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Pifarre J, Esquerda M, Torralba F, Bátiz J, Bofarull M. Persons with mental disorders and assisted dying practices in Spain: In response to Ramos et al. INTERNATIONAL JOURNAL OF LAW AND PSYCHIATRY 2024; 94:101980. [PMID: 38493732 DOI: 10.1016/j.ijlp.2024.101980] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/13/2024] [Revised: 03/06/2024] [Accepted: 03/06/2024] [Indexed: 03/19/2024]
Abstract
Ramos et al. paper offers a narrative review of Spanish Organic Law 3/2021, which regulates euthanasia, focusing on its application to individuals with mental disorders. Ramos et al. examine the application of legal prerequisites from an ethical-legal perspective to ascertain the conditions under which psychiatric euthanasia might be considered legitimate and compliant with legal stipulations. Nevertheless, it is apparent that the core ethical inquiries linked to this matter have not been exhaustively investigated. The criteria laid out are, in our assessment, still open to further debate and broader deliberation. Our article emphasizes the need for a comprehensive ethical and legal debate in Spain regarding psychiatric euthanasia. Competency assessment is central to the legislation, but there are concerns about the validity of assessment tools and the subjective nature of interviews. Furthermore, defining irreversible suffering in mental health contexts poses challenges. The article advocates for a deeper understanding of the needs of individuals with mental disorders before considering euthanasia and emphasizes the importance of comprehensive care and psychosocial interventions in reducing the desire for euthanasia. Ultimately, it underscores the ethical complexities of euthanasia in mental health and the necessity of prioritizing comprehensive care in addressing these complexities.
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Affiliation(s)
- Josep Pifarre
- Institut Borja de Bioética, Universitat Ramon Llull, Barcelona, Spain; San Juan de Dios Provincia de España, Madrid, Spain
| | - Montse Esquerda
- Institut Borja de Bioética, Universitat Ramon Llull, Barcelona, Spain; Hospital Sant Joan de Déu Terres de Lleida, Spain.
| | - Francesc Torralba
- Institut Borja de Bioética, Universitat Ramon Llull, Barcelona, Spain
| | - Jacinto Bátiz
- Institut Borja de Bioética, Universitat Ramon Llull, Barcelona, Spain; San Juan de Dios Provincia de España, Madrid, Spain
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Stergiopoulos V, Bastidas-Bilbao H, Gupta M, Buchman DZ, Stewart DE, Rajji T, Simpson AIF, van Kesteren MR, Cappe V, Castle D, Shields R, Hawke LD. 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. BMC Psychiatry 2024; 24:120. [PMID: 38355467 PMCID: PMC10865571 DOI: 10.1186/s12888-024-05541-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2023] [Accepted: 01/19/2024] [Indexed: 02/16/2024] Open
Abstract
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.
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Affiliation(s)
- Vicky Stergiopoulos
- Centre for Addiction and Mental Health, Toronto, Ontario, Canada.
- University of Toronto, Toronto, Ontario, Canada.
| | | | - Mona Gupta
- Centre hospitalier de l'Université de Montréal, Montréal, Québec, Canada
| | - Daniel Z Buchman
- Centre for Addiction and Mental Health, Toronto, Ontario, Canada
- University of Toronto, Toronto, Ontario, Canada
| | - Donna E Stewart
- University of Toronto, Toronto, Ontario, Canada
- University Health Network, Toronto, Ontario, Canada
| | - Tarek Rajji
- Centre for Addiction and Mental Health, Toronto, Ontario, Canada
- University of Toronto, Toronto, Ontario, Canada
| | - Alexander I F Simpson
- Centre for Addiction and Mental Health, Toronto, Ontario, Canada
- University of Toronto, Toronto, Ontario, Canada
| | | | - Vivien Cappe
- Centre for Addiction and Mental Health, Toronto, Ontario, Canada
| | - David Castle
- University of Tasmania, Hobart, Tasmania, Australia
- Statewide Mental Health Service, Hobart, Tasmania, Australia
| | - Roslyn Shields
- Centre for Addiction and Mental Health, Toronto, Ontario, Canada
| | - Lisa D Hawke
- Centre for Addiction and Mental Health, Toronto, Ontario, Canada
- University of Toronto, Toronto, Ontario, Canada
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Favron-Godbout C, Racine E. Medical assistance in dying for people living with mental disorders: a qualitative thematic review. BMC Med Ethics 2023; 24:86. [PMID: 37875867 PMCID: PMC10594804 DOI: 10.1186/s12910-023-00971-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2023] [Accepted: 10/15/2023] [Indexed: 10/26/2023] Open
Abstract
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.
