Psychiatric patients requesting euthanasia: Guidelines for sound clinical and ethical decision making

Multidimensional Study of the Attitude towards Euthanasia of Older Adults with Mixed Anxiety-Depressive Disorder

INTRODUCTION

This study aims to verify if older adults with mixed anxiety-depressive disorder are more prone to euthanasia and identify factors that interfere with their satisfaction with health and capacity for well-informed decisions.

MATERIAL AND METHODS

The study applied a paper questionnaire composed of a sociodemographic section and a battery of scales (to assess depression, anxiety, cognitive performance, suicide risk, therapeutic adhesion, functionality, loneliness, attitude towards euthanasia, decision pattern, personality, empathy, and health status) in the Psychogeriatric Unity of Senhora da Oliveira Hospital in Portugal. The sample was collected by convenience to include patients and controls of the same age. Six months later, a reassessment was performed. Patients and controls were compared using descriptive statistics and a multiple-regression model.

RESULTS

A total of 114 patients and 25 controls were included. Eighty-one point six percent of patients had four or fewer years of schooling. Contrary to controls, they presented mild depressive and anxiety symptoms, loneliness feelings, worse cognitive performance, a more fragile personality, higher personal distress, and a poorer health state. No statistically significant differences were found between controls and patients regarding their attitudes towards euthanasia. Patients more favourable to euthanasia had higher empathic concern, conscientiousness, and fantasy, and lower personal distress.

DISCUSSION AND CONCLUSION

When addressing euthanasia in these patients, it is crucial to ensure they are fully self-determinate and that all the necessary treatment and support are available. It may not be the case when the educational level is low and a mild disease persists, significantly affecting their well-being and cognitive performance.

Perspectives on the eligibility criteria for euthanasia for mental suffering caused by psychiatric disorder under the Belgian Euthanasia Law: A qualitative interview study among mental healthcare workers

INTRODUCTION

Euthanasia in adults with psychiatric conditions (APC) is allowed in Belgium and impacts a variety of workers in this field, including psychiatrists, psychiatric nurses, psychologists, and support "buddies". This study examines their perspectives on the appropriateness of the current legal criteria for, and practice of, euthanasia in the context of psychiatry, and their suggestions to properly implement or amend these criteria.

METHODS

Semi-structured interviews were conducted with 30 Dutch-speaking mental healthcare workers who had at least one experience with an APC requesting euthanasia, in Flanders and Brussels (Belgium), between August 2019 and August 2020. Interview transcripts were analyzed through qualitative content analysis.

FINDINGS

Our study shows that, for these mental healthcare workers, only one of the legal eligibility criteria to assess euthanasia requests by APC (i.e., unbearable suffering) is rather straightforward to interpret. In addition, there was a lack of consensus on what aspects of the Euthanasia Law should be modified and in what way.

CONCLUSIONS

Many mental healthcare workers do not well understand or misinterpret the legal criteria for euthanasia involving APC. Criteria are sometimes defined so narrowly that euthanasia requests by APC are generally deemed ineligible or, alternatively, are stretched to allow for inclusion of cases that go beyond what the Law intended. Our study indicates the need for an authoritative professional code of conduct offering clear advice for Belgian euthanasia practice in the context of psychiatry. It is also recommended that future trainings are standardized, supported by the most important professional associations in the field, and freely available to all who are confronted with euthanasia requests from APC or who offer support to APC who consider euthanasia.

Care considerations in medical assistance in dying for persons with mental illness as the sole underlying medical condition: a qualitative study of patient and family perspectives

BACKGROUND

Persons with mental illness as their sole underlying medical condition are eligible to access medical assistance in dying (MAiD) in a small number of countries, including Belgium, the Netherlands, Luxemburg and Switzerland. In Canada, it is anticipated that people experiencing mental illness as their sole underlying medical condition (MI-SUMC) will be eligible to request MAiD as of March 17th 2024. To date, few studies have addressed patient and family perspectives on MAiD MI-SUMC care processes. This study aimed to address this gap and qualitatively explore the perspectives of persons with lived experience of mental illness and family members on care considerations during MI-SUMC implementation.

METHODS

Thirty adults with lived experience of mental illness and 25 adult family members residing in Ontario participated in this study. To facilitate participant engagement, the semi-structured interview used a persona-scenario exercise to discuss perspectives on MAiD MI-SUMC acceptability and care considerations. Framework analysis was used to inductively analyze data using NVivo 12 Pro. Steps, processes, or other care considerations suggested by the participants were charted in a framework matrix after familiarization with the narratives. Key themes were further identified. A lived-experience advisory group participated in every aspect of this study.

