Capacity Evaluations of Psychiatric Patients Requesting Assisted Death in the Netherlands

Assessing and managing patients with borderline personality disorder requesting medical assistance in dying

Background

When physician assisted dying (referred to as Medical Assistance in Dying or MAiD in this article) is available for individuals with mental disorders as the sole underlying medical condition (MD-SUMC), patients with borderline personality disorder (BPD) frequently request MAiD. Psychiatrists and other clinicians must be prepared to evaluate and manage these requests.

Objectives

The purposes of this paper are to define when patients with BPD should be considered to have an irremediable, treatment resistant disorder and provide clinicians with an approach to assess and manage their patients with BPD making requests for MAiD.

Methods

This perspective paper developed the authors' viewpoint by using a published, authoritative definition of irremediability and including noteworthy systematic and/or meta-analytic reviews related to the assessment of irremediability.

Results

The clinician must be aware of the eligibility requirements for granting MAiD in their jurisdiction so that they can appropriately prepare themselves and their patients for the assessment process. The appraisal of the intolerability of the specific person's suffering comes from having an extensive dialogue with the patient; however, the assessment of whether the patient has irremediable BPD should be more objectively and reliably determined. A systematic approach to the assessment of irremediability of BPD is reviewed in the context of the disorder's severity, treatment resistance and irreversibility.

Conclusion

In addition to characterizing irremediability, this paper also addresses the evaluation and management of suicide risk for patients with BPD undergoing the MAiD assessment process.

Case report: Organ donation after euthanasia for psychiatric suffering: some of the practical and ethical lessons Martijn taught us

Euthanasia in psychiatric patients presents unique challenges, especially when combined with organ donation. In this article, the hurdles psychiatric patients might encounter after expressing their wish for organ donation after euthanasia, are discussed and illustrated by the case of Martijn, a 45-year-old psychiatric patient who altruistically donated his organs after euthanasia. Hospital and physician-related factors, including caution in determination of mental capacity, consideration of conflicting interests, and healthcare staff stress are discussed as impediments to organ donation after euthanasia (ODE) in psychiatric patients. The primary objective of this article is to raise awareness among psychiatrists regarding the fact that although the combination of euthanasia and organ donation is an uncommonly performed procedure, it is frequently requested by psychiatric patients. In conclusion, the article advocates for a nuanced approach, respecting patients' altruistic wishes while at the same time addressing challenges associated with ODE in psychiatric suffering. Where possible, and within the current medical, ethical and legal boundaries, the importance of facilitating organ donation without unnecessarily prolonging the suffering of competent psychiatric patients seeking euthanasia is emphasized. The topic calls, for example, for further qualitative research to understand the stakeholders' perspectives to determine the perceived possibilities on the one hand and boundaries on the other.

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.

The capacity to consent to treatment is altered in suicidal patients

BACKGROUND

Many patients with depression refuse treatment. Moreover, suicide attempters often display low perceived need of treatment and impaired decision-making. These observations raise questions about the capacity to treatment consent in depressed suicide attempters (SA).

METHODS

In patients with current depressive episode (N = 33 SAs and N = 27 non-SAs), consent capacity was evaluated with the MacArthur Competence Assessment Tool for Treatment (MacCAT-T), insight with the Beck Cognitive Insight Scale, and depression severity with the Beck Depression Inventory (BDI).

RESULTS

The median BDI score in the whole sample (N = 60) was 21 [10;36], and was higher in SAs than non-SAs (27 [11;36] vs. 15 [10:33], p < 0.001). Consent capacity was impaired in 30% (appreciation), 53% (reasoning) and 60% (understanding) of all patients. MacCAT-T sub-scores were lower in SAs than non-SAs (understanding: 4.4 [2.35;5.8] vs. 5.3 [3.13;6]); appreciation: 3 [1;4] vs. 4 [2;4]); reasoning (4 [1;7] vs. 7 [3;8]), and ability to express a choice: 1 [0;2] vs. 2 [0;2]; all p < 0.001). In multivariate analyses, suicide attempt history and depression severity (but not insight) were negatively associated with MacCAT-T sub-scores.

CONCLUSION

More research is needed on the capacity to consent to treatment of patients with depression, particularly suicidal individuals, to make informed choices about their treatment. Trial registration The Montpellier University Hospital Institutional Review Board approved the study (No. 202100714).