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Affiliation(s)
- Caroline Favron-Godbout
- Pragmatic Health Ethics Research Unit, Montreal Clinical Research Institute, 110 av. des Pins O, Montreal, QC, H2W 1R7, Canada
| | - Eric Racine
- Pragmatic Health Ethics Research Unit, Montreal Clinical Research Institute, 110 av. des Pins O, Montreal, QC, H2W 1R7, Canada.
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Baylis P, Shaw J, Schatzmann EJ, Pouliot V, Lalonde L. Clinical presentations of suicidality in relation to medical assistance in dying. Suicide Life Threat Behav 2023; 53:818-825. [PMID: 37646301 DOI: 10.1111/sltb.12985] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2023] [Revised: 07/24/2023] [Accepted: 07/24/2023] [Indexed: 09/01/2023]
Abstract
INTRODUCTION This study explores the assessments of mental health clinicians working with suicidal patients who requested access to medical assistance in dying (MAiD). METHODS A sample of convenience completed an online questionnaire about their experiences with suicidal patients. Respondents described their encounters with 227 suicidal patients: 44 requested access to MAiD, and 183 did not. Data were analyzed using chi-squared and simple t-test to identify differences between the respondents' descriptions of the two groups. RESULTS Results noted differences between patients who experience suicide ideation and request MAiD (SPM), and those who experience suicide ideation and do not (SP). Overall, the SPM group was older, more physical health concerns, chronic pain, existential distress, and less hope. Many had experienced several episodes of mental health care and medication trials, though unlike the SP group, they had a split between accessing a little care and a lot of care. They also engaged in less suicide planning, and some had no history of suicide attempts. CONCLUSION It is important that mental health clinicians learn to differentiate between MAiD requests due to an ongoing and irremediable mental disorder, and MAiD requests in response to circumscribed psychological suffering that could be relieved via a change in circumstances and/or access to different treatment options amenable to the patient.
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Affiliation(s)
- Peter Baylis
- Alberta Health Services, Canmore, Alberta, Canada
- University of Calgary, Calgary, Alberta, Canada
| | | | | | | | - Lise Lalonde
- Alberta Health Services, Canmore, Alberta, Canada
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Xu H, Stjernswärd S, Glasdam S, Fu C. Circumstances affecting patients' euthanasia or medically assisted suicide decisions from the perspectives of patients, relatives, and healthcare professionals: A qualitative systematic review. DEATH STUDIES 2023; 48:326-351. [PMID: 37390123 DOI: 10.1080/07481187.2023.2228730] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/02/2023]
Abstract
This study aims to explore circumstances affecting patients' euthanasia and medically assisted suicide (MAS) decisions from the perspectives of patients, relatives, and healthcare professionals. A qualitative systematic review was performed following PRISMA recommendations. The review protocol is registered in PROSPERO (CRD42022303034). Literature searches were conducted in MEDLINE, EMBASE, CINAHL Complete, Eric, PsycInfo, and citation pearl search in Scopus from 2012 to 2022. In total, 6840 publications were initially retrieved. The analysis included a descriptive numerical summary analysis and a qualitative thematic analysis of 27 publications, resulting in two main themes-Contexts and factors influencing actions and interactions, and Finding support while dealing with resistance in euthanasia and MAS decisions-and related sub-themes. The results illuminated the dynamics in (inter)actions between patients and involved parties that might both impede and facilitate patients' decisions related to euthanasia/MAS, potentially influencing patients' decision-making experiences, and the roles and experiences of involved parties.
