process of Dutch GPs (n=13)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eSomatic Requests\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003ePsychiatric Requests\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eOpenness to evaluate requests\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eAll GPs (except 1) were open to evaluating somatic EAS requests.\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eMore divergent opinions. Some GPs excluded psychiatric EAS from their scope.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eComplexity in assessing suffering\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eSuffering perceived as clearer and supported by medical evidence.\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eMore subjective; less measurable; difficulty in determining hopelessness.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eTreatment exhaustion\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eOften confirmed with clear documentation from specialists.\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eHarder to verify; lacks objective markers. \u0026nbsp;GPs struggle to assess when all treatments have truly failed.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eDecision-making capacity\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eGenerally perceived as more stable and straightforward.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eGreater doubts about whether the wish to die stems from autonomous choice or the psychiatric disorder.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eKnowledge and expertise needs\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eGPs felt more capable and confident.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eGPs emphasized need for psychiatric expertise or external input.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eReferral behavior\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eReferral to Euthanasia Centre mentioned less frequently.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eReferral to Euthanasia Centre or need for consultation was more common.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eEthical reflection\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eGeneral moral reflection noted.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eAdditional ethical concerns raised, e.g. societal failure, professional boundaries.\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eEmpathy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eGPs often able to empathize with somatic suffering.\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eSome struggled to emotionally connect despite recognizing real suffering.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eProcess time\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eSeen as faster and more straightforward.\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003ePerceived as more time-intensive and requiring more consultation.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eFear of legal prosecution\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eRarely mentioned; low concern.\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eSome indication of fear but rarely mentioned\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eGuidelines and law clarity\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eKNMG guidelines widely used and understood.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003ePsychiatric guidelines less known or seen as restrictive.\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eInfluence of patient characteristics\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eYounger patients with families raised some concern.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eYouth often seen as a barrier; more hesitation reported.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e"},{"header":"Discussion","content":"\u003cp\u003e\u003cb\u003eStudy Results in the Context of Existing Evidence\u003c/b\u003e\u003c/p\u003e\u003cp\u003eThis study offers new insights into Dutch GPs willingness to grant and perform EAS for psychiatric versus somatic patients, and highlights key differences in their decision-making processes. Quantitative results showed that psychiatric requests were significantly less likely to be granted, religious GPs were less likely to grant EAS requests, and euthanasia was more likely to be granted than assisted suicide. The lower odds of granting psychiatric requests aligns with findings by Bolt et al., who reported that Dutch physicians found EAS more conceivable for physical conditions (82%) than for psychiatric ones (34%) [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. The influence of religion supports previous findings that it can act as a barrier, with religious physicians being more likely to oppose EAS [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. In contrast to a prior study reporting no significant difference between euthanasia and assisted suicide [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e], this study observed a clear preference for euthanasia, matching attitudes found in Table\u0026nbsp;\u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e5\u003c/span\u003e. Differences may stem from sample composition, as the earlier study included elderly care physicians and specialists, while this one focused solely on GPs. When directly asked about willingness to perform EAS, most GPs were open to doing so for somatic patients, but fewer than half of the GPs were willing to perform psychiatric EAS, which is consistent with earlier studies by