Palliating in Avoidable Death: Reconciling Psychiatrists' Roles as Treaters on Death Row With Participation in a System of Overt Harm

ABSTRACT

Although nations across the globe have eliminated capital punishment, the United States remains one of the few countries in the Americas and Europe that still uses execution. There has been little discussion around the implications of psychiatry's involvement in providing care to incarcerated individuals awaiting death. The following perspective examines the United States as an example of a democratic and highly developed country where the death penalty remains an undeniable reality; the piece provides a brief discussion on psychiatry's relationship with end-of-life care to provide context for subsequent discussion on the role of the psychiatrist on death row in the United States. Medicolegal and ethical considerations are further outlined to identify specific concessions that might be made by the US criminal justice system to truly allow death row psychiatrists to practice to the highest standard of compassionate care.

Rapid-Response Treatments for Depression and Requests for Physician-Assisted Death: An Ethical Analysis

Depression is common at the end of life, and there is longstanding concern that it may affect terminally ill patients' decisions to request physician-assisted death (PAD). However, it is difficult for clinicians to determine the role of depression in a patient's PAD request. A recent case series described rapid responses to intranasal ketamine in three patients with terminal illness and comorbid depression who had requested PAD. One patient withdrew her request (which, in retrospect, had been driven by her depression) while the others maintained their requests; in all three, the rapid relief clarified the role of depression in the patients' decision-making. In addition to ketamine, there are other emerging rapid-response treatments for depression, including psilocybin with psychological support and functional connectivity-guided transcranial magnetic stimulation. We examine three key ethical implications of such treatments: their role in clarifying the decision-making capacity of depressed patients requesting PAD; the potential tension between the legal definition of irremediability in some jurisdictions and the ethical obligations of clinicians; and the likely obstacles to treatment access and their implications for equal respect for autonomy of patients.

Making a case for the inclusion of refractory and severe mental illness as a sole criterion for Canadians requesting medical assistance in dying (MAiD): a review

BACKGROUND

Following several landmark rulings and increasing public support for physician-assisted death, in 2016, Canada became one of a handful of countries legalising medical assistance in dying (MAiD) with Bill C-14. However, the revised Bill C-7 proposes the specific exclusion of MAiD where a mental disorder is the sole underlying medical condition (MAiD MD-SUMC).

AIM

This review explores how some persons with serious and persistent mental illness (SPMI) could meet sensible and just criteria for MAiD under the Canadian legislative framework.

METHODS

We review the proposed Bill C-7 criteria (capacity, voluntariness, irremediability and suffering) as well as the nuances involved in separating a well-reasoned request for assisted suicide from what might be solely a manifestation of a SPMI.

FINDINGS

In this paper, we argue against the absolute exclusion of patients with SPMIs from accessing MAiD. Instead, we propose that in some circumstances, MAiD MD-SUMC may be justifiable while remaining the last resort. Conducting MAiD eligibility assessments removes the need to introduce diagnosis-specific language into MAiD legislation. Competent psychiatric patients who request MAiD should not be treated any differently from other eligible candidates. Many individuals with psychiatric disorders will be incapable of consenting to MAiD. The only ethical option is to assess eligibility for MAiD on an individual basis and include as legitimate candidates those who suffer solely from psychiatric illness who have the decisional capacity to consent to MAiD.

A Systematic Review of Barriers and Facilitators to Implementing Assisted Dying: A Qualitative Evidence Synthesis of Professionals' Perspectives

Assisted dying is a divisive topic and draws both lamenting and approving commentary from political, medical, legal, and philosophical domains. This systematic review and qualitative evidence synthesis aims to identify the factors that healthcare professionals experience when working within assisted dying frameworks. PRISMA guidelines for systematic reviews were followed. Search results yielded 15,426 papers with 39 papers meeting inclusion criteria for this review. Remaining papers were subjected to critical appraisal and a thematic synthesis. Eight themes fell under the domain of 'barrier' and represented different personal and professional factors that hinder professionals from delivering assisted dying healthcare. Five themes came under the domain of 'facilitators' and represent factors that contribute to the smooth implementation and delivery of assisted dying services. Health professionals experience a range of factors that both impede and propel delivery of assisted dying frameworks.

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.