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Affiliation(s)
- Hongxuan Xu
- Department of Health Sciences, Faculty of Medicine, Lund University, Lund, Sweden
| | - Sigrid Stjernswärd
- Department of Health Sciences, Faculty of Medicine, Lund University, Lund, Sweden
| | - Stinne Glasdam
- Department of Health Sciences, Faculty of Medicine, Lund University, Lund, Sweden
| | - Cong Fu
- Department of Health Sciences, Faculty of Medicine, Lund University, Lund, Sweden
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Bahji A, Delva N. 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. JOURNAL OF MEDICAL ETHICS 2022; 48:929-934. [PMID: 33849958 DOI: 10.1136/medethics-2020-107133] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/03/2020] [Revised: 03/04/2021] [Accepted: 03/20/2021] [Indexed: 06/12/2023]
Abstract
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.
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Affiliation(s)
- Anees Bahji
- Department of Psychiatry, University of Calgary, Calgary, Alberta, Canada
| | - Nicholas Delva
- Department of Psychiatry, Queen's University, Kingston, Ontario, Canada
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Gaudiani JL, Bogetz A, Yager J. Terminal anorexia nervosa: three cases and proposed clinical characteristics. J Eat Disord 2022; 10:23. [PMID: 35168671 PMCID: PMC8845309 DOI: 10.1186/s40337-022-00548-3] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2021] [Accepted: 02/01/2022] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Most individuals with eating disorders will either recover, settle into an unrecovered but self-defined acceptable quality of life, or continue to cycle from crisis to relative stability over time. However, a minority of those with severe and enduring eating disorders recognize after years of trying that recovery remains elusive, and further treatment seems both futile and harmful. No level of harm reduction proves achievable or adequately ameliorates their suffering. In this subgroup, many of those with anorexia nervosa will experience the medical consequences of malnutrition as their future cause of death. Whereas anyone who wishes to keep striving for recovery despite exhaustion and depletion should wholeheartedly be supported in doing so, some patients simply cannot continue to fight. They recognize that death from anorexia nervosa, while perhaps not welcome, will be inevitable. Unfortunately, these patients and their carers often receive minimal support from eating disorders health professionals who are conflicted about terminal care, and who are hampered and limited by the paucity of literature on end-of-life care for those with anorexia nervosa. CASE PRESENTATION Three case studies elucidate this condition. One patient was so passionate about this topic that she asked to be a posthumous co-author of this paper. CONCLUSIONS Consistent with literature on managing terminal illness, this article proposes clinical characteristics of patients who may be considered to have a terminal eating disorder: diagnosis of anorexia nervosa, older age (e.g. age over 30), previous participation in high quality care, and clear and consistent determination by a patient who possesses decision-making capacity that additional treatment would be futile, knowing their actions will result in death. By proposing the clinical characteristics of terminal anorexia nervosa, we hope to educate, inspire compassion, and help providers properly assess these patients and provide appropriate care. We hope that this proposal stimulates further expert consensus definitions and clinical guidelines for management of this population. In our view, these patients deserve the same attendant care and rights as all other patients with terminal illness, up to and including medical aid in dying in jurisdictions where such care is legal.
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Affiliation(s)
| | - Alyssa Bogetz
- Department of Psychiatry, University of Colorado School of Medicine, Aurora, CO, USA
| | - Joel Yager
- Department of Psychiatry, University of Colorado School of Medicine, Aurora, CO, USA
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Abstract
PURPOSE OF REVIEW Over the last 30 years, medical assistance in dying (MAiD) including euthanasia (EU) and physician-assisted death (or suicide, PAS) has become the center of a large debate, particularly when these practices have involved people with psychiatric illness, including resistant depression, schizophrenia, personality, or other severe psychiatric disorders. We performed a review utilizing several databases, and by including the most relevant studies in full journal articles investigating the problem of MAiD in patients with psychiatric disorders but not in physical terminal conditions (non-terminal, MAiD-NT). RECENT FINDINGS Literature has shown that a small percentage of people with psychiatric disorders died by MAiD-NT in comparison with patients with somatic diseases in terminal clinical conditions (e.g., cancer, AIDS). However, the problem in the field is complex and not solved yet as confirmed by the fact that only a few countries (e.g., the Netherlands, Belgium, Luxemburg) have legalized MAiD-NT for patients with psychiatric disorders, while most have maintained the practices accessible only to people with somatic disease in a terminal phase. Also, how to make objective the criterion of irremediability of a mental disorder; how to balance suicide prevention with assisted suicide; how to avoid the risk of progressively including in requests for MAiD-NT vulnerable segments of the population, such as minors, elderly, or people with dementia, in a productive-oriented society, are some of the critical points to be discussed. The application of MAiD-NT in people with psychiatric disorders should be further explored to prevent end-of-life rights from contradicting the principles of recovery-oriented care.