Pronk et al. and Evenblij et al., who similarly found that less than half of the GPs find performing psychiatric EAS conceivable [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eThe results also demonstrated that prior experience performing psychiatric EAS significantly increased willingness to do so again, aligning with research suggesting experience reduces hesitation [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. However, while Evenblij et al. found that experience receiving psychiatric EAS requests increased openness to performing it, this study found no significant effect [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. A likely explanation is that Evenblij et al. used broader, more general questions about conceivability and included a wider physician sample rather than only GPs. Moreover, while religion significantly influenced willingness to grant EAS, it did not affect willingness to perform it. This may suggest that religious beliefs impact formal approval more than personal action. Another explanation is that the analysis excluded GPs entirely unwilling to perform EAS due to their small number. Strictly religious GPs may have been overrepresented in this group or chose not to answer, as personal willingness may conflict more directly with their beliefs than hypothetical case questions.\u003c/p\u003e\u003cp\u003e The interviews provided deeper insight into GPs\u0026rsquo; decision-making processes and confirmed a general consensus: evaluating psychiatric EAS requests is more challenging than somatic ones. These findings complement the quantitative results and explain lower willingness towards psychiatric EAS. In general, GPs valued a strong doctor\u0026ndash;patient relationship, engaged in moral reflection, and described emotional and organizational strains, in line with prior research [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. While earlier studies emphasized the importance of understanding patient requests, this study notably found that GPs highlighted the need to empathize with a patient\u0026rsquo;s wish - a dimension rarely discussed in existing literature [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. Furthermore, while some studies suggest that family opinions can significantly influence or even pressure physicians, most participants in this study valued family input without feeling pressured. This aligns with recent findings showing that Dutch physicians often seek relatives\u0026rsquo; views, but only 35% actually consider them in their decisions [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. Comparing psychiatric with somatic requests revealed that psychiatric cases are experienced as more difficult by the GPs, mainly due to challenges in assessing due care criteria. Difficulties included objectifying psychiatric suffering, distinguishing requests from illness symptoms, evaluating decision-making capacity, fearing potential recovery, and determining treatment exhaustion, all of which contributed to a lengthier decision-making process. These challenges, though not often compared directly with somatic cases, are well-documented in psychiatric EAS literature [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]. Furthermore, the interviews revealed that GPs had additional ethical concerns and greater uncertainty about their own capabilities and knowledge when evaluating psychiatric EAS requests, often expressing a need for support from a psychiatrist. These findings align with previous studies and the attitudinal data in Table\u0026nbsp;\u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e5\u003c/span\u003e, which show that many GPs feel less confident assessing psychiatric cases [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eThis research also identified less-explored contributors to the disparity between psychiatric and somatic EAS, such as patient age. GPs expressed greater personal resistance to psychiatric requests from younger individuals, suggesting that age plays a more decisive role in psychiatric cases. This aligns with findings from a Psychiatry study reporting concerns about future recovery, developmental maturity, and long-term prognosis in younger psychiatric patients [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]. A notable new insight was that GPs felt more emotionally distant from psychiatric requests; they found it harder to relate to or empathize with these cases. This often-overlooked emotional aspect may help explain why they are less willing to handle such requests. In response to these challenges, GPs discussed referring psychiatric cases to the Euthanasia Expertise Center more or sought their support, echoing national data from the Center [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e]. Lastly, although most GPs reported using KNMG guidelines, few were familiar with the NVvP\u0026rsquo;s specific psychiatric guideline. This aligns with findings that even psychiatrists sometimes lack awareness or application of this standard [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e]. While not required by the RTE, the NVvP guideline offers valuable support, for instance on treatment refusal, and could strengthen GP confidence and provide additional support, as GPs now indicated a lack of support from existing guidelines (Table \u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e5\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003cb\u003eStrengths and limitations\u003c/b\u003e\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eThis study used a concurrent mixed-methods approach, combining quantitative and qualitative data to strengthen