Physician Assisted Death for Psychiatric Suffering: Experiences in the Netherlands

Physician assisted death (PAD) for patients with a psychiatric disorder is a controversial topic of increasing relevance, since a growing number of countries are allowing it. General requirements for PAD include that patients possess decision-making capacity to decide on PAD and that their suffering is unbearable and irremediable. In the Netherlands PAD has been eligible for patients with psychiatric disorders since the 1990s, making it one of the few countries that can offer insights on the practice from real life experience. Much of the literature describing these experiences is only available in Dutch. This article aims to make this knowledge more widely available and provide a comprehensive overview of the experience with PAD for psychiatric suffering in the Netherlands. First, the history of PAD for patients suffering from a psychiatric disorder is described. Second, an overview of relevant rules and regulations governing the practice is given. Third, an overview is provided of the scarce epidemiological data. Finally, we will discuss two major clinical challenges; establishing irremediability and decision-making capacity.

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.

Do Doctors Differentiate Between Suicide and Physician-Assisted Death? A Qualitative Study into the Views of Psychiatrists and General Practitioners

Physician-assisted death for patients suffering from psychiatric disorders is allowed in the Netherlands under certain circumstances. One of the central problems that arise with regard to this practice is the question of whether it is possible to distinguish between suicidality and a request for physician-assisted death. We set up this study to gain insight into how psychiatrists and general practitioners distinguish between suicidality and physician-assisted death. The data for this study were collected through qualitative interviews with 20 general practitioners and 17 psychiatrists in the Netherlands. From the interviews, we conclude that physicians distinguish three types of death wishes among patients suffering from psychiatric disorders: 'impulsive suicidality,' 'chronic suicidality,' and 'rational death wishes.' To discern between them they evaluate whether the death wish is seen as part of the psychopathology, whether it is consistent over time, and whether they consider it treatable. Some considered physician-assisted death an alternative to a 'rational suicide,' as this was perceived to be a more humane manner of death for the patient and their relatives. We argue that physician-assisted death can be justified also in some cases in which the death wish is part of the psychopathology, as the patient's suffering can be unbearable and irremediable. Physician-assisted death in these cases may remain the only option left to relieve the suffering.

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.

[Euthanasia and assisted suicide for psychiatric disorder]

OBJECTIVES

Assisted death has been discussed for years in medicine. Ten countries have adopted legislation that authorises some form of euthanasia or assisted suicide, and the incidence and practices vary from country to country. Consideration of psychological pain linked to psychiatric disorders as a sufficient legal condition for enabling assisted death has added a new layer of complexity to the debate. Thus, Switzerland, Netherlands, Belgium and Luxembourg legalised assisted suicide or euthanasia for psychiatric reasons. In these cases, it is not a question of choosing death conditions but the occurrence of death. This manuscript is a narrative review of the literature about characteristics of patients with psychiatric disorders who requested assisted death in these countries.

METHODS

Scientific manuscripts, reports and legal documents were reviewed.

RESULTS

The incidence of assisted death for psychiatric reasons was low but has increased over the years. They represented 1.1 % of assisted deaths in Belgium (n=23) and 1.3 % in Netherlands (n=83) in 2017, and 4.5 % in Switzerland in 2014 when also considering dementia. The most frequent diagnoses were depressive and personality disorders. Patients were more often women than men, unlike suicide and middle aged.

CONCLUSIONS

Authors who support these practices emphasise the right to die with dignity and the inequality of ruling out patients with psychiatric reasons, whereas they meet the legal requirements, and psychological pain is as severe as somatic pain. Some major issues are highlighted: the close relationship between mood symptoms and death wish, thinking biases and cognitive disturbances that limit the ability to decide, access and consent to medical care, the difficulty of assessing psychological pain, and the definitions of incurability or treatment refractoriness in psychiatry. To date, medical knowledge and assessment tools are not sufficient to define possible indications and offer the best support possible to these patients.

"Nothing Hurts Less Than Being Dead": Psychological Pain in Case Descriptions of Psychiatric Euthanasia and Assisted Suicide from the Netherlands: « Rien ne fait moins mal qu'être mort »: La douleur psychologique dans les descriptions de cas d'euthanasie et de suicide assisté psychiatrique aux Pays-Bas

OBJECTIVES

Euthanasia and assisted suicide (EAS) of individuals with mental disorders is a growing practice in several countries, including the Netherlands. Here, we aimed to identify the most frequent dimensions of and associated factors to psychological pain, which has been associated with suicidality, in individuals undergoing psychiatric EAS.

