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Mukhopadhyay S, Banerjee D. Physician assisted suicide in dementia: A critical review of global evidence and considerations from India. Asian J Psychiatr 2021; 64:102802. [PMID: 34388669 DOI: 10.1016/j.ajp.2021.102802] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2021] [Revised: 07/23/2021] [Accepted: 08/02/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND Dementias are a group of gradually progressing neurodegenerative conditions, leading to significant impairment in cognition, functioning, decision-making, capacity and autonomy. With the rise of human rights and patient-centred perspectives in psychogeriatric management, physician-assisted suicide (PAS) has emerged as an important and integral part of end-of-life care in advanced dementias. METHODS With only few original studies in the area, this paper takes a narrative and critical approach to review the global legislations, treatment decisions, debates as well as perspectives from patients, families and medical professionals. RESULTS PAS and euthanasia are legally allowed in countries like Belgium, Netherlands, Switzerland and few states of the United States (U.S.). Germany has fewer clearer legislations in this regard. The Oregon state requirement and care criteria of the Dutch euthanasia act form the basis of most such laws. Even in the presence of these provisions, PAS is fraught with multiple medical, ethical, moral and legal dilemmas and physicians as well as caregivers are quite heterogenous in their outlook. While right to live with dignity and need to end incurable suffering form the main arguments for PAS, several arguments against it are possibility of undue influence, impaired judgement leading to biased decision-making such as depression and suicidality, inappropriate assessment of capacity, and that all deaths are not necessarily painful. These dilemmas are critically discussed in light of autonomy, decision-making and advanced directives in people living with dementia as well as the rationality of ending life and 'right to live vs right to die'. Based on the findings, certain balanced strategies are highlighted for the health professionals. CONCLUSION The 'slippery slope' of PAS needs to be carefully evaluated from a social justice and human rights perspective to improve dignified end-of-life care in dementia. Considerations are also discussed from India, a rapidly-ageing nation with no current provisions for PAS.
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Affiliation(s)
- Sanchari Mukhopadhyay
- Geriatric Unit and Clinical Services, Department of Psychiatry, National Institute of Mental Health and Neurosciences (NIMHANS), Near Dairy Circle, Hosur Road, Bangalore 560029, India
| | - Debanjan Banerjee
- Geriatric Unit and Clinical Services, Department of Psychiatry, National Institute of Mental Health and Neurosciences (NIMHANS), Near Dairy Circle, Hosur Road, Bangalore 560029, India.
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Allan A, Allan MM. Ethical issues when working with terminally ill people who desire to hasten the ends of their lives: a western perspective. ETHICS & BEHAVIOR 2019. [DOI: 10.1080/10508422.2019.1592683] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Affiliation(s)
- Alfred Allan
- School of Arts and Humanities, Edith Cowan University, Australia
| | - Maria M Allan
- School of Arts and Humanities, Edith Cowan University, Australia
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Fujioka JK, Mirza RM, McDonald PL, Klinger CA. Implementation of Medical Assistance in Dying: A Scoping Review of Health Care Providers' Perspectives. J Pain Symptom Manage 2018; 55:1564-1576.e9. [PMID: 29477968 DOI: 10.1016/j.jpainsymman.2018.02.011] [Citation(s) in RCA: 61] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2017] [Revised: 02/12/2018] [Accepted: 02/13/2018] [Indexed: 11/16/2022]
Abstract
RESEARCH AIMS With the growing interest in Medical Assistance in Dying (MAiD), understanding health care professionals' roles and experiences in handling requests is necessary to evaluate the quality, consistency, and efficacy of current practices. This scoping review sought to map the existing literature on health care providers' perspectives of their involvement in MAiD. METHODS A scoping review was conducted to address the following: 1) What are the roles of diverse health care professionals in the provision of MAiD? and 2) What professional challenges arise when confronted with MAiD requests? A literature search in electronic databases and gray literature sources was performed. Articles were screened, and a thematic content analysis synthesized key findings. RESULTS After evaluating 1715 citations and 148 full-text papers, 33 articles were included. Perspectives of nurses (n = 10), physicians (n = 7), mental health providers (n = 7), pharmacists (n = 4), social workers (n = 3), and medical examiners (n = 1) were explored. Professional roles included consulting/supporting patients and/or other staff members with requests, assessing eligibility, administering/dispensing the lethal drugs, providing aftercare to bereaved relatives, and regulatory oversight. Challenges included lack of clear guidelines/protocols, role ambiguity, evaluating capacity/consent, conscientious objection, and lack of interprofessional collaboration. CONCLUSION Evidence from various jurisdictions highlighted a need for clear guidelines and protocols that define each profession's role, scope of practice, and legal boundaries for MAiD. Comprehensive models of care that incorporate multidisciplinary teams alongside improved clinician education may be effective to support MAiD implementation. Little is known about health care providers' perspectives in handling requests, especially outside physician practice and nursing.
