1
|
Links PS, Aslam H, Brodeur J. Assessing and managing patients with borderline personality disorder requesting medical assistance in dying. Front Psychiatry 2024; 15:1364621. [PMID: 38919634 PMCID: PMC11196780 DOI: 10.3389/fpsyt.2024.1364621] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2024] [Accepted: 06/03/2024] [Indexed: 06/27/2024] Open
Abstract
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.
Collapse
Affiliation(s)
- Paul S. Links
- Department of Psychiatry and Behavioural Neurosciences, McMaster University, Hamilton, ON, Canada
| | - Hira Aslam
- Michael G. DeGroote School of Medicine, McMaster University, Hamilton, ON, Canada
| | - Jonah Brodeur
- Department of Family Medicine, University of Toronto, Toronto, ON, Canada
| |
Collapse
|
2
|
Teo MTL. Why the irremediability requirement is not sufficient to deny psychiatric euthanasia for patients with treatment-resistant depression. JOURNAL OF MEDICAL ETHICS 2024:jme-2023-109644. [PMID: 38216330 DOI: 10.1136/jme-2023-109644] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/09/2023] [Accepted: 12/27/2023] [Indexed: 01/14/2024]
Abstract
Treatment-resistant depression (TRD) holds centrality in many debates regarding psychiatric euthanasia. Among the strongest reasons cited by opponents of psychiatric euthanasia is the uncertainty behind the irremediability of psychiatric illnesses. According to this argument, conditions that cannot be considered irremediable imply that there are possible remedies that remain for the condition. If there are possible remedies that remain for the condition, then patients with that condition cannot be considered for access to euthanasia. I call this the irremediability requirement (IR). I argue that patients with TRD can, indeed, meet the operationalisation of irremediability in the IR. This is because the irremediability it asks for is not some global or absolute irremediability, but rather a present irremediability based on the current state of medical science. I show this by considering irremediability relating to (1) possible future treatments and (2) not trying presently available alternative treatments. I extend Schuklenk nd van de Vathorst's argument from parity to terminal malignancies, to show that (1) is an unreasonable expectation for all cases of euthanasia. Taking (2) as a more serious opponent to psychiatric euthanasia, I show how the IR, based on how it is presently operationalised, can be realistically applied to cases of TRD. I do this by further developing Tully's argument on broad-sense treatment resistance with the robust empirical data from the STAR*D trials. If my argument from Tully's is valid, then we have reasons to, again, seek parity between the operationalisations of irremediability in terminal malignancies and TRD.
Collapse
Affiliation(s)
- Marcus T L Teo
- Centre for Biomedical Ethics, National University of Singapore, Singapore
| |
Collapse
|
3
|
Garel N, Nazon M, Naghi K, Willis E, Looper K, Rej S, Greenway KT. Ketamine for depression: a potential role in requests for Medical Aid in Dying? Int Clin Psychopharmacol 2023; 38:352-355. [PMID: 37159173 DOI: 10.1097/yic.0000000000000462] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/10/2023]
Abstract
Medical Aid in Dying (MAiD) is the act of a healthcare provider ending a patient's life, at their request, due to unbearable suffering from a grievous and incurable disease. Access to MAiD has expanded in the last decade and, more recently, it has been made available for psychiatric illnesses in a few countries. Recent studies have found that such psychiatric requests are rapidly increasing and primarily involve mood disorders as the primary condition. Nevertheless, MAiD for psychiatric disorders is associated with significant controversy and debate, especially regarding the definition and determination of irremediability - that a given patient lacks any reasonable prospect for recovery. In this article, we report the case of a Canadian patient who was actively requesting Medical Assistance in Dying for severe and prolonged treatment-resistant depression until she experienced remarkable benefits from a course of intravenous ketamine infusions. To our knowledge, this is the first report of ketamine or any other intervention yielding remission in a patient who would have otherwise likely been eligible for MAiD for depression. We discuss implications for the evaluation of similar requests and, more specifically, why a trial of ketamine warrants consideration.