validity. While the survey identified broad patterns in GPs willingness toward EAS, interviews provided deeper insight into the reasoning behind their decisions, enhancing the study\u0026rsquo;s comprehensiveness and interpretative depth. The research is particularly timely given the rise in psychiatric EAS cases in the Netherlands and the growing international debate surrounding such practices. Insights from the Dutch context may serve as a useful reference for countries navigating similar legal and ethical considerations [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. Nevertheless, this study has some limitations. The relatively small sample size (n\u0026thinsp;=\u0026thinsp;103) may limit the generalizability of the findings, although most results are in line with prior research. Some GPs indicated that the survey answer options did not fully reflect their views particularly regarding the lack of an option to refer a patient\u0026rsquo;s request. Furthermore, due to convergence issues, multilevel modelling was not used for Models 4 and 5. Although binary logistic regression without hierarchical structure was used. Odds ratios (ORs) and confidence intervals (CIs) for most predictors remained consistent with those in the hierarchical models indicating that this modeling approach did not impact the interpretation of the results.\u003c/p\u003e\u003cp\u003e\u003cb\u003eRecommendations for future research\u003c/b\u003e\u003c/p\u003e\u003cp\u003eAs psychiatric EAS cases rise in the Netherlands, ongoing research remains critical. This study highlights the need to explore empathy in greater depth, particularly how they affect physicians willingness to engage with psychiatric requests. Future qualitative research should further examine how patient characteristics, especially younger age, shape GPs\u0026rsquo; decisions, as youth often provokes stronger ethical hesitation. Additionally, larger-scale quantitative studies are recommended to assess how physician traits such as experience, religion, and psychiatric EAS exposure influence clinical decisions. These insights can inform more tailored training, support structures, and policies to better equip GPs for complex EAS requests.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003e These findings highlight the need to strengthen support measures by improving and increasing awareness of existing guidelines, facilitating access to psychiatric or SCEN consultations, encouraging collaboration with the Euthanasia Expertise Center, and enhancing training to better support GPs in evaluating due care criteria in psychiatric EAS cases.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eAI\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eArtificial Intelligence\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eCI\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eConfidence Interval\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eDSM-5\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eDiagnostic and Statistical Manual of Mental Disorders, Fifth Edition\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eEAS\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eEuthanasia and Assisted Suicide\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eGP\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eGeneral Practitioner\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eKNMG\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eRoyal Dutch Medical Association\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eKNMP\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eRoyal Dutch Pharmacists Association\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eMAiD\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eMedical Assistance in Dying (Canadian term)\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eMAXQDA\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eSoftware for qualitative and mixed methods data analysis\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eNVvP\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eDutch Association of Psychiatrists (Nederlandse Vereniging voor Psychiatrie)\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eOR\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eOdds Ratio\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003ePAD\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003ePhysician-Assisted Dying\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003ePAS\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003ePhysician-Assisted Suicide\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eRTE\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eRegional Euthanasia Review Committees\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eSCEN\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eSupport and Consultation on Euthanasia in the Netherlands\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eSPSS\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eStatistical Package for the Social Sciences\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was conducted in compliance with the Declaration of Helsinki. Ethical approval for this study was obtained from the Ethics Committee of the Management Center Innsbruck (MCI). All participants received information about the study\u0026rsquo;s aims. Informed consent was obtained prior to participation in both the survey and the interviews. Interviews were recorded with permission, and all data were securely stored and accessible only to the researcher. Anonymity and confidentiality were strictly maintained throughout the research process. Given the sensitivity of the topic, special attention was paid to participants comfort and the voluntary nature of their involvement.