RESULTS

Six themes were developed from the patient and family narratives: (1) Raising MAiD MI-SUMC awareness; (2) Sensitive Introduction of MAiD MI-SUMC in goals of care discussions; (3) Asking for MAiD MI-SUMC: a person-focused response; (4) A comprehensive circle of MAiD MI-SUMC care; (5) A holistic, person-centered assessment process; and (6) Need for support in the aftermath of the decision. These themes highlighted a congruence of views between patient and family members and described key desired process ingredients, including a person-centred non-judgmental stance by care providers, inter-professional holistic care, shared decision making, and the primacy of patient autonomy in healthcare decision making.

CONCLUSIONS

Family and patient perspectives on the implementation of MAiD MI-SUMC offer important considerations for service planning that could complement existing and emerging professional practice standards. These stakeholders' perspectives will continue to be essential in MAiD MI-SUMC implementation efforts, to better address the needs of diverse communities and inform improvement efforts.

Why the irremediability requirement is not sufficient to deny psychiatric euthanasia for patients with treatment-resistant depression

Treatment-resistant depression (TRD) holds centrality in many debates regarding psychiatric euthanasia. Among the strongest reasons cited by opponents of psychiatric euthanasia is the uncertainty behind the irremediability of psychiatric illnesses. According to this argument, conditions that cannot be considered irremediable imply that there are possible remedies that remain for the condition. If there are possible remedies that remain for the condition, then patients with that condition cannot be considered for access to euthanasia. I call this the irremediability requirement (IR). I argue that patients with TRD can, indeed, meet the operationalisation of irremediability in the IR. This is because the irremediability it asks for is not some global or absolute irremediability, but rather a present irremediability based on the current state of medical science. I show this by considering irremediability relating to (1) possible future treatments and (2) not trying presently available alternative treatments. I extend Schuklenk nd van de Vathorst's argument from parity to terminal malignancies, to show that (1) is an unreasonable expectation for all cases of euthanasia. Taking (2) as a more serious opponent to psychiatric euthanasia, I show how the IR, based on how it is presently operationalised, can be realistically applied to cases of TRD. I do this by further developing Tully's argument on broad-sense treatment resistance with the robust empirical data from the STAR*D trials. If my argument from Tully's is valid, then we have reasons to, again, seek parity between the operationalisations of irremediability in terminal malignancies and TRD.

What Domains of Belgian Euthanasia Practice are Governed and by Which Sources of Regulation: A Scoping Review

BACKGROUND

Multiple sources of regulation seek to shape euthanasia practice in Belgium, including legislation and training. This study comprehensively mapped which of these sources govern which domains of euthanasia practice, such health professionals' obligations, or managing patient requests.

METHOD

Scoping review methodology was used to search for scholarly records which discussed Belgian euthanasia regulation. Template analysis was used to generate themes describing the domains of euthanasia practice governed by sources of regulation.

RESULTS

Of 1364 records screened, 107 records were included. Multiple sources of regulation govern each domain, which are: the permissible scope of euthanasia; the legal status of a euthanasia death; the euthanasia process; the rights, obligations, and roles of those involved; system workings; and support for health professionals who provide euthanasia.

CONCLUSIONS

Domains with significant yet fragmented regulation may lead to inconsistent care provision. Policymakers should develop coherent guidance to support health professionals to navigate this regulatory landscape.

Mapping Sources of Assisted Dying Regulation in Belgium: A Scoping Review of the Literature

Belgium has over 20 years of experience regulating assisted dying (AD). While much research considers this end-of-life practice, no studies have comprehensively analysed the various sources of regulation that govern it, including law, professional standards, and ethics. A scoping review identified all sources of regulation that guide AD practice, and their regulatory functions. Databases and reference lists were searched for records which met inclusion criteria between 11/2/22 and 25/3/22. Existing scholarship was used to identify sources of regulation, and thematically analyse their functions. Of the initial sample of 1364 records, 107 were included. Six sources of regulation were identified: law, policies, professional standards, training, advisory documents, and system design. Three regulatory functions were identified: prescribing conduct, scaffolding to support practice, and monitoring the system. The Belgian AD regulatory framework is multifaceted, complex, and fragmented. Providers must navigate and reconcile numerous sources of guidance providing this form of end-of-life care.

Medical assistance in dying for people living with mental disorders: a qualitative thematic review

BACKGROUND

Medical assistance in dying (MAiD) sparks debate in several countries, some of which allow or plan to allow MAiD where a mental disorder is the sole underlying medical condition (MAiD-MD). Since MAiD-MD is becoming permissible in a growing number of jurisdictions, there is a need to better understand the moral concerns related to this option. Gaining a better understanding of the moral concerns at stake is a first step towards identifying ways of addressing them so that MAiD-MD can be successfully introduced and implemented, where legislations allow it.