Collapse
Affiliation(s)
- Nicolas Garel
- Department of Psychiatry, Faculty of Medicine, McGill University, Ludmer Research and Training Building
| | | | - Kamran Naghi
- Department of Psychiatry, Jewish General Hospital
| | - Elena Willis
- Department of Psychiatry, Jewish General Hospital
| | - Karl Looper
- Department of Psychiatry, Faculty of Medicine, McGill University, Ludmer Research and Training Building
- Department of Psychiatry, Jewish General Hospital
| | - Soham Rej
- Department of Psychiatry, Faculty of Medicine, McGill University, Ludmer Research and Training Building
- Department of Psychiatry, Jewish General Hospital
- Department of Psychiatry, McGill Meditation and Mind-Body Medicine Research Clinic and Geri-PARTy Research Group, Lady Davis Research Institute and Jewish General Hospital, Montreal, Quebec, Canada
| | - Kyle T Greenway
- Department of Psychiatry, Faculty of Medicine, McGill University, Ludmer Research and Training Building
- Department of Psychiatry, Jewish General Hospital
- Department of Psychiatry, McGill Meditation and Mind-Body Medicine Research Clinic and Geri-PARTy Research Group, Lady Davis Research Institute and Jewish General Hospital, Montreal, Quebec, Canada
| |
Collapse
|
4
|
Kratina S, Lo C, Strike C, Schwartz R, Rush B. Psychedelics to Relieve Psychological Suffering Associated with a Life-Threatening Diagnosis: Time for a Canadian Policy Discussion. Healthc Policy 2023; 18:134-142. [PMID: 37486818 PMCID: PMC10370393 DOI: 10.12927/hcpol.2023.27048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/26/2023] Open
Abstract
In Canada, the conversation to enable access to therapeutic psychedelics is under way. With recent federal initiatives, Canadians can request access to psychedelic-assisted therapies (PATs) to alleviate enduring and intolerable psychological suffering (EIPS) associated with life-threatening conditions on a case-by-case basis. The resurgence of past research concerning the therapeutic potential of PATs, promising preliminary results from contemporary clinical trials, public and media interest and the recognition of traditional Indigenous use of psychedelics have facilitated a change in the popular narrative around these stigmatized substances. A lack of access to PATs for treating EIPS, especially at end of life, is a public policy problem worth addressing.
Collapse
Affiliation(s)
- Sarah Kratina
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, ON
| | - Christopher Lo
- Assistant Professor, Department of Psychiatry, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Associate Professor, School of Social and Health Sciences, James Cook University, Singapore
| | - Carol Strike
- Professor and Associate Dean, Public Health Sciences, Dalla Lana School of Public Health, University of Toronto, Toronto, ON
| | - Robert Schwartz
- Professor, Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Senior Scientist, Institute for Mental Health Policy Research, Centre for Addiction and Mental Health, Toronto, ON
| | - Brian Rush
- Emeritus Scientist, Centre for Addiction and Mental Health, Professor, Dalla Lana School of Public Health, University of Toronto, Toronto, ON
| |
Collapse
|
5
|
Wojtkowiak J, Geusendam E, van Dijk R, Smid GE. Perspectives on dying in severe and enduring eating disorders (SEEDs): A qualitative study among Dutch mental healthcare providers. DEATH STUDIES 2023; 48:43-53. [PMID: 36930988 DOI: 10.1080/07481187.2023.2186534] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/18/2023]
Abstract
Dying of severe and enduring eating disorders (SEEDs) was studied using semi-structured interviews (n = 7) and a follow-up videoconferencing focus group (n = 3) with Dutch mental healthcare providers. We identified three main themes: the uncertainties of dying from SEEDs, dilemmas in defining treatment resistance and palliative care, and suicidal ideation and intent. There were two contrasting perspectives on good care, both centering on the patient. While mental healthcare providers strive toward healthy living, palliative care strives toward quality of life and dying. Clarifying underlying concepts enables flexibility in applying these perspectives to optimize individual patient care.