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Allard J, Ballesteros F, Fortin MC. Québec health care professionals' perspectives on organ donation after medical assistance in dying. BMC Med Ethics 2021; 22:23. [PMID: 33663501 PMCID: PMC7934363 DOI: 10.1186/s12910-021-00594-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2020] [Accepted: 02/24/2021] [Indexed: 11/18/2022] Open
Abstract
Background Medical assistance in dying (MAID) has been legal in Québec since December 2015 and in the rest of Canada since July 2016. Since then, more than 60 people have donated their organs after MAID. Such donations raise ethical issues about respect of patients’ autonomy, potential pressure to choose MAID, the information given to potential donors, the acceptability of directed donations in such a context and the possibility of death by donation. The objective of this study was to explore Québec professionals’ perspectives on the ethical issues related to organ donation after MAID. Methods We conducted semi-directed interviews with 21 health care professionals involved in organ donation such as intensivists and intensive care nurses, operating room nurses, organ donation nurses and coordinators. Results The participants were all favourable to organ donation after MAID in order to respect patients’ autonomy. They also favoured informing all potential donors of the possibility of donating organs. They highlighted the importance of assessing donors’ reasons for requesting MAID during the assessment. They were divided on directed donation, living donation before MAID and death by donation. Conclusion Organ donation after MAID was widely accepted among the participants, based on the principle of respect for the donor’s autonomy. The findings of this study only provide the perspectives of Québec health care professionals involved in organ donation. Future studies are needed to gather other stakeholders’ perspectives on this issue as well as patients’ and families’ experiences of organ donation after MAID.
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Affiliation(s)
- Julie Allard
- Bioethics Program, Department of Social and Preventive Medicine, École de Santé Publique de l'Université de Montréal, Montréal, Canada.,Canadian Donation and Transplantation Research Program, Edmonton, Canada
| | - Fabian Ballesteros
- Department of Medicine, Centre de Recherche du Centre Hospitalier de l'Université de Montréal (CHUM), 900, rue Saint-Denis, R12-418, Montréal, QC, H2X 0A9, Canada
| | - Marie-Chantal Fortin
- Bioethics Program, Department of Social and Preventive Medicine, École de Santé Publique de l'Université de Montréal, Montréal, Canada. .,Canadian Donation and Transplantation Research Program, Edmonton, Canada. .,Department of Medicine, Centre de Recherche du Centre Hospitalier de l'Université de Montréal (CHUM), 900, rue Saint-Denis, R12-418, Montréal, QC, H2X 0A9, Canada.
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Levitt S, Buchman DZ. Applying futility in psychiatry: a concept whose time has come. JOURNAL OF MEDICAL ETHICS 2020; 47:medethics-2020-106654. [PMID: 33443107 DOI: 10.1136/medethics-2020-106654] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Revised: 09/20/2020] [Accepted: 11/15/2020] [Indexed: 06/12/2023]
Abstract
Since its introduction in the 1980s, futility as a concept has held contested meaning and applications throughout medicine. There has been little discussion within the psychiatric literature about the use of futility in the care of individuals experiencing severe and persistent mental illness (SPMI), despite some tacit acceptance that futility may apply in certain cases of psychiatric illness. In this paper, we explore the literature surrounding futility and argue that its connotation within medicine is to describe situations where patients (or their substitute decision-makers) believe that interventions will almost certainly provide no meaningful benefit. We then provide two arguments in support of the use of futility within the care of individuals experiencing SPMI: that some SPMI can be considered a terminal illness, and that the risk-benefit ratio is a dynamic entity such that futility can help describe what Gillett calls the 'risk of unacceptable badness' when it comes to considering how an intervention might impact a patient's quality of life. We posit that capacity should not pose an obstacle to declaring futility when caring for individuals experiencing SPMI and explain how futility is not antithetical to recovery in mental health. Finally, we describe how using futility within psychiatric practice can allow for a reorientation of care by signalling the need to shift to a palliative approach.