METHODS

Thus, this article aims (1) to better understand the moral concerns regarding MAiD-MD, and (2) to identify potential solutions to promote stakeholders' well-being. A qualitative thematic review was undertaken, which used systematic keyword-driven search and thematic analysis of content. Seventy-four publications met the inclusion criteria.

RESULTS

Various moral concerns and proposed solutions were identified and are related to how MAiD-MD is introduced in 5 contexts: (1) Societal context, (2) Healthcare system, (3) Continuum of care, (4) Discussions on the option of MAiD-MD, (5) MAiD-MD practices. We propose this classification of the identified moral concerns because it helps to better understand the various facets of discomfort experienced with MAiD-MD. In so doing, it also directs the various actions to be taken to alleviate these discomforts and promote the well-being of stakeholders.

CONCLUSION

The assessment of MAiD-MD applications, which is part of the context of MAiD-MD practices, emerges as the most widespread source of concern. Addressing the moral concerns arising in the five contexts identified could help ease concerns regarding the assessment of MAiD-MD.

Persons with mental disorders and assisted dying practices in Spain: An overview

On 25 June 2021, the Law on Euthanasia in Spain came into force, providing for two modes of helping an individual end their life: euthanasia and/or medically assisted suicide. Among the requisites that a request for euthanasia has to fulfil are that the individual must be suffering a severe, chronic and debilitating condition or a severe and incurable disease, at the same time as that person shows the necessary competence to decide. The possibility exists that a patient suffering mental health problems submits such a request; however, the specific characteristics of a mental health disorder make such a request considerably more complex. In this article, based on a narrative review of the law itself and the related literature, the requisites established under the law are analysed from an ethical-legal perspective with the aim of defining when a request for euthanasia from a person with a mental health disorder may be deemed legitimate and in line with legal provisions. This should help clinicians make rational, reasoned decisions when dealing with a request of this type.

The new Code of Ethics of the World Psychiatric Association: A fresh look at the ethical issues of the psychiatric profession

This article develops the WPA's new Code of Ethics that was developed in 2020. It succeeds the Declaration of Hawaii of 1977 and the Declaration of Madrid of 1996. The Code is divided into four sections that cover the practice of psychiatry in clinical practice, education, research and publication as well as public mental health. We will discuss the new ethical issues that this Code raises in parallel with the development of psychiatry and psychiatrists' role in society in recent years.

Implications of psychiatric diagnosis for Voluntary Assisted Dying in Victoria

Voluntary Assisted Dying is a process whereby terminally ill patients are provided a lethal dose of medication for them to voluntarily ingest to end their life. Victoria, Australia, implemented legislation permitting Voluntary Assisted Dying for terminally ill adult patients with a life expectancy less than 6 months. Ethical dilemmas arise when terminally ill patients with a comorbid mental illness attempt to access Voluntary Assisted Dying because of the complex relationship between psychiatric conditions and suicidal ideation. This paper seeks to investigate the most ethical approach for doctors to respond to such a request by discussing objections raised in other literature to patients with a comorbid psychiatric illness aiming to access Voluntary Assisted Dying in Victoria. To answer this question, objections to terminally ill patients with a comorbid psychiatric illness accessing Voluntary Assisted Dying were found through review of literature. Discussion of these objections centred around unpacking the two historical ethical justifications for Voluntary Assisted Dying: respect for autonomy and relief of suffering. Regarding autonomy, contention focused on competency to make autonomous decisions. Not all psychiatric patients lack competency to decide about Voluntary Assisted Dying, and there are comparable competency assessments used in psychiatry today. Considering suffering, objections related to the authenticity of the intolerable nature of a patient's suffering out of concerns that it has been influenced by their condition, and that the psychiatric illness may still be treatable. However, given suffering is subjective, its perception is not lessened if the source is psychological in nature. Furthermore, it is challenging to justify a position where a patient is forced to spend the last months of their life enduring suffering that has been historically refractory to multiple, genuine treatment efforts. Not all terminally ill patients with a comorbid psychiatric disorder will lack competency to choose Voluntary Assisted Dying, and many will have genuine suffering for which they are requesting Voluntary Assisted Dying. Multidisciplinary, holistic assessments for these patients are not mandated, but would be useful to address the issues, overcome barriers to access and determine that applicants are making an authentic request.