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Affiliation(s)
- Jamie K Fujioka
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada; Institute for Life Course and Aging, Factor-Inwentash Faculty of Social Work, University of Toronto, Toronto, Ontario, Canada; National Initiative for the Care of the Elderly, Toronto, Ontario, Canada.
| | - Raza M Mirza
- Institute for Life Course and Aging, Factor-Inwentash Faculty of Social Work, University of Toronto, Toronto, Ontario, Canada; National Initiative for the Care of the Elderly, Toronto, Ontario, Canada
| | - P Lynn McDonald
- Institute for Life Course and Aging, Factor-Inwentash Faculty of Social Work, University of Toronto, Toronto, Ontario, Canada; National Initiative for the Care of the Elderly, Toronto, Ontario, Canada
| | - Christopher A Klinger
- Institute for Life Course and Aging, Factor-Inwentash Faculty of Social Work, University of Toronto, Toronto, Ontario, Canada; National Initiative for the Care of the Elderly, Toronto, Ontario, Canada
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Butt ZA, Overholser JC, Danielson CK. Predictors of Attitudes Towards Physician-Assisted Suicide. OMEGA-JOURNAL OF DEATH AND DYING 2016; 47:107-17. [PMID: 15085822 DOI: 10.2190/dy9y-ya97-wg3n-cqth] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Psychological factors may influence an individual's acceptance of euthanasia and physician-assisted suicide (PAS). The purpose of the present investigation was to evaluate predictors of attitudes towards PAS. Data were collected from 136 college students at a private Midwestern university. In addition to demographic and family history information, respondents completed measures of attitudes towards seeking mental health services, depression, hopelessness, and PAS attitudes. Respondent age, race, and hopelessness scores emerged as the only significant predictors ( R2 = .20) in a multiple regression model used to identify potential predictors of PAS attitudes. Younger, non-minority respondents, and those endorsing more hopelessness reported more accepting attitudes towards PAS. Data from a three month follow-up assessment supported the stability of this pattern. The findings highlight the important role that mental health professionals should play in PAS decision making. Implications for the evaluation of medically ill considering PAS and their caregivers are discussed.
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Affiliation(s)
- Zeeshan A Butt
- Department of Psychology, Case Western Reserve University, 10900 Euclid Avenue, Cleveland, OH 44106-7123, USA.
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Werth JL, Holdwick DJ. A Primer on Rational Suicide and Other Forms of Hastened Death. COUNSELING PSYCHOLOGIST 2016. [DOI: 10.1177/0011000000284003] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
This article provides an overview of the major mental health issues involved in the debate over rational suicide and other forms of hastened death. In doing so, it covers the arguments for including counseling psychologists and other mental health professionals in discussions about hastened death; highlights the relevant empirical research associated with the topic, with special attention given to the studies involving psychologists and areas needing more investigation; and reviews the implications for practice and training and provides direction for those counseling psychologists who are working with persons who may be rational in their decisions to hasten death.