METHODS

An exploratory retrospective content analysis of the English translation of 66 digital case records of individuals who died by EAS in the Netherlands between 2011 and 2014 was performed. Nine standard psychological pain dimensions (irreversibility, loss of control, emptiness, emotional flooding, freezing, social distancing, narcissistic wounds, confusion, and self-estrangement), illness, and sociodemographic variables were evaluated by 2 independent raters using a premade data abstraction form (Kohen κ > 0.8 in all cases).

RESULTS

The mean number of dimensions was 4.64 ± 1.20 (median = 5), out of 9. The most frequent dimensions were irreversibility, loss of control, emptiness, and emotional flooding, in decreasing order. Past treatment refusal and the mention of social connections in case descriptions were related to the higher number of psychological pain dimensions (4.89 ± 1.24 vs. 4.31 ± 1.07, P = 0.03 and 5.05 ± 1.17 vs. 4.43 ± 1.17, P = 0.03, respectively). Emotional flooding was the only dimension specifically associated with specific psychiatric conditions, namely posttraumatic phenomena and personality disorders.

CONCLUSIONS

Numerous psychological pain dimensions were detected in case descriptions of individuals who underwent EAS before the procedure. Subjective nature of the study precludes definite conclusions but suggest that future studies should explore psychological pain and the role of interventions targeting it in patients requesting EAS.

Is this person with dementia (currently) competent to request euthanasia? A complicated and underexplored question

In euthanasia and/or assisted suicide (EAS) of persons with dementia, the controversy has mostly focused on decisionally incapable persons with very advanced dementia for whom the procedure must be based on a written advance euthanasia directive. This focus on advance euthanasia directive-based EAS has been accompanied by scant attention to the issue of decision-making capacity assessment of persons with dementia who are being evaluated for concurrent request EAS. We build on a previous analysis of concurrent request EAS cases from the Netherlands, which showed that many such cases involve persons with significant cognitive impairment. We use illustrative cases to describe the difficulty of determining decisional capacity in persons whose stage of dementia falls between severely impaired and mildly impaired. We show that the Dutch practice of capacity assessment in such dementia cases is difficult to reconcile with the widely accepted functional model of capacity-a model explicitly endorsed by the Dutch euthanasia review committees. We discuss why such deviations from the standard functional model might be occurring, as well as their ethical implications for dementia EAS policy and practice.

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.

Assessment of patient decision-making capacity in the context of voluntary euthanasia for psychic suffering caused by psychiatric disorders: a qualitative study of approaches among Belgian physicians

OBJECTIVE

In Belgium, people with an incurable psychiatric disorder can file a request for euthanasia claiming unbearable psychic suffering. For the request to be accepted, it has to meet stringent legal criteria. One of the requirements is that the patient possesses decision-making capacity. The patient's decision-making capacity is assessed by physicians.The objective of our study is to provide insight in the assessment of decision-making capacity in the context of euthanasia for patients with psychic suffering caused by a psychiatric disorder.

METHOD

Twenty-two semistructured interviews with psychiatrists and neurologists were analysed with NVivo, a qualitative analysis software to code and organise transcribed data.

RESULTS

Different views and approaches regarding decision-making capacity in the context of euthanasia emerged from the data.Most of the physicians have some knowledge of the cognitive ability approach on decision-making capacity. According to this approach, four abilities constitute decision-making capacity: communication, understanding, appreciation and reasoning. We observed differences in the way these abilities are valued in relation to competence. Some physicians take additional elements into consideration when assessing decision-making capacity.Physicians acquired their knowledge on the subject in many different ways. Most of the physicians reported that decision-making capacity was not part of their training.

CONCLUSION

We conclude that physicians assess decision-making capacity in different ways and that personal values and beliefs influence their approach. As such, a common approach in assessing the decision-making capacity of a patient among the interviewed physicians is lacking. Less arbitrariness could be obtained by consistently implementing the cognitive ability approach.

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.