Euthanasia in Mental Suffering—Overview and Discussion of the Arguments of the Roman Catholic Church

Euthanasia for mental suffering in a nonterminal situation has been decriminalized only in a few countries, including Belgium, under certain conditions. The aim of this article is to provide an overview and an ethical discussion of the arguments of the Roman Catholic Church concerning euthanasia in mental suffering. In the research material, we include documents from the Vatican’s Magisterium, with particular reference to the recent Letter Samaritanus Bonus, and from the Belgian Bishops’ Conference. We structure the many arguments around three values: the inviolability of life, the good care by the professionals and the patients’ experience of meaning. We discuss the arguments and find that they are strongly normative and do not enter into discussion with scientific positions and other worldviews. As a result, the arguments are not convincing for people with a different view, while the underlying values remain very valid. This is why we nuance and reinterpret certain arguments. Based on Pope Francis’ Exhortation Amoris Laetitia, we make a plea to place less emphasis on the norms and rules, and more on the conscience of those involved and on their ethical discernment of the underlying values.

The impact of the euthanasia assessment procedure: a qualitative interview study among adults with psychiatric conditions

BACKGROUND

Assisted dying for adults with psychiatric conditions (APC) is highly controversial but legally possible in a few countries, including Belgium. Previous research has suggested that the complex euthanasia assessment procedure may cause additional suffering in APC but may also induce positive experiences. This study reports on the impact of the euthanasia assessment procedure as experienced by APC on three counts: 1) their mental state, including death ideation; 2) their treatment trajectory; 3) their social relationships.

METHODS

We performed an in-depth qualitative interview study with 16 APC in Flanders, Belgium, who had voiced a euthanasia request between 2016-2020. Thematic coding was used.

FINDINGS

We interviewed 16 APC. Euthanasia assessment procedures brought out a plethora of experiences in APC, both favourable and unfavourable. Whereas thoughts of suicide remain present to a certain extent, being in the assessment procedure allows some APC to reconsider alternatives towards life, and also to attempt new treatment options. However, many APC experience ambivalence about the supposedly inherent desirability and dignity in euthanasia. Worries also surfaced about the rationale behind and effects of involvement of APCs' social circle, and about the impact it could have on them.

CONCLUSION

Further research, including other stakeholder perspectives, is recommended with a view to maximising favourable and minimising unfavourable impacts for all involved. In clinical practice attention to these impacts is paramount, and clear communication and management of expectations between physician and patient, seems appropriate to address the many ambivalent experiences that accompany APC during the euthanasia assessment procedure. Policy attention could in this regard go to clarifying certain sources of ambivalence and issues that are insufficiently addressed, such as modalities of relatives' involvement.

État des lieux des législations sur l’aide active à mourir dans le monde au 31 janvier 2022

Au 31 janvier 2022, dix pays ont légiféré en faveur de l’aide active à mourir au terme de débats politiques, éthiques et sociaux. Cet article reprend le parcours législatif de ces pays (Suisse, États-Unis, Pays-Bas, Belgique, Luxembourg, Canada, Australie, Nouvelle-Zélande, Espagne et Autriche) et décrit les conditions prescrites par chaque loi pour encadrer et contrôler la pratique de l’euthanasie ou du suicide assisté. L’objectif est de mettre en lumière les arguments indispensables à la mise en place et à la mise en œuvre d’une loi ainsi que les critères d’éligibilité et garde-fous communs, avec une attention particulière portée aux critères relatifs à la maladie psychiatrique.

Understanding why patients request euthanasia when it is illegal: a qualitative study in palliative care units on the personal and practical impact of euthanasia requests

Context

Some patients in palliative care units request euthanasia regardless of legislation. Although studies have explored the reasons for these requests, little is known about the subjective, relational, and contextual repercussions for the patient.

Objectives

The aim of this study is to understand the purpose of euthanasia requests from the patient's viewpoint and their personal and practical impact.

Methods

We conducted in-depth interviews with patients requesting euthanasia, their family members, and health care providers in 11 French palliative care units. A thematic analysis of the data was performed.

Results

In total, 18 patients were interviewed within 48 h of the request being made; 1 week later, 9 patients were interviewed again. Five main themes emerged: assuming the possibility of transgressing the forbidden, a call for unbearable suffering to be recognized, encouragement to change clinical practice, reclaiming a sense of freedom over medical constraints, and imagining a desirable future for oneself.

Conclusions

A request for euthanasia appears to be a willful means to remove oneself from the impasse of an existence paralyzed by suffering. It creates a space for discussion, which promotes negotiation with patients on care practices and therapeutics, and strengthens patients' sense of autonomy. Investigating the relationship between the evolution of euthanasia requests within the palliative care setting could be beneficial. It is important to encourage health care professionals to adopt a readiness to listen by interacting with patients in a way that is not momentarily action-oriented but rather focused on proactive discussion.

