Euthanasia among people with dementia in the Netherlands has nearly tripled since 2020. The number of people with dementia receiving euthanasia rose from 170 in 2020 to 499 last year, according to new figures from the Regional Euthanasia Review Committees (RTE).

According to NU.nl, the case of Jaap Breugem, who received euthanasia in November due to Alzheimer’s disease, illustrates how individuals try to act before losing legal capacity. Breugem explained his reasoning before his death: “I will have to give up some things. But I would rather die in one go than lose a little bit of myself every day.” He added: “I want to die as myself, not as a shadow of myself.” He was ultimately euthanized on Nov. 15.

Once a person becomes no longer mentally competent, euthanasia becomes extremely difficult because the legal requirement of “unbearable suffering” can no longer be clearly assessed by the patient. Last year, only seven patients who were no longer mentally competent received euthanasia in the Netherlands, according to RTE figures. That number has remained stable for five years.

Marcel Gigengack, a geriatric care specialist and euthanasia consultant, told NU.nl that a highly specific advance directive is required in such cases. “Once in that situation, suffering must be visible and felt as unbearable. For example, by daily hours of crying or aggression that cannot be treated with medication,” he said. “If you are calmly watching television all day, euthanasia is not an option, despite your advance directive.”

The Dutch End-of-Life Association (NVVE) describes the decision as requiring “timing at five to twelve,” meaning just before loss of mental capacity. “Ahead-of-time euthanasia requires courage,” an NVVE spokesperson said. “Because you give up good days and weeks to avoid the situation you fear. In dementia, there is a period in which your condition shifts from competent to incompetent.”

The organization said the transition period is crucial. “Not so early that you are still fully engaged in life, but not so late that you already suffer from decline. And especially suffering from the suffering you anticipate.” They added that patients often rely on relatives to recognize when capacity is fading.

Despite the increase, euthanasia in dementia cases remains rare compared with the roughly 300,000 people living with dementia in the Netherlands.

Gigengack also cautioned against assuming worst-case outcomes. “People always have a certain expectation of the future: ‘If this or that happens to me, it will be terrible.’ But you only know how bad it really is when you get there,” he said. “There are certainly people with advanced dementia who experience unbearable suffering. But most enjoy the present, the attention of the care staff. A nursing home may seem terrible, but the social environment and routine can also work out well,” he said.