Technology for Our Future? Exploring the Duty to Report and Processes of Subjectification Relating to Digitalized Suicide Prevention

Digital and networking technologies are increasingly used to predict who is at risk of attempting suicide. Such digitalized suicide prevention within and beyond mental health care raises ethical, social and legal issues for a range of actors involved. Here, I will draw on key literature to explore what issues (might) arise in relation to digitalized suicide prevention practices. I will start by reviewing some of the initiatives that are already implemented, and address some of the issues associated with these and with potential future initiatives. Rather than addressing the breadth of issues, however, I will then zoom in on two key issues: first, the duty of care and the duty to report, and how these two legal and professional standards may change within and through digitalized suicide prevention; and secondly a more philosophical exploration of how digitalized suicide prevention may alter human subjectivity. To end with the by now famous adagio, digitalized suicide prevention is neither good nor bad, nor is it neutral, and I will argue that we need sustained academic and social conversation about who can and should be involved in digitalized suicide prevention practices and, indeed, in what ways it can and should (not) happen.

Euthanasia and assisted suicide of persons with psychiatric disorders: the challenge of personality disorders

BACKGROUND

Euthanasia or assisted suicide (EAS) for psychiatric disorders, legal in some countries, remains controversial. Personality disorders are common in psychiatric EAS. They often cause a sense of irremediable suffering and engender complex patient-clinician interactions, both of which could complicate EAS evaluations.

METHODS

We conducted a directed-content analysis of all psychiatric EAS cases involving personality and related disorders published by the Dutch regional euthanasia review committees (N = 74, from 2011 to October 2017).

RESULTS

Most patients were women (76%, n = 52), often with long, complex clinical histories: 62% had physical comorbidities, 97% had at least one, and 70% had two or more psychiatric comorbidities. They often had a history of suicide attempts (47%), self-harming behavior (27%), and trauma (36%). In 46%, a previous EAS request had been refused. Past psychiatric treatments varied: e.g. hospitalization and psychotherapy were not tried in 27% and 28%, respectively. In 50%, the physician managing their EAS were new to them, a third (36%) did not have a treating psychiatrist at the time of EAS request, and most physicians performing EAS were non-psychiatrists (70%) relying on cross-sectional psychiatric evaluations focusing on EAS eligibility, not treatment. Physicians evaluating such patients appear to be especially emotionally affected compared with when personality disorders are not present.

CONCLUSIONS

The EAS evaluation of persons with personality disorders may be challenging and emotionally complex for their evaluators who are often non-psychiatrists. These factors could influence the interpretation of EAS requirements of irremediability, raising issues that merit further discussion and research.

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

BACKGROUND

Since Belgium legalised euthanasia, the number of performed euthanasia cases for psychological suffering in psychiatric patients has significantly increased, as well as the number of media reports on controversial cases. This has prompted several healthcare organisations and committees to develop policies on the management of these requests.

METHOD

Five recent initiatives that offer guidance on euthanasia requests by psychiatric patients in Flanders were analysed: the protocol of Ghent University Hospital and advisory texts of the Flemish Federation of Psychiatry, the Brothers of Charity, the Belgian Advisory Committee on Bioethics, and Zorgnet-Icuro. These were examined via critical point-by-point reflection, focusing on all legal due care criteria in order to identify: 1) proposed measures to operationalise the evaluation of the legal criteria; 2) suggestions of additional safeguards going beyond these criteria; and 3) remaining fields of tension.

RESULTS

The initiatives are well in keeping with the legal requirements but are often more stringent. Additional safeguards that are formulated include the need for at least two positive advices from at least two psychiatrists; an a priori evaluation system; and a two-track approach, focusing simultaneously on the assessment of the patient's euthanasia request and on that person's continuing treatment. Although the initiatives are similar in intent, some differences in approach were found, reflecting different ethical stances towards euthanasia and an emphasis on practical clinical assessment versus broad ethical reflection.

CONCLUSIONS

All initiatives offer useful guidance for the management of euthanasia requests by psychiatric patients. By providing information on, and proper operationalisations of, the legal due care criteria, these initiatives are important instruments to prevent potential abuses. Apart from the additional safeguards suggested, the importance of a decision-making policy that includes many actors (e.g. the patient's relatives and other care providers) and of good aftercare for the bereaved are rightly stressed. Shortcomings of the initiatives relate to the aftercare of patients whose euthanasia request is rejected, and to uncertainty regarding the way in which attending physicians should manage negative or conflicting advices, or patients' suicide threats in case of refusal. Given the scarcity of data on how thoroughly and uniformly requests are handled in practice, it is unclear to what extent the recommendations made in these guidelines are currently being implemented.