Improving control over euthanasia of persons with psychiatric illness: Lessons from the first Belgian criminal court case concerning euthanasia

BACKGROUND

Belgium is one of very few countries that legally allow euthanasia for suffering caused by psychiatric illness. In the first criminal trial in Belgium of physicians involved in euthanasia, three physicians recently faced the accusation of "murder by poisoning," for allegedly having failed to comply with several requirements of the Belgian Euthanasia Law in granting the euthanasia request a woman suffering from psychiatric illness. Although all three physicians were acquitted, the case generated much debate among policy makers, medical professionals, and the general public.

METHOD

We use this trial as the starting point for a critical analysis of the adequacy of the three-level control system established in the Euthanasia Law, as it is applied in the evaluation of euthanasia requests from persons who suffer unbearably from a psychiatric illness. This analysis is based on information presented during the criminal trial as well as information on the euthanasia that was published in the press.

RESULTS

Our analysis highlights substantial problems in the assessment and granting of the euthanasia request. The patient was euthanized without it having been substantiated that her psychiatric illness had no prospect of improvement and that her suffering could not be alleviated. The three-step control system enshrined in the Law and promoted by the Federal Control and Evaluation Commission for Euthanasia appears to have failed at each level.

CONCLUSION

To evaluate requests for euthanasia for mental suffering caused by psychiatric illness, the requirements of the Belgian Euthanasia Law should be complemented by mandating the advice of two psychiatrists, and face-to-face discussions between all physicians involved. In parallel with the process of evaluating the euthanasia request, a treatment track should be guaranteed where reasonable evidence-based treatments and recovery-oriented options are tried.

Assisted dying requests from people in detention: Psychiatric, ethical, and legal considerations-A literature review

The principle of equivalence of care states that prisoners must have access to the same standard of health care as the general population. If, as recent court decisions suggest, assisted dying is not limited to people with a terminal physical illness or irremediable suffering, it might also be requested by people with severe mental illness in detention. Some of the countries with legal regulations on assisted dying also have recommendations on how to handle requests from prisoners. However, detention itself can lead to psychological distress and suicidality, so we must consider whether and how people in such settings can make autonomous decisions. Ethical conflicts arise with regard to an individual's free will, right to life, and physical and personal integrity and to the right of a state to inflict punishment. Furthermore, people in prison often receive insufficient mental health care. In this review, we compare different practices for dealing with requests for assisted dying from people in prison and forensic psychiatric facilities and discuss the current ethical and psychiatric issues concerning assisted dying in such settings.

Concrete Experiences and Support Needs Regarding the Euthanasia Practice in Adults With Psychiatric Conditions: A Qualitative Interview Study Among Healthcare Professionals and Volunteers in Belgium

OBJECTIVE

Although euthanasia in the context of adult psychiatry is legalized in Belgium, it poses major ethical and clinical challenges for the health care professionals and volunteers involved. This study aimed to address these members' concrete experiences and support needs.

METHODS

A qualitative semi-structured interview study was conducted with 16 physicians and 14 other health care professionals and volunteers, with at least one concrete experience with euthanasia requests and procedures concerning adults with psychiatric conditions.

FINDINGS

Concrete experiences concerned the following 8 domains: (1) the impact of euthanasia on the clinical trajectory and (2) on the therapeutic relationship, (3) internal and (4) external collaborative partnerships, (5) patients' social inner circle (non-)involvement, (6) the use of recently published guidelines and, (7) the first criminal trials on this topic, and (8) the act of euthanasia. The following 8 main support needs emerged; (1) protocols addressing specific sub-populations and pathologies, (2) protocols specifically drawn up for non-medics, (3) guidance on how to adequately implement the two-track approach, (4) (after)care for patients, (5) (after)care for the health care team, (6) guidance on the patient's social inner circle involvement, (7) enhanced education measures, and (8) enhanced financial measures, including incentives for holistic, palliative care approaches.

CONCLUSION

The health care professionals and volunteers reported many positive and negative experiences in dealing with euthanasia requests in adult psychiatry. They reported several support needs across the extensive euthanasia trajectory, pertaining to concrete management of thorny issues that guidelines do not (yet) touch on. Important implications of our study relate to tackling these existing issues, and to paying sufficient attention to the impact of a euthanasia trajectory on all actors, including the patients and their social inner circle, involved.

Why adults with psychiatric conditions request euthanasia: A qualitative interview study of life experiences, motives and preventive factors

OBJECTIVE

As the empirical picture of adults with psychiatric conditions (further referred to as 'patients') requesting euthanasia is still incomplete, this study aims to deepen our understanding of why these patients request euthanasia, how this relates to the option of suicide, and what could have prevented these patients from considering death and requesting euthanasia.

METHODS

A qualitative study using in-depth, face-to-face interviews was conducted with 16 patients who had their euthanasia request under assessment in the period 2016-2020. Thematic coding was used.