Collapse
Affiliation(s)
- Joanna Wojtkowiak
- Department of Humanist Chaplaincy Studies, University of Humanistic Studies, Utrecht, the Netherlands
| | - Eline Geusendam
- Department of Humanist Chaplaincy Studies, University of Humanistic Studies, Utrecht, the Netherlands
| | - Rob van Dijk
- GGz Breburg, Centrum voor Eetstoornissen Tilburg and Breda, the Netherlands
| | - Geert E Smid
- Department of Humanist Chaplaincy Studies, University of Humanistic Studies, Utrecht, the Netherlands
- ARQ National Psychotrauma Centre, Amsterdam, the Netherlands
| |
Collapse
|
6
|
Moureau L, Verhofstadt M, Liégeois A. Mapping the ethical aspects in end-of-life care for persons with a severe and persistent mental illness: A scoping review of the literature. Front Psychiatry 2023; 14:1094038. [PMID: 37009126 PMCID: PMC10062453 DOI: 10.3389/fpsyt.2023.1094038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2022] [Accepted: 02/20/2023] [Indexed: 03/18/2023] Open
Abstract
Persons with severe and persistent mental illness (SPMI) make up a vulnerable group within mental healthcare and society. Not only do they suffer from long-term, serious psychiatric disorders; they often also experience considerable problems in their psychosocial functioning. Research has disclosed that the care needs of this target group are complex, and that the life expectancy of these persons is significantly lower than in the general population. Given (1) the lower life expectancy of persons with SPMI, (2) the higher suicide risk related to mental disorders, and (3) the legalization and practice of medical assistance in dying in an increasing number of countries, it is of utmost importance to map the ethical aspects and challenges of end-of-life care needs in persons with SPMI. Therefore, we charted the way end-of-life care is provided for them by means of a scoping review of the scientific literature, with an emphasis on the ethical aspects surrounding it. We explore existing ethical dilemmas; the underlying ethical values, principles and attitudes; and the locus and stakeholders of ethical dialog regarding end-of-life care in persons with SPMI. The results indicate that the four guiding principles of biomedical ethics can well be identified in the literature, and are each addressed in their own specific way: Autonomy in relation to questions regarding the decision-making capacity of persons with SPMI; Justice in relation to access to quality care and the presence of stigma; and Non-maleficence and Beneficence in relation to the ongoing debate regarding the benefits and obstacles in applying palliative care approaches in the context of psychiatry, and the status of the futility-concept therein. Personal virtues and attitudes in care professionals, like compassion, non-abandonment and upholding dignity are key, as care professionals are the main advocates of persons with SPMI, which often lack an extensive social network. Further, we find that the ethical dialog is mainly focused on care professionals and relatives, rather than the persons with SPMI themselves. This is reflected in the existing research that often had the voices of the latter missing. Future research may benefit from the inclusion of persons with SMPI’s first-hand accounts. End-of-life care for persons with SPMI may benefit from identifying and integrating (locally developed) good practices like cross-sectoral education, specific care models, and ethics support.
Collapse
Affiliation(s)
- Loïc Moureau
- Faculty of Theology and Religious Studies, KU Leuven, Leuven, Belgium
- *Correspondence: Loïc Moureau,
| | - Monica Verhofstadt
- Medical and Health Sciences, Ghent University, Ghent, East Flanders, Belgium
| | - Axel Liégeois
- Faculty of Theology and Religious Studies, KU Leuven, Leuven, Belgium
| |
Collapse
|
7
|
Simpson AIF, Tran J, Jones RM. Ethical considerations regarding mental disorder and medical assistance in dying (MAiD) in the prison population. MEDICINE, SCIENCE, AND THE LAW 2023; 63:3-5. [PMID: 36571789 DOI: 10.1177/00258024221146725] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/17/2023]
Affiliation(s)
| | | | - Roland M Jones
- University of Toronto, Canada
- Centre for Addiction and Mental Health (CAMH), Canada
| |
Collapse
|
8
|
van Veen S, Widdershoven G, Beekman A, Evans N. Physician Assisted Death for Psychiatric Suffering: Experiences in the Netherlands. Front Psychiatry 2022; 13:895387. [PMID: 35795029 PMCID: PMC9251055 DOI: 10.3389/fpsyt.2022.895387] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2022] [Accepted: 05/12/2022] [Indexed: 11/13/2022] Open
Abstract
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.
Collapse
Affiliation(s)
- Smp van Veen
- Department of Psychiatry, Amsterdam University Medical Center, Amsterdam, Netherlands.,Department of Ethics, Law and Humanities, Amsterdam University Medical Center, Amsterdam, Netherlands.,113 Suicide Prevention, Amsterdam, Netherlands
| | - Gam Widdershoven
- Department of Ethics, Law and Humanities, Amsterdam University Medical Center, Amsterdam, Netherlands
| | - Atf Beekman
- Department of Psychiatry, Amsterdam University Medical Center, Amsterdam, Netherlands
| | - N Evans
- Department of Ethics, Law and Humanities, Amsterdam University Medical Center, Amsterdam, Netherlands
| |
Collapse
|