Factors associated with requesting and receiving euthanasia: a nationwide mortality follow-back study with a focus on patients with psychiatric disorders, dementia, or an accumulation of health problems related to old age

BACKGROUND

Recently, euthanasia and assisted suicide (EAS) in patients with psychiatric disorders, dementia, or an accumulation of health problems has taken a prominent place in the public debate. However, limited is known about this practice. The purpose of this study was threefold: to estimate the frequency of requesting and receiving EAS among people with (also) a psychiatric disorder, dementia, or an accumulation of health problems; to explore reasons for physicians to grant or refuse a request; and to describe differences in characteristics, including the presence of psychiatric disorders, dementia, and accumulation of health problems, between patients who did and did not request EAS and between patients whose request was or was not granted.

METHODS

A nationwide cross-sectional survey study was performed. A stratified sample of death certificates of patients who died between 1 August and 1 December 2015 was drawn from the central death registry of Statistics Netherlands. Questionnaires were sent to the certifying physician (n = 9351, response 78%). Only deceased patients aged ≥ 17 years and who died a non-sudden death were included in the analyses (n = 5361).

RESULTS

The frequency of euthanasia requests among deceased people who died non-suddenly and with (also) a psychiatric disorder (11.4%), dementia (2.1%), or an accumulation of health problems (8.0%) varied. Factors positively associated with requesting euthanasia were age (< 80 years), ethnicity (Dutch/Western), cause of death (cancer), attending physician (general practitioner), and involvement of a pain specialist or psychiatrist. Cause of death (neurological disorders, another cause) and attending physician (general practitioner) were also positively associated with receiving euthanasia. Psychiatric disorders, dementia, and/or an accumulation of health problems were negatively associated with both requesting and receiving euthanasia.

CONCLUSIONS

EAS in deceased patients with psychiatric disorders, dementia, and/or an accumulation of health problems is relatively rare. Partly, this can be explained by the belief that the due care criteria cannot be met. Another explanation is that patients with these conditions are less likely to request EAS.

Advance euthanasia directives: a controversial case and its ethical implications

Authorising euthanasia and assisted suicide with advance euthanasia directives (AEDs) is permitted, yet debated, in the Netherlands. We focus on a recent controversial case in which a Dutch woman with Alzheimer's disease was euthanised based on her AED. A Dutch euthanasia review committee found that the physician performing the euthanasia failed to follow due care requirements for euthanasia and assisted suicide. This case is notable because it is the first case to trigger a criminal investigation since the 2002 Dutch euthanasia law was enacted. Thus far, only brief descriptions of the case have been reported in English language journals and media. We provide a detailed description of the case, review the main challenges of preparing and applying AEDs for persons with dementia and briefly assess the adequacy of the current oversight system governing AEDs.

Euthanasia and assisted suicide for people with an intellectual disability and/or autism spectrum disorder: an examination of nine relevant euthanasia cases in the Netherlands (2012-2016)

BACKGROUND

Euthanasia and assisted suicide (EAS) have been legally possible in the Netherlands since 2001, provided that statutory due care criteria are met, including: (a) voluntary and well-considered request; (b) unbearable suffering without prospect of improvement; (c) informing the patient; (d) lack of a reasonable alternative; (e) independent second physician's opinion. 'Unbearable suffering' must have a medical basis, either somatic or psychiatric, but there is no requirement of limited life expectancy. All EAS cases must be reported and are scrutinised by regional review committees (RTE). The purpose of this study was to investigate whether any particular difficulties arise when the EAS due care criteria are applied to patients with an intellectual disability and/or autism spectrum disorder.

METHODS

The 416 case summaries available on the RTE website (2012-2016) were searched for intellectual disability (6) and autism spectrum disorder (3). Direct content analysis was used on these nine cases.

RESULTS

Assessment of decisional capacity was mentioned in eight cases, but few details given; in two cases, there had been uncertainty or disagreement about capacity. Two patients had progressive somatic conditions. For most, suffering was due to an inability to cope with changing circumstances or increasing dependency; in several cases, suffering was described in terms of characteristics of living with an autism spectrum disorder, rather than an acquired medical condition. Some physicians struggled to understand the patient's perspective. Treatment refusal was a common theme, leading physicians to conclude that EAS was the only remaining option. There was a lack of detail on social circumstances and how patients were informed about their prognosis.