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Affiliation(s)
- Sarah Levitt
- Department of Psychiatry, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
- Department of Psychiatry, University Health Network, Toronto, Ontario, Canada
| | - Daniel Z Buchman
- Department of Bioethics, University Health Network, Toronto, Ontario, Canada
- Joint Centre for Bioethics, University of Toronto, Toronto, Ontario, Canada
- Centre for Addiction and Mental Health, Toronto, Ontario, Canada
- Krembil Research Institute, Unviersity Health Network, Toronto, Ontario, Canada
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
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Montreuil M, Séguin M, Gros CP, Racine E. Survey of Mental Health Care Providers’ Perspectives on the Everyday Ethics of Medical-Aid-in-Dying for People with a Mental Illness. CANADIAN JOURNAL OF BIOETHICS 2020. [DOI: 10.7202/1070236ar] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Context: In most jurisdictions where medical-aid-in-dying (MAiD) is available, this option is reserved for individuals suffering from incurable physical conditions. Currently, in Canada, people who have a mental illness are legally excluded from accessing MAiD. Methods: We developed a questionnaire for mental health care providers to better understand their perspectives related to ethical issues in relation to MAiD in the context of severe and persistent suffering caused by mental illness. We used a mixed-methods survey approach, using a concurrent embedded model with both closed and open-ended questions. Findings: 477 healthcare providers from the province of Québec (Canada) completed the questionnaire. One third of the sample (34.4%) were nurses, one quarter psychologists (24.3%) and one quarter psycho-educators (24%). Nearly half of the respondents (48.4%) considered that people with a severe mental illness should be granted the right to opt for MAiD as a way to end their suffering. Respondents were more likely to feel comfortable listening to the person and participating in discussions related to MAiD for a mental illness than offering care or the means for the person to access MAiD. Most (86.2%) reported that they had not received adequate/sufficient training, education or preparation in order to address ethical questions surrounding MAiD. Conclusions: The findings highlight how extending MAiD to people with a mental illness would affect daily practices for mental healthcare providers who work directly with people who may request MAiD. The survey results also reinforce the need for adequate training and professional education in this complex area of care.
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Affiliation(s)
- Marjorie Montreuil
- Ingram School of Nursing, McGill University, Montreal; Quebec Network on Suicide, Mood Disorders and Related Disorders, Douglas Mental Health University Institute, Verdun; Institut de recherches cliniques de Montréal, Montréal, Québec, Canada
| | - Monique Séguin
- Quebec Network on Suicide, Mood Disorders and Related Disorders, Douglas Mental Health University Institute, Verdun; Department of Psychology, Université du Québec en Outaouais, Gatineau, Québec, Canada
| | - Catherine P. Gros
- Ingram School of Nursing, McGill University, Montreal; Quebec Network on Suicide, Mood Disorders and Related Disorders, Douglas Mental Health University Institute, Verdun, Québec, Canada
| | - Eric Racine
- Institut de recherches cliniques de Montréal, Montréal; Université de Montréal, Montréal; McGill University, Montreal, Québec, Canada
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12
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Rosenblat JD, Kurdyak P, Cosci F, Berk M, Maes M, Brunoni AR, Li M, Rodin G, McIntyre RS, Carvalho AF. Depression in the medically ill. Aust N Z J Psychiatry 2020; 54:346-366. [PMID: 31749372 DOI: 10.1177/0004867419888576] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Depressive disorders are significantly more common in the medically ill compared to the general population. Depression is associated with worsening of physical symptoms, greater healthcare utilization and poorer treatment adherence. The present paper provides a critical review on the assessment and management of depression in the medically ill. METHODS Relevant articles pertaining to depression in the medically ill were identified, reviewed and synthesized qualitatively. A systematic review was not performed due to the large breadth of this topic, making a meaningful summary of all published and