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003cstrong\u003eFunding Declaration\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003cstrong\u003eClinical Trial Number\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCorresponding author\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eMSc Esmee PGM Jenniskens\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eEmail: [email protected]\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eEJ conceived the study, designed the methodology, developed the survey and interview instruments, coordinated and conducted all data collection (including survey distribution and interviews), and performed the full quantitative and qualitative analyses. EJ also created all tables and figures, drafted the manuscript, and ensured the overall integrity, structure, and coherence of the project from inception to completion.NM served as the academic supervisor, providing conceptual input, methodological guidance, and critical feedback throughout the study. NM reviewed and commented on multiple drafts of the manuscript and contributed to improving its clarity.Both authors read and approved the final manuscript.\u003c/p\u003e\u003ch2\u003eAcknowledgement\u003c/h2\u003e\u003cp\u003eI sincerely thank the general practitioners who generously shared their time and experiences through the survey and interviews, providing invaluable perspectives on their willingness to grant and perform EAS for somatic versus psychiatric patients and their decision making process.\u003c/p\u003e\u003ch2\u003eData Availability\u003c/h2\u003e\u003cp\u003eThe datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eTermination of Life on Request and Assisted Suicide (Review Procedures) Act. Act of April 1, 2001. Bull Acts Decrees. 2001;194. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://wfrtds.org/dutch-law-on-termination-of-life-on-request-and-assisted-suicide-complete-text/\u003c/span\u003e\u003cspan address=\"https://wfrtds.org/dutch-law-on-termination-of-life-on-request-and-assisted-suicide-complete-text/\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eGovernment of the Netherlands. Is euthanasia allowed? [Internet]. [cited 2025 Jan 21]. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.government.nl/topics/euthanasia/is-euthanasia-allowed\u003c/span\u003e\u003cspan address=\"https://www.government.nl/topics/euthanasia/is-euthanasia-allowed\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eNetherlands Penal Code. 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Considerations on requests for euthanasia or assisted suicide: a qualitative study with Dutch general practitioners. Fam Pract. 2017;34(6):723\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eRoest B, Trappenburg M, Leget C. The involvement of family in the Dutch practice of euthanasia and physician-assisted suicide: a systematic mixed studies review. BMC Med Ethics. 2019;20:1\u0026ndash;21.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eDe Boer ME, Depla MF, den Breejen M, Slottje P, Onwuteaka-Philipsen BD, Hertogh CM. Pressure in dealing with requests for euthanasia or assisted suicide: experiences of general practitioners. J Med Ethics. 2019;45(7):425\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003evan Zwol M, de Boer F, Evans N, Widdershoven G. Moral values of Dutch physicians in relation to requests for euthanasia: a qualitative study. BMC Med Ethics. 2022;23(1):94.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003evan Veen SMP, Widdershoven GAM, Beekman ATF, Evans N. Physician assisted death for psychiatric suffering: experiences in the Netherlands. Front Psychiatry. 2022;13:895387.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eCreswell JW. Chapter 1, The selection of a research design. Research design: qualitative, quantitative, and mixed methods approaches. 3rd ed. Thousand Oaks (CA): SAGE; 2009. pp. 3\u0026ndash;21.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eKouwenhoven PS, Raijmakers NJ, van Delden JJ, Rietjens JA, Schermer MH, van Thiel GJ, et al. Opinions of health care professionals and the public after eight years of euthanasia legislation in the Netherlands: a mixed methods approach. Palliat Med. 2013;27(3):273\u0026ndash;80.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eHox JJ. Why do we need special multilevel analysis techniques? 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Ethical perspectives regarding euthanasia, including in the context of adult psychiatry: a qualitative interview study among healthcare workers in Belgium. BMC Med Ethics. 2024;25(1):19. PMID: 38773465; PMCID: PMC11107029.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eSchweren LJ, Rasing SP, Kammeraat M, et al. Requests for medical assistance in dying by young Dutch people with psychiatric disorders. JAMA Psychiatry. 2025;82(3):246\u0026ndash;52.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eExpertisecentrum Euthanasie. Feiten en cijfers over 2024 [Internet]. 2025 [cited 2025 May 1]. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://expertisecentrumeuthanasie.nl/app/uploads/2025/04/EE-Feiten-en-Cijfers-over-2024_web.pdf\u003c/span\u003e\u003cspan address=\"https://expertisecentrumeuthanasie.nl/app/uploads/2025/04/EE-Feiten-en-Cijfers-over-2024_web.pdf\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eKim SY, De Vries RG, Peteet JR. Euthanasia and assisted suicide of patients with psychiatric disorders in the Netherlands 2011 to 2014. JAMA Psychiatry. 