CONCLUSIONS

Autonomy and decisional capacity are highly complex for patients with intellectual disabilities and difficult to assess; capacity tests in these cases did not appear sufficiently stringent. Assessment of suffering is particularly difficult for patients who have experienced life-long disability. The sometimes brief time frames and limited number of physician-patient meetings may not be sufficient to make a decision as serious as EAS. The Dutch EAS due care criteria are not easily applied to people with intellectual disabilities and/or autism spectrum disorder, and do not appear to act as adequate safeguards.

Attitudes Toward Euthanasia for Patients Who Suffer From Physical or Mental Illness

This study examined whether attitudes toward euthanasia vary with type of illness and with the source of the desire to end the patient’s life. The study used a 3 (illness type: cancer, schizophrenia, depression) × 2 (euthanasia type: patient-initiated, family-initiated) between-groups experimental design. An online questionnaire was administered to 324 employees and students from a Australian public university following random assignment of participants to one of the six vignette-based conditions. Attitudes toward euthanasia were more positive for patients with a physical illness than a mental illness. For a patient with cancer or depression, but not schizophrenia, approval was greater for patient-, than, family-, initiated euthanasia. Relationships between illness type and attitudes were mediated by perceptions of patient autonomy and illness controllability. Findings have implications for debate, practices, and legislation regarding euthanasia.

A National Survey of Canadian Psychiatrists' Attitudes toward Medical Assistance in Death

BACKGROUND

Bill C-14 allows for medical assistance in dying (MAID) for patients who have intolerable physical or psychological suffering that occurs in the context of a reasonably foreseeable death. In Canada, psychiatrist support for MAID on the basis of mental illness and beliefs influencing level of support are unknown. The objectives of this research were to 1) determine if psychiatrists are supportive of MAID under certain conditions and on the basis of mental illness and 2) determine what factors are related to psychiatrist support for MAID on the basis of mental illness.

METHODS

This cross-sectional study was conducted among 528 psychiatrists in Canada using an online survey platform (February 19 to March 11, 2016).

RESULTS

The response rate was 20.9% ( n = 528). Most psychiatrists supported the legalisation of MAID in some circumstances (72%); however, only 29.4% supported MAID on the basis of mental illness. Factors correlating with decreased support for MAID for mental illness were the belief that MAID for mental illness would change the psychiatrists' commitment to their patients through enduring suffering, having a personal faith, and having had past patients who would have received MAID for mental illness were it legal but instead went on to recover.

INTERPRETATION

This study found that most psychiatrists do not support the legalisation of MAID for mental illness, despite being quite supportive of MAID in general. Objections seemed to be based upon concern for vulnerable patients, personal moral objections, and concern for the effect it would have on the therapeutic alliance.

Euthanasia and physician-assisted suicide not meeting due care criteria in the Netherlands: a qualitative review of review committee judgements

ObjectivesTo assess how Dutch regional euthanasia review committees (RTE) apply the euthanasia and physician-assisted suicide (EAS) due care criteria in cases where the criteria are judged not to have been met ('due care not met' (DCNM)) and to evaluate how the criteria function to set limits in Dutch EAS practice.

DESIGN

A qualitative review using directed content analysis of DCNM cases in the Netherlands from 2012 to 2016 published on the RTE website (https://www.euthanasiecommissie.nl/) as of 31 January 2017.

RESULTS

Of 33 DCNM cases identified (occurring 2012-2016), 32 cases (97%) were published online and included in the analysis. 22 cases (69%) violated only procedural criteria, relating to improper medication administration or inadequate physician consultation. 10 cases (31%) failed to meet substantive criteria, with the most common violation involving the no reasonable alternative (to EAS) criterion (seven cases). Most substantive cases involved controversial elements, such as EAS for psychiatric disorders or 'tired of life', in incapacitated patients or by physicians from advocacy organisations. Even in substantive criteria cases, the RTE's focus was procedural. The cases were more about unorthodox, unprofessional or overconfident physician behaviours and not whether patients should have received EAS. However, in some cases, physicians knowingly pushed the limits of EAS law. Physicians from euthanasia advocacy organisations were over-represented in substantive criteria cases. Trained EAS consultants tended to agree with or facilitate EAS in DCNM cases. Physicians and families had difficulty applying ambiguous advance directives of incapacitated patients.