unpublished studies not feasible. Notable studies were reviewed and synthesized by a diverse set of experts to provide a balanced summary. RESULTS Depression is frequently under-recognized in medical settings. Differential diagnoses include delirium, personality disorders and depressive disorders secondary to substances, medications or another medical condition. Depressive symptoms in the context of an adjustment disorder should be initially managed by supportive psychological approaches. Once a mild to moderate major depressive episode is identified, a stepped care approach should be implemented, starting with general psychoeducation, psychosocial interventions and ongoing monitoring. For moderate to severe symptoms, or mild symptoms that are not responding to low-intensity interventions, the use of antidepressants or higher intensity psychotherapeutic interventions should be considered. Psychotherapeutic interventions have demonstrated benefits with small to moderate effect sizes. Antidepressant medications have also demonstrated benefits with moderate effect sizes; however, special caution is needed in evaluating side effects, drug-drug interactions as well as dose adjustments due to impairment in hepatic metabolism and/or renal clearance. Novel interventions for the treatment of depression and other illness-related psychological symptoms (e.g. death anxiety, loss of dignity) are under investigation. LIMITATIONS Non-systematic review of the literature. CONCLUSION Replicated evidence has demonstrated a bidirectional interaction between depression and medical illness. Screening and stepped care using pharmacological and non-pharmacological interventions is merited.
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Affiliation(s)
- Joshua D Rosenblat
- Mood Disorder Psychopharmacology Unit, University Health Network, Toronto, ON, Canada.,Department of Psychiatry, University of Toronto, Toronto, ON, Canada
| | - Paul Kurdyak
- Department of Psychiatry, University of Toronto, Toronto, ON, Canada.,Centre for Addiction and Mental Health (CAMH), Toronto, ON, Canada.,Institute for Clinical Evaluative Sciences (ICES), Toronto, ON, Canada
| | - Fiammetta Cosci
- Department of Health Sciences, University of Florence, Florence, Italy.,Department of Psychiatry and Neuropsychology, Maastricht University, Maastricht, The Netherlands
| | - Michael Berk
- Deakin University, IMPACT Strategic Research Centre, School of Medicine, Barwon Health, Geelong, VIC, Australia.,The University of Melbourne, Department of Psychiatry, Royal Melbourne Hospital, Parkville, VIC, Australia.,Florey Institute for Neuroscience and Mental Health, The University of Melbourne, Royal Melbourne Hospital, Parkville, VIC, Australia.,Centre of Youth Mental Health, The University of Melbourne, Parkville, VIC, Australia.,Orygen, The National Centre of Excellence in Youth Mental Health, Parkville, VIC, Australia
| | - Michael Maes
- Deakin University, IMPACT Strategic Research Centre, School of Medicine, Barwon Health, Geelong, VIC, Australia.,Department of Psychiatry, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand.,Department of Psychiatry, Medical University of Plovdiv, Plovdiv, Bulgaria
| | - Andre R Brunoni
- Service of Interdisciplinary Neuromodulation (SIN), Laboratory of Neuroscience (LIM27) and National Institute of Biomarkers in Neuropsychiatry (INBioN), Department and Institute of Psychiatry, University of São Paulo Medical School, São Paulo, Brazil.,Department of Psychiatry and Psychotherapy, University Hospital, Ludwig Maximilian University of Munich, Munich, Germany
| | - Madeline Li
- Department of Psychiatry, University of Toronto, Toronto, ON, Canada.,Department of Supportive Care, Princess Margaret Cancer Centre, University of Toronto, Toronto, ON, Canada
| | - Gary Rodin
- Department of Psychiatry, University of Toronto, Toronto, ON, Canada.,Department of Supportive Care, Princess Margaret Cancer Centre, University of Toronto, Toronto, ON, Canada
| | - Roger S McIntyre
- Mood Disorder Psychopharmacology Unit, University Health Network, Toronto, ON, Canada.,Department of Psychiatry, University of Toronto, Toronto, ON, Canada
| | - Andre F Carvalho
- Department of Psychiatry, University of Toronto, Toronto, ON, Canada.,Centre for Addiction and Mental Health (CAMH), Toronto, ON, Canada
