Palliative sedation vs euthanasia: what is the difference
The two are confused often, even by people who have lived with serious illness in the family. Both involve a doctor, both happen near the end of life, and both bring relief from suffering. But in Dutch medicine and Dutch law they are entirely different acts, governed by different rules, with different effects on the body and on the time that remains.
This explainer sets out what each is, who decides, and where the boundary lies.
What palliative sedation is
Palliatieve sedatie (palliative sedation) is the deliberate lowering of consciousness in the last phase of life, to relieve symptoms that cannot be controlled in any other way — often severe pain, breathlessness, agitation or delirium. The patient is given sedating medication, usually midazolam, in doses calibrated to the level of relief needed. Sedation can be intermittent or continuous; the form most discussed publicly is continue palliatieve sedatie tot het overlijden (continuous sedation until death).
In the KNMG/Pallialine guideline, continuous palliative sedation may be started when two conditions are met: there is one or more refractoire symptomen (refractory symptoms — symptoms that cannot be relieved by other reasonable means), and the patient's life expectancy is no more than approximately two weeks. The intention is symptom control, not death. Studies and the guideline both confirm that, when applied correctly, palliative sedation does not shorten life.
Palliative sedation is regarded in the Netherlands as normaal medisch handelen — normal medical practice. It is not regulated by a special statute. It does not require an independent second opinion under law. It does not need to be reported to a review committee. The doctor records the decision in the medical file and acts on standard professional guidelines.
In 2024, palliative sedation preceded an estimated 27.5% of all deaths in the Netherlands, up from 8.2% in 2005 [Pallialine / KNMG]. The increase reflects both improved recognition of refractory symptoms and the move of more dying out of hospitals into homes and hospices.
What euthanasia is
Euthanasie (euthanasia) is the deliberate ending of a patient's life by a doctor, at the patient's explicit and voluntary request, by administering a lethal substance. Hulp bij zelfdoding (physician-assisted suicide) falls under the same legal framework — the doctor prepares the substance and the patient takes it themselves.
Euthanasia is governed by the Wet toetsing levensbeeindiging op verzoek en hulp bij zelfdoding (the 2002 Termination of Life on Request Act). Under the Dutch penal code it remains a criminal offence; the Act creates an exception for doctors who comply with six zorgvuldigheidseisen (due care criteria) and report the case to a Regionale Toetsingscommissie Euthanasie (RTE — regional review committee).
The intention is to end life. The substance and dose follow the KNMG/KNMP standard for euthanatica. Death follows minutes after administration. Every case is reviewed by the RTE after the fact and, in case of doubt, by the Public Prosecution Service.
In 2024, the RTE received 9,958 reported euthanasia cases, around 5.8% of all deaths [euthanasiecommissie.nl, RTE Jaarverslag 2024]. Provisional 2025 estimates suggest continued growth, but the full Jaarverslag 2025 is still pending.
The core difference
| Palliative sedation | Euthanasia | |
|---|---|---|
| Intention | Relieve refractory symptoms | End life on patient's request |
| Effect on time of death | Does not shorten life | Death follows within minutes |
| Patient consent | Required if competent; may proceed in best interest if not | Required, voluntary, sustained — no exception |
| Legal status | Normal medical practice | Criminal act with statutory defence under 2002 Act |
| Second opinion | Recommended for complex cases; not required by law | Mandatory: independent SCEN-arts |
| Review after | Internal medical record | Mandatory report to RTE |
| Medication | Sedatives, mainly midazolam | Lethal dose, KNMG/KNMP protocol |
| Life expectancy condition | Approximately two weeks or less | No statutory limit, but unbearable suffering required |
The difference, simplified: palliative sedation lowers consciousness to make the dying tolerable. Euthanasia ends life because the suffering is not. They are not steps on the same ladder.
Who decides, and what the family is asked
For palliative sedation, the decision is medical. The treating doctor — usually the huisarts (general practitioner) — concludes that there are refractory symptoms and that life expectancy is short enough. If the patient is wilsbekwaam (mentally competent), informed consent is required. If not, the doctor proceeds in the patient's best interest, in consultation with naasten (close relatives). Family members are informed and involved, but family consent is not legally required. The family is part of the conversation about timing, presence at the bedside, and what to expect.
For euthanasia, the decision rests on the patient's own, repeated, voluntary request. Family members may be present in the conversations and at the procedure, but they cannot request euthanasia for someone else, and they cannot block it if the patient and doctor have met the criteria. The patient must remain wilsbekwaam at the moment of administration, with one narrow exception for advance directives in advanced dementia, where the bar is high and contested.
Where confusion arises
Three points are worth being precise about.
It is not a continuum. A patient does not "move on to" euthanasia from palliative sedation. They are alternative responses to different situations: refractory symptoms in a clearly terminal patient versus an explicit, sustained request for an end to suffering. Some patients consider both at different points in their illness. The clinical and legal pathways remain separate.
Palliative sedation is not "slow euthanasia." This phrase appears in public debate and is rejected by the KNMG. The intention, the dose, the timing and the legal status are different. Cases where sedation is used as a workaround for euthanasia are by definition outside the guideline and would be reportable.
A wilsverklaring (advance directive) is not the trigger. Neither sedation nor euthanasia happens because a document exists. Sedation is initiated when the clinical conditions are met. Euthanasia requires the doctor to be personally convinced that all six due care criteria are met at the moment, with or without an advance directive in the file.
Talking about either, in advance
Both are easier when discussed early — with the huisarts, and with the people closest to the patient. For palliative sedation, the question to record in a wilsverklaring is your attitude toward continuous sedation if symptoms become refractory in the last weeks. For euthanasia, the document is one part of a longer conversation; on its own it does not initiate anything.
In the app
In the Personal Portal you record your attitude toward palliative sedation and euthanasia separately, with the date you last discussed each with your huisarts. The two questions stay distinct, the way the law and the guidelines keep them distinct.
Closed beta — access by invitation.
Sources
- KNMG — Royal Dutch Medical Association, professional guidance on palliative sedation and euthanasia. https://www.knmg.nl
- Pallialine / IKNL — KNMG-richtlijn palliatieve sedatie and clinical guidance. https://palliaweb.nl
- Regionale Toetsingscommissies Euthanasie — annual reports and 2025 case figures. https://www.euthanasiecommissie.nl