FINDINGS

Most patients were in a state of feeling emotionally worn-out as a result of the many accumulated misfortunes and setbacks, leading to the all-pervasive sense that life is no longer worth living. Whereas some patients reported lifelong adversity, others struggled predominantly in later life. Whereas some patients longed for death strongly, others expressed ambivalence towards death ideation, and some even requested euthanasia to hear of their ineligibility for it, to restore hope and to (re)find meaning in life. patients valued euthanasia over suicide as being more dignified and acceptable, both for themselves and for their inner circle. With regard to preventive factors, patients posited the need for improved accessibility and quality of mental healthcare, as well as a profound change in society's perception of, and support for, these patients.

CONCLUSIONS

This study revealed the many complexities of euthanasia in the context of psychiatry, due to the many differences in patients' background characteristics, in their motives for requesting euthanasia, and the multi-layered aspects of mental suffering that go beyond the field of psychiatry.

Euthanasia in adults with psychiatric conditions: A descriptive study of the experiences of Belgian psychiatrists

To investigate the experience of psychiatrists who completed assessment procedures of euthanasia requests from adults with psychiatric conditions (APC) over the last 12 months. Between November 2018 and April 2019 a cross-sectional survey was sent to a sample of 753 psychiatrists affiliated with Belgian organisations of psychiatrists to gather detailed information on their latest experience with a completed euthanasia assessment procedure, irrespective of its outcome (i.e. euthanasia being performed or not). Information on 46 unique cases revealed that most APC suffered from comorbid psychiatric and/or somatic disorders, and had received different kinds of treatment for many years prior to their euthanasia request. Existential suffering was the main reason for the request. The entire procedure spanned an average of 14 months, and an average of 13.5 months in the 23 cases that culminated in the performance of euthanasia. In all cases, the entire procedure entailed multidisciplinary consultations, including with family and friends. Psychiatrists reported fewer difficulties in assessing due care criteria related to the APC's self-contemplation - for example, unbearable suffering on top of the due care criteria related to their medical condition; incurability due to lack of reasonable treatment perspectives. In a few cases in which euthanasia was the outcome, not all legal criteria were fulfilled in the reporting physicians' opinions. Both positive and negative experiences of the assessment procedure were reported: for example, reduced suicide risk for the APC; an emotional burden and a feeling of being pressured for the psychiatrist. This study confirms that euthanasia assessment in APC entails a lengthy process with diverse complexities, and psychiatrists require support in more than one respect if the assessments are to be handled adequately. Thorough evaluation of current guidelines is recommended: that is, to what extent the guidelines sufficiently address the complexities around (e.g.) assessing legal criteria or involving relatives. We formulate various avenues for further research to build on this study's insights and to fill remaining knowledge gaps.

Wish for euthanasia persists for at least one year after the request was declined by Euthanasia Expertise Center

BACKGROUND

Euthanasia Expertise Center (EEC) in the Netherlands provides euthanasia or physician-assisted suicide for patients who meet all requirements of the Dutch Euthanasia Law, but whose treating physician declined their request. Little is known about how life continues for a patient after a request for physician-assisted death (PAD) is also declined by EEC.

OBJECTIVE

To follow-up patients whose request for PAD was declined at EEC.

METHODS

Between December 2016 and January 2020, 66 patients were prospectively followed for one year after their request was declined. Their general well-being and health, persistence of the wish for PAD, and mortality was measured by means of a questionnaire administered after three, six and 12 months. Furthermore, information was extracted from the patient's medical record.

FINDINGS

More than half (58%) of the included patients suffered from an accumulation of old-age complaints. In the year after the request was declined, 15 patients (23%) died, three of whom committed suicide. Almost all patients who were alive after one year, persisted in their wish for PAD. Moreover, they were often not doing well.

CONCLUSIONS

Considering that EEC is a last resort for those who were not granted PAD elsewhere, and that the wish for PAD persists, aftercare services should be provided to people whose request has been declined.

The ongoing discussion on termination of life on request. A review from a German/European perspective

BACKGROUND

Interest in the topic of termination of life has been growing for 2 decades. After legalisation of active euthanasia and assisted suicide (EAS) in the Netherlands in 2002, movements to implement similar laws started in other European countries. However, many people objected to legalisation on the basis of the experiences in the Netherlands and as a matter of principal.

METHODS

This selected and focussed review presents the theoretical discussions about EAS and describes the respective parliamentary discussions in Germany and the data and experiences in the Netherlands. It also considers people with mental disorders in the context of termination-of-life services.

RESULTS

So far, only a few European countries have introduced legislation on EAS. Legalisation of EAS in the Netherlands resulted in an unexpectedly large increase in cases. The number of people with mental disorders who terminate their lives on request remains low.

