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 national guideline on palliative sedation (Richtlijn palliatieve sedatie, published on Palliaweb), 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.
Pharmacy data from the SFK (Stichting Farmaceutische Kengetallen) suggest that palliative sedation preceded about 27.5% of all deaths in the Netherlands in 2024, up from 19.9% in 2015. These figures come from community pharmacies and leave out hospitals, so the real share is probably somewhat higher. 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 2025, the RTE received 10,341 reported euthanasia cases, about 6% of all deaths (5.8% in 2024: 9,958). In 7 cases the committee found the due-care criteria were not met (RTE Jaarverslag 2025).
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 the patient can no longer decide, their legal representative (WGBO) must consent, except in an acute emergency | 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 the patient can no longer decide, their legal representative under the WGBO (often the partner or an adult child) must consent, except in an acute emergency. 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: a written euthanasia request made earlier by someone aged 16 or over who can no longer express their will (article 2(2) of the Act). In practice this mostly concerns advanced dementia, and 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, in Legal Papers, you record which documents you have (for example a euthanasieverklaring or a behandelverbod), where they are kept and when you discussed them with your huisarts, and you can write down your wishes in your own words. The app does not draft these documents for you. You fill it in at your own pace, and what you record becomes part of your Zorgmap, a PDF you print or hand to the people you trust.
Closed beta — access by invitation.
Sources
- KNMG — Royal Dutch Medical Association, professional guidance on palliative sedation and euthanasia. https://www.knmg.nl
- Palliaweb (PZNL, Palliatieve Zorg Nederland) — Richtlijn palliatieve sedatie and clinical guidance. https://palliaweb.nl
- SFK (Stichting Farmaceutische Kengetallen) — 3,6% meer palliatieve sedatie in 2024. https://www.sfk.nl/publicatie/2025/farmacie-cijfers/36-meer-palliatieve-sedatie-2024
- Regionale Toetsingscommissies Euthanasie — annual reports, including the Jaarverslag 2025. https://www.euthanasiecommissie.nl