2016;73(4):362\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-medical-ethics","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"meth","sideBox":"Learn more about [BMC Medical Ethics](http://bmcmedethics.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/meth/default.aspx","title":"BMC Medical Ethics","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Euthanasia, Assisted Suicide, General Practitioners, Psychiatric Patients, Somatic Patients, Decision-Making, Mixed-Methods Study, Netherlands","lastPublishedDoi":"10.21203/rs.3.rs-7165404/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7165404/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e\u003cp\u003eThe Netherlands legalized euthanasia and assisted suicide (EAS) in 2002, permitting requests from both somatic and psychiatric patients under strict conditions. However, physicians are not obligated to comply. General practitioners (GPs), who receive most EAS requests, play a central role in this process. Although EAS for somatic conditions is common in the Netherlands, psychiatric EAS remains relatively rare and controversial, despite a growing number of requests. This study explores how Dutch eneral practitioners willingness to grant and perform EAS requests differs between psychiatric and somatic patients and compares the underlying decision-making processes.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e\u003cp\u003eA concurrent mixed-methods design was employed, combining a quantitative survey and qualitative interviews. The survey included sociodemographic and attitudinal questions, experience with EAS, and six randomized vignettes varying by somatic and psychiatric diagnosis (cancer, depression) and method (euthanasia or assisted suicide) to examine willingness to perform EAS. Semi-structured interviews explored GPs reasoning and experiences in more depth.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e\u003cp\u003eGPs were significantly less likely to grant psychiatric than somatic EAS requests (OR\u0026thinsp;=\u0026thinsp;0.02, 95% CI [0.009\u0026ndash;0.04]). Religious GPs were less likely to approve EAS (OR\u0026thinsp;=\u0026thinsp;0.31, 95% CI [0.11\u0026ndash;0.85]), and euthanasia was favored over assisted suicide (OR\u0026thinsp;=\u0026thinsp;2.3, 95% CI [1.31\u0026ndash;4.03]). Psychiatric diagnosis type and prior experience receiving psychiatric requests showed no significant effect. Willingness to perform EAS was higher for somatic (95.1%) than psychiatric cases (45.6%). Prior experience performing psychiatric EAS was associated with a lower likelihood of restricting their willingness to somatic cases alone (OR\u0026thinsp;=\u0026thinsp;0.15, 95% CI [0.02\u0026ndash;0.73]). Interviews underscored the greater complexity of psychiatric EAS, citing challenges in assessing due care criteria, empathizing with requests, ethical dilemmas, extended processes, and lack of confidence. Psychiatric cases were more often referred to specialists.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e\u003cp\u003eDutch GPs are less willing to grant and perform EAS for psychiatric patients compared to somatic ones. This may reflect difficulties assessing due care criteria, clinical uncertainty, difficulties empathizing, prolonged processes and ethical complexity, highlighting the need for clearer guidelines, targeted training, and stronger support for GPs involved in psychiatric EAS.\u003c/p\u003e","manuscriptTitle":"Willingness of Dutch general practitioners to grant and perform Euthanasia and Assisted Suicide: A mixed methods study comparing psychiatric and somatic cases and the factors guiding their decisions","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-08-01 11:01:53","doi":"10.21203/rs.3.rs-7165404/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-08-25T04:18:49+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-08-21T13:59:36+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-08-21T12:55:27+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"264211375012761090506929581388068518816","date":"2025-08-13T12:32:32+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"64854977752549140208248859075066925666","date":"2025-07-29T15:52:28+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-07-29T08:51:30+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-07-29T07:03:43+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-07-28T07:03:52+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-07-28T07:03:00+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Medical Ethics","date":"2025-07-19T15:23:34+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-medical-ethics","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"meth","sideBox":"Learn more about [BMC Medical Ethics](http://bmcmedethics.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/meth/default.aspx","title":"BMC Medical Ethics","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"f311811b-15fb-4be8-bb2d-f2fb510437f3","owner":[],"postedDate":"August 1st, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-12-01T16:05:13+00:00","versionOfRecord":{"articleIdentity":"rs-7165404","link":"https://doi.org/10.1186/s12910-025-01333-y","journal":{"identity":"bmc-medical-ethics","isVorOnly":false,"title":"BMC Medical Ethics"},"publishedOn":"2025-11-25 15:57:31","publishedOnDateReadable":"November 25th, 2025"},"versionCreatedAt":"2025-08-01 11:01:53","video":"","vorDoi":"10.1186/s12910-025-01333-y","vorDoiUrl":"https://doi.org/10.1186/s12910-025-01333-y","workflowStages":[]},"version":"v1","identity":"rs-7165404","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7165404","identity":"rs-7165404","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}