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Affiliation(s)
- James L. Werth
- American Psychological Association AIDS Policy Congressional Fellow,
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Parker M. Defending the indefensible? Psychiatry, assisted suicide and human freedom. INTERNATIONAL JOURNAL OF LAW AND PSYCHIATRY 2013; 36:485-497. [PMID: 23845163 DOI: 10.1016/j.ijlp.2013.06.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
The siege guns of the forces for change to euthanasia and assisted suicide laws have been pounding for decades, but the longstanding proscription on these practices has held out in all but a few jurisdictions. A few psychiatrists have enlisted with the challengers, but many remain on the battlements, defending the impermissibility of active assistance in dying. Given the long history of the separation of church and state and the significant secularisation of society; the recognition by the law of both acts and omissions as legal causes; lenient sentences for mercy killers; critiques of the "psychiatriatisation" of different aspects of life; and the consistency of public opinion, this recalcitrant stand bespeaks undercurrents and positions that are often by rationalised or camouflaged, and which call for exploration. In this paper, I examine connections between psychiatry and conceptualisations of harm, suffering and natural death; medicalisation, psychiatrisation and medical paternalism; decision-making capacity, rationality and diagnosis; recent legal developments; social pluralism; and religious intuitionism. I conclude that psychiatrists and the psychiatry profession, concerned as they are with enlarging the province of human freedom, should begin a more transparent rapprochement with those they would repel.
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Affiliation(s)
- Malcolm Parker
- Mayne Medical School, 288 Herston Road, Herston, Queensland 4006, Australia; School of Medicine, University of Queensland, Australia.
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Abstract
Confidentiality is one of the foundations on which psychotherapy is built. Limitations on confidentiality in the therapeutic process have been explained and explored by many authors and organizations. However, controversy and confusion continue to exist with regard to the limitations on confidentiality in situations where clients are considering their options at the end of life and after a client has died. This article review these 2 areas and provides some suggestions for future research.
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Affiliation(s)
- James L Werth
- Department of Psychology, Third Floor, Polsky Building, University of Akron, Akron, OH 44325-4301, USA.
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Werth JL. How do the mental health issues differ in the withholding/withdrawing of treatment versus assisted death? OMEGA-JOURNAL OF DEATH AND DYING 2003; 41:259-78. [PMID: 12557882 DOI: 10.2190/ugym-4gvu-f5c2-8cu7] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
This article reviews ten of the most common mental health-related arguments against assisted death and applies them to the withholding/withdrawal of treatment to determine if the concerns expressed are truly unique to assisted death. After this analysis it is suggested that the mandatory involvement of a mental health professional can alleviate many of the concerns specifically associated with assisted death and that a mental health professional may also be helpful in situations involving the withholding/withdrawal of treatment.
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Affiliation(s)
- J L Werth
- Department of Psychiatry, Third Floor, Polsky Building, The University of Akron, Akron, OH 44325-4301, USA
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Curry L, Schwartz HI, Gruman C, Blank K. Physicians' voices on physician-assisted suicide: looking beyond the numbers. ETHICS & BEHAVIOR 2002; 10:337-61. [PMID: 11785548 DOI: 10.1207/s15327019eb1004_2] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
Abstract
Most empirical research examining physician views on physician-assisted suicide (PAS) has used quantitative methods to characterize positions and identify predictors of individual attitudes. This approach has generated limited information about the nature and depth of sentiments among physicians most impassioned about PAS. This study reports qualitative data provided by 909 physicians as part of a larger survey (N = 2,805) regarding attitudes toward and experiences with PAS and palliative care. Emergent themes illustrate important clinical, social, and ethical considerations in this area. The data illustrate the diverse and ardent responses that PAS evokes among certain physicians. The role of physicians' personal values is central to discussions about legalization of PAS. Polarized views such as those expressed by physicians in this study are not likely to be reconciled, thereby constraining the development of public policy regarding PAS.