CONCLUSIONS

Experience from the Netherlands shows that widening criteria for EAS has problematic consequences.KEY POINTSTermination of life on request, which a subgroup of people support, is a matter of ongoing debate.Because of several problematic aspects, including ethical considerations, only a few countries in the world allow active euthanasia or assisted suicide.Even if euthanasia is well regulated, legalising it can have problematic consequences that are difficult to control, such as an unwanted excessive increase in euthanasia cases.The well-documented experiences with the euthanasia law in the Netherlands serve as an example of what is to be expected when euthanasia is legalised.We need to pay close attention to the relationship between suicide and suicide prevention on the one hand and euthanasia acts and promotion of euthanasia on the other.Further ethical, psychological and legal research is needed. In particular, the role of palliative medicine in societies' approach to end-of-life care must be explored in much more detail.

Euthanasia and assisted suicide in psychiatric patients: A systematic review of the literature

The number of psychiatric patients requesting Euthanasia or Assisted Suicide (EAS) continues to increase. The aims of this systematic review were to: 1) describe the available data related to psychiatric patients having received or requesting EAS (pEAS) for each country in which is allowed; 2) and describe the ethically salient points that arise. PubMed, PsycINFO, and Scopus databases were searched to identify articles published up to September 2020. Among the retrieved publications, only studies on pEAS cases (pEAS-C), pEAS requests, or physician reports/attitude towards pEAS reporting some quantitative data on patients having received or requesting pEAS were retained. Among the 24 included studies, thirteen (54%) were about pEAS in the Netherlands, four (17%) in Belgium, and seven (29%) in Switzerland. Results were different across different countries. In the Netherlands, pEAS-C were mostly women (70-77%) and often had at least two psychiatric disorders (56-97%). Mood disorders were mainly represented (55-70%) together with personality disorders (52-54%). History of suicide attempts was present in 34-52%. Moreover, 37-62% of them had at least one comorbid medical condition. In Belgium pEAS-C were mostly women (75%), but the majority (71%) had a single diagnosis, mood disorder. In Switzerland available data were less detailed. As pEAS-C seem to be very similar to 'traditional suicides', pEAS procedures should be carefully revised to establish specific criteria of access and guidelines of evaluation of the request. A deeper focus on unbearable suffering, decision capacity and possibilities of improvements is warranted as well as the involvement of mental health professionals.

The engagement of psychiatrists in the assessment of euthanasia requests from psychiatric patients in Belgium: a survey study

BACKGROUND

Since its legalisation in 2002, the number of times euthanasia has been carried out in response to requests from adults with psychiatric conditions (APC) has continued to increase. However, little is known about why and how psychiatrists become engaged in the assessment of such euthanasia requests.

METHODS

A cross-sectional survey study was conducted between November 2018 and April 2019 of 499 psychiatrists affiliated with the Flemish Psychiatry Association. Chi square/Fisher's exact tests were performed to examine if, and to what extent, psychiatrists' backgrounds relate to their concrete experiences. The answers to the open question regarding motives for (non-) engagement were thematically coded.

RESULTS

Two hundred one psychiatrists participated, a response rate of 40%. During their careers, 80% of those responding have been confronted with at least one euthanasia request from an APC patient and 73% have become involved in the assessment procedure. Their engagement was limited to the roles of: referring physician (in 44% of the psychiatrists), attending physician (30%), legally required 'advising physician' (22%), and physician participating in the actual administration of the lethal drugs (5%). Within the most recent 12 months of practice, 61% of the respondents have been actively engaged in a euthanasia assessment procedure and 9% have refused at least once to be actively engaged due to their own conscientious objections and/or the complexity of the assessment. The main motive for psychiatrists to engage in euthanasia is the patient's fundamental right in Belgian law to ask for euthanasia and the psychiatrist's duty to respect that. The perception that they were sufficiently competent to engage in a euthanasia procedure was greater in psychiatrists who have already had concrete experience in the procedure.

CONCLUSIONS

Although the majority of psychiatrists have been confronted with euthanasia requests from their APC patients, their engagement is often limited to referring the request to a colleague physician for further assessment. More research is needed to identify the determinants of a psychiatrist's engagement in euthanasia for their APC patients and to discover the consequences of their non-, or their restricted or full engagement, on both the psychotherapeutic relationship and the course of the euthanasia request.

Belgian psychiatrists' attitudes towards, and readiness to engage in, euthanasia assessment procedures with adults with psychiatric conditions: a survey

BACKGROUND

Although the Belgian assessment pathway for legal euthanasia requires the engagement of at least one psychiatrist, little is known about psychiatrists' attitudes towards euthanasia for adults with psychiatric conditions (APC). This study aims to gauge psychiatrists' attitudes towards and readiness to engage in euthanasia assessment and/or performance procedures in APC.