CONCLUSION

As a retrospective review of physician self-reported data, the Dutch RTEs do not focus on whether patients should have received EAS, but instead primarily gauge whether doctors conducted EAS in a thorough, professional manner. To what extent this constitutes enforcement of strict safeguards, especially when cases contain controversial features, is not clear.

About the practice of psychiatric euthanasia: a commentary

Euthanasia motivated by mental disorders is legal in only a few countries and has a short history. In a recent report of all psychiatric euthanasia cases in Belgium between 2002 and 2013, Dierickx and colleagues suggest that the number of these cases is increasing, and provide a profile of the applicants. To date, knowledge of the practice of psychiatric euthanasia is limited, but rising public awareness might increase the number of requests. The authors reveal several shortcomings in cases of psychiatric euthanasia and open avenues for future research.Please see related article: https://bmcpsychiatry.biomedcentral.com/articles/10.1186/s12888-017-1369-0.

Euthanasia for people with psychiatric disorders or dementia in Belgium: analysis of officially reported cases

BACKGROUND

Euthanasia for people who are not terminally ill, such as those suffering from psychiatric disorders or dementia, is legal in Belgium under strict conditions but remains a controversial practice. As yet, the prevalence of euthanasia for people with psychiatric disorders or dementia has not been studied and little is known about the characteristics of the practice. This study aims to report on the trends in prevalence and number of euthanasia cases with a psychiatric disorder or dementia diagnosis in Belgium and demographic, clinical and decision-making characteristics of these cases.

METHODS

We analysed the anonymous databases of euthanasia cases reported to the Federal Control and Evaluation Committee Euthanasia from the implementation of the euthanasia law in Belgium in 2002 until the end of 2013. The databases we received provided the information on all euthanasia cases as registered by the Committee from the official registration forms. Only those with one or more psychiatric disorders or dementia and no physical disease were included in the analysis.

RESULTS

We identified 179 reported euthanasia cases with a psychiatric disorder or dementia as the sole diagnosis. These consisted of mood disorders (N = 83), dementia (N = 62), other psychiatric disorders (N = 22) and mood disorders accompanied by another psychiatric disorder (N = 12). The proportion of euthanasia cases with a psychiatric disorder or dementia diagnosis was 0.5% of all cases reported in the period 2002-2007, increasing from 2008 onwards to 3.0% of all cases reported in 2013. The increase in the absolute number of cases is particularly evident in cases with a mood disorder diagnosis. The majority of cases concerned women (58.1% in dementia to 77.1% in mood disorders). All cases were judged to have met the legal requirements by the Committee.

CONCLUSIONS

While euthanasia on the grounds of unbearable suffering caused by a psychiatric disorder or dementia remains a comparatively limited practice in Belgium, its prevalence has risen since 2008. If, as this study suggests, people with psychiatric conditions or dementia are increasingly seeking access to euthanasia, the development of practice guidelines is all the more desirable if physicians are to respond adequately to these highly delicate requests.

Meeting Its Mission: Does Psychosomatics Align With the Mission of Its Parent Organization, the Academy of Psychosomatic Medicine?

BACKGROUND

The vision and mission statements of the Academy of Psychosomatic Medicine (APM) indicate that the APM should promote excellence in clinical care for patients with comorbid psychiatric and general medical conditions by seeking to influence research, public policy, and interdisciplinary education.

OBJECTIVE

As the APM owns the journal, Psychosomatics, we sought to assess whether the APM's journal was fulfilling the vision and mission of its parent organization by reviewing the content of articles published in the journal to determine whether it sufficiently addresses the various clinical care knowledge areas it seeks to influence.

METHODS

We categorized content in all review articles, case reports, and original research articles published in Psychosomatics in 2015 and 2016. Each article was assigned to as many categories that it covered.

RESULTS

In the 163 articles reviewed, the most frequently covered fund of knowledge area was psychiatric morbidity in medical populations (44.2%); among psychiatric disorders, mood disorders (22.1%), psychiatric disorders due to a general medical condition or toxic substance (21.5%), anxiety disorders (14.7%), and delirium (13.5) were the most frequently covered. Of the medical and surgical topics, neurology (19.6%), coping with chronic illness/psychological response to illness (17.8%), toxicology (11.7%), outpatient medicine (10.4%), and cardiology (9.8%) appeared most often.

CONCLUSIONS

Psychosomatics appears to be successfully providing content relevant to the APM's vision and mission statements and to practitioners of psychosomatic medicine.