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Affiliation(s)
- L Curry
- Braceland Center for Mental Health and Aging, Institue of Living, 400 Washington St., Hartford, CT 06106.
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Mishara BL. Synthesis of research and evidence on factors affecting the desire of terminally ill or seriously chronically ill persons to hasten death. OMEGA-JOURNAL OF DEATH AND DYING 2001; 39:1-70. [PMID: 11657878 DOI: 10.2190/5yed-ykmy-v60g-l5u5] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Review of empirical studies indicates that suicide is more common in persons suffering from some physical illnesses (e.g., epilepsy, head injuries, Huntington's Chorea, gastrointestinal diseases, AIDS, and cancer), but other chronic diseases and disabilities have not been linked to increased suicide risk (e.g., blindness, senile dementia, multiple sclerosis, and other physical handicaps). The timing of increased suicide risk varies in different illnesses from early presymptomatic stages to the terminal phase. Difficulties in reliably determining when someone is “terminally ill” and problems of the competence of persons with a poor prognosis complicate empirical investigations of euthanasia, assisted suicide, and the desire to hasten death. The role of family and caregivers in end of life decisions needs further clarification. Researchers have found that pain and suffering and quality of life variables may be linked to the desire to die prematurely, particularly in cancer patients. Others find that clinical depression is a major factor. But, since depression is often present, we do not know why a small minority of depressed patients desire and choose to hasten death. Support for alternative hypotheses is examined, including the role of pre-morbid suicidality and depression, individual differences in coping strategies and indirect consequences of the illness. There is a need to clarify links between attitudes, which is the major variable studied, and actual behaviors and decisions. Furthermore, we need theoretical and empirical links between studies of suicide, which is linked to clinical depression and characterized by ambivalence and studies of euthanasia, which is often depicted as rational and with little ambivalence. Evaluative research should be conducted to determine if interventions to reduce the desire for a premature death by suicide, euthanasia, or assisted suicide are effective. In the light of this review, we present several considerations for those involved in proposing changes in public policy concerning euthanasia and assisted suicide.
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Abstract
For the clinician who works in a behavioral-medicine or primary-care setting, this article presents the association between medical illness and suicide. Specific illnesses such as HIV/AIDS, cancers of the brain and nervous system, and multiple sclerosis all are associated with an increased risk of suicide. Rates of major depression rise with increasing rates of serious medical illness; however, depression and associated suicidal ideation tend to be undertreated in the medically ill. When medical illness becomes terminal, the clinician's patient may be confronted with difficult end-of-life decisions. Great concern exists in the United States about the ethics of end-of-life decision making and the issue of physician-assisted suicide. The latter part of this article examines the terminally ill patient's right to refuse life-sustaining treatments or to have death hastened according to the principle of the "double effect." It also reviews psychologists' apparent acceptance of the concept of rational suicide, as well as assisted suicide under certain conditions, and offers several caveats. A reexamination of psychology's role, standards, and principles with respect to rational suicide is recommended.
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Affiliation(s)
- P M Kleespies
- Psychology Service, VA Boston Healthcare System and Boston University School of Medicine, MA 02130, USA
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Werth JL. The role of the mental health professional in helping significant others of persons who are assisted in death. DEATH STUDIES 1999; 23:239-255. [PMID: 10848153 DOI: 10.1080/074811899201064] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/23/2023]
Abstract
The involvement of mental health professionals with people who are considering assisted death due to a terminal illness is beginning to be discussed more frequently in the professional literature; however, one neglected area is working with the significant others of the person who is suffering. This article covers ways both before and after the death that counselors can help significant others cope with the dying process, the decision to request assisted death, and the death itself.
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Affiliation(s)
- J L Werth
- University of Nebraska--Lincoln, USA
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