METHODS

This cross-sectional survey study was performed between November 2018 and April 2019. The survey was sent to a sample of 499 eligible psychiatrists affiliated to the Flemish Association for Psychiatry, a professional association that aims to unite and represent all psychiatrists working in Flanders, the Dutch-speaking, northern part of Belgium. The Association's members comprise an estimated 80-90% of all psychiatrists active in Flanders. Only psychiatrists working with APC (83% of the association's total membership) were included. Factorial Anova and Chi Square tests were performed to examine if and to what extent psychiatrists' backgrounds were associated with, respectively, their attitudes and their readiness to play a role in euthanasia procedures concerning APC.

RESULTS

One hundred eighty-four psychiatrists completed the questionnaire (response rate 40.2%); 74.5% agree that euthanasia should remain permissible for APC. However, 68.9% question some of the approaches taken by other physicians during the euthanasia assessment and only half consider euthanasia assessment procedures compatible with the psychiatric care relationship. Where active engagement is concerned, an informal referral (68%) or preliminary advisory role (43.8%) is preferred to a formal role as a legally required advising physician (30.3%), let alone as performing physician (< 10%).

CONCLUSION

Although three quarters agree with maintaining the legal option of euthanasia for APC, their readiness to take a formal role in euthanasia procedures appears to be limited. More insight is required into the barriers preventing engagement and what psychiatrists need, be it education or clarification of the legal requirements, to ensure that patients can have their euthanasia requests assessed adequately.

Should euthanasia and assisted suicide for psychiatric disorders be permitted? A systematic review of reasons

BACKGROUND

Euthanasia and assisted suicide (EAS) based on a psychiatric disorder (psychiatric EAS) continue to pose ethical and policy challenges, even in countries where the practice has been allowed for years. We conducted a systematic review of reasons, a specific type of review for bioethical questions designed to inform rational policy-making. Our aims were twofold: (1) to systematically identify all published reasons for and against the practice (2) to identify current gaps in the debate and areas for future research.

METHODS

Following the PRISMA guidelines, we performed a search across seven electronic databases to include publications focusing on psychiatric EAS and providing ethical reasons. Reasons were grouped into domains by qualitative content analysis.

RESULTS

We included 42 articles, most of which were written after 2013. Articles in favor and against were evenly distributed. Articles in favor were mostly full-length pieces written by non-clinicians, with articles against mostly reactive, commentary-type pieces written by clinicians. Reasons were categorized into eight domains: (1) mental and physical illness and suffering (2) decisional capacity (3) irremediability (4) goals of medicine and psychiatry (5) consequences for mental health care (6) psychiatric EAS and suicide (7) self-determination and authenticity (8) psychiatric EAS and refusal of life-sustaining treatment. Parity- (or discrimination-) based reasons were dominant across domains, mostly argued for by non-clinicians, while policy reasons were mostly pointed to by clinicians.

CONCLUSIONS

The ethical debate about psychiatric EAS is relatively young, with prominent reasons of parity. More direct engagement is needed to address ethical and policy considerations.

Euthanasia, medically assisted dying or assisted suicide: time for psychiatrists to say no

OBJECTIVE

Euthanasia has been considered unethical for most of the history of medicine. Recently it has been legalised in some countries, including parts of Australasia. We describe the recent history of euthanasia, paying attention to the extension of criteria that impact on the poor, elderly and vulnerable members of society in countries that currently have legalised this. In four of the five countries where euthanasia is legalised, there have been extensions of its criteria, either by revision of legislation or changes in practice.

CONCLUSIONS

We suggest that this dynamic can be halted by international agreements of medical societies to shun involvement in euthanasia, as has been the case with other legal interventions that stigmatise. We may, as we have in the past, need to work collectively to meet this ethical challenge.

Compulsory Psychiatric Admission in a Patient With Metastatic Breast Cancer: From Palliative Care to Assisted Suicide

The provision of palliative care in psychiatry and the use of coercion in palliative care are underexplored areas. We report the case of a 65-year-old woman with cerebral metastatic breast cancer who was compulsorily admitted from a specialized palliative care ward to a psychiatric inpatient ward in Zurich, Switzerland. While in specialized inpatient palliative care, the patient had resisted palliative care but was found to lack decision-making capacity for her treatment due to disordered thought process and paranoid delusions. Under our care, which involved coercive treatment in the form of concealed administration of an antipsychotic, the patient's psychiatric symptoms improved. She regained decision-making capacity, was granted discharge from hospital, and ended her life by assisted suicide on the day of discharge.