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Fujioka JK, Mirza RM, Klinger CA, McDonald LP. Medical assistance in dying: implications for health systems from a scoping review of the literature. J Health Serv Res Policy 2019; 24:207-216. [DOI: 10.1177/1355819619834962] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Objective Medical assistance in dying (MAiD) is the medical provision of substances to end a patient’s life at their voluntary request. While legal in several countries, the implementation of MAiD is met with ethical, legislative and clinical challenges, which are often overshadowed by moral discourse. Our aim was to conduct a scoping review to explore key barriers for the integration of MAiD into existing health systems. Methods We searched electronic databases (CINAHL, Embase, MEDLINE, and PsycINFO) and grey literature sources from 1990 to 2017. Studies discussing barriers and/or challenges to implementing MAiD from a health system’s perspective were included. Full-text papers were screened against inclusion/exclusion criteria for article selection. A thematic content analysis was conducted to summarize data into themes to highlight key implementation barriers. Results The final review included 35 articles (see online Appendix 1). Six categories of implementation challenges emerged: regulatory (n = 26), legal (n = 15), social (n = 9), logistical (n = 9), financial (n = 3) and compatibility with palliative care (n = 3). Within four of the six identified implementation barriers (regulatory, legal, social and logistical) were subthemes, which described barriers related to legalizing MAiD in more detail. Conclusion Despite multiple challenges related to its implementation, MAiD remains a requested end-of-life option, requiring careful examination to ensure adequate integration into existing health services. Comprehensive models of care incorporating multidisciplinary teams and regulatory oversight alongside improved clinician education may be effective to streamline MAiD services.
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Affiliation(s)
- Jamie K. Fujioka
- Researcher, Factor-Inwentash Faculty of Social Work, Institute for Life Course and Aging, University of Toronto, Canada
- Researcher, National Initiative for the Care of the Elderly, Canada
- Researcher, Dalla Lana School of Public Health, University of Toronto, Canada
| | - Raza M. Mirza
- Senior Research Associate, Factor-Inwentash Faculty of Social Work, Institute for Life Course and Aging, University of Toronto, Canada
- Senior Research Associate, National Initiative for the Care of the Elderly, Canada
| | - Christopher A. Klinger
- Senior Research Associate, Factor-Inwentash Faculty of Social Work, Institute for Life Course and Aging, University of Toronto, Canada
- Senior Research Associate, National Initiative for the Care of the Elderly, Canada
| | - Lynn P. McDonald
- Professor, Factor-Inwentash Faculty of Social Work, Institute for Life Course and Aging, University of Toronto, Canada
- Scientific Director, National Initiative for the Care of the Elderly, Canada
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14
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Simpson AIF. Medical Assistance in Dying and Mental Health: A Legal, Ethical, and Clinical Analysis. CANADIAN JOURNAL OF PSYCHIATRY. REVUE CANADIENNE DE PSYCHIATRIE 2018; 63:80-84. [PMID: 29216738 PMCID: PMC5788138 DOI: 10.1177/0706743717746662] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Medical assistance in dying (MAiD) legislation is now over a year old in Canada, and consideration is turning to whether MAiD should be extended to include serious mental illness as the sole qualifying condition for being eligible for MAiD. This article considers this question from ethical and clinical perspectives. It argues that extending the eligibility for MAiD to include those with a serious mental illness as the sole eligibility criterion is not ethical, necessary, or supported current psychiatric practice or opinion.
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Affiliation(s)
- Alexander I. F. Simpson
- Complex Care and Recovery Program, Forensic Division, Centre for Addiction and Mental Health, Toronto, Ontario
- Division of Forensic Psychiatry, University of Toronto, Toronto, Ontario
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15
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Rooney W, Schuklenk U, van de Vathorst S. Are Concerns About Irremediableness, Vulnerability, or Competence Sufficient to Justify Excluding All Psychiatric Patients from Medical Aid in Dying? HEALTH CARE ANALYSIS 2017. [DOI: 10.1007/s10728-017-0344-8] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
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