[Towards a proactive psychiatric ethics: a care ethics perspective]

Background Proactive psychiatry requires proactive psychiatric ethics. Aim To describe ethical considerations with regard to proactive psychiatry. Method Discussion of care ethics aimed at proactive psychiatric care. Results In this contribution, we plea for a proactive psychiatric ethics, stimulating and supporting healthcare professionals in working from a developmental and contextual perspective. We describe care ethics, and show that it is in line with the principles of proactive psychiatry. We address three issues related to the development of proactive psychiatry: the goals of care; identifying risk factors; and the division of responsibilities in mental healthcare. Conclusion Proactive psychiatric ethics can be useful in identifying and discussing ethical issues associated with proactive psychiatry and thus contribute to improving practice. Tijdschrift voor Psychiatrie 63(2021)2, 150-153.

[Waiting for death: an analysis of the waiting list of the expertise centre for euthanasia]

BACKGROUND

The waiting list of the expertise center euthanasia (EE) in the Netherlands for patients requesting euthanasia on the basis of psychiatric suffering has increased to two years in a short space of time.

AIM

Clarity about the causes and direct consequences of the EE waiting list and an answer to the question: what now?

METHOD

We analyzed the EE waiting list based on various media reports, annual reports from the EE and scientific studies.

RESULTS

The EE waiting list arose because, on the one hand, the demand for euthanasia among patients with a mental illness has increased, while on the other hand, the willingness to perform euthanasia among psychiatrists appears to be declining. The reasons for both trends seem multifactorial. The direct consequence of the waiting list is that patients with a mental illness have less access to euthanasia, which in itself can also have harmful and protective consequences.

CONCLUSION

The EE waiting list is the result of an increasing number of requests and an apparent decrease in psychiatrists' willingness to perform euthanasia. In response to this situation, roughly three ways forward are conceivable: first the mental health care sector can assign itself a more active role in the field of euthanasia, second a further demedicalisation of the end of life is possible, or third a choice can be an amendment to EE's referral procedure. All of these options have potential pros and cons.

[Physician-assisted death in psychiatry]

In recent years, more patients with psychiatric disorders are receiving physician-assisted death (PAD). In the Netherlands, since more than 25 years psychiatric suffering is seen as a legitimate reason for PAD, but an additional independent assessment is required. Scarce empirical research shows that patients who receive PAD on the basis of psychiatric suffering have long-standing and complex complaints. Among these patients, depression and personality disorders are relatively common. The ethical justification of PAD for patients with psychiatric disorders has been the subject of debate for decades. Decisions about competence and the irremediability of suffering are challenging and for many authors reason enough to reject PAD based on psychiatric suffering. Others regard the exclusion of all patients with mental disorders as unjust. Empirical research and ethical consideration are needed for better founded considerations and a more widely supported practice concerning patients with a mental disorder who request PAD.

Last-Minute Recovery of a Psychiatric Patient Requesting Physician-Assisted Death

Physician-assisted death is becoming legal in an increasing number of jurisdictions, but psychiatric patients are often explicitly excluded. However, in some countries, including the Netherlands, physician-assisted death of psychiatric patients is allowed. This Open Forum describes a patient with schizophrenia and symptoms diagnosed as refractory musical hallucinations. The patient requested assistance in dying only to recover after a mandatory second opinion, where his complaints were recognized as intrusive thoughts and treated accordingly. This case is used to reflect on how to deal with uncertainty about physician-assisted death of psychiatric patients and to argue for implementation of a due-diligence procedure, such as the one proposed in the Dutch Psychiatric Association's recent guideline concerning this issue.

[Euthanasia of Dutch psychiatric patients in 2015-2017]

The Netherlands is one of the few countries in the world that allows euthanasia and assisted suicide (EAS) due to psychiatric suffering. METHODS In 2015-2017 the Dutch regional euthanasia review committees published 43 case summaries online. Of these, 35 were suitable for analysis regarding patient characteristics and physician involvement, and 3 cases were described in detail.<br/> RESULTS: In total, 77% of the patients were women and 51% were aged 50-70 years. Major depression disorder and personality disorders were present in almost half of the patients. All patients were considered mentally competent. CONCLUSIONS Although the incidence of psychiatric EAS cases is rising, we found no shift in patient characteristics. The division between psychiatric and somatic suffering may prove more complicated than expected. Patients dying from suicide differ in various ways from patients dying through EAS. The fact that all patients are considered competent could mean that they are unjustly seen as being vulnerable or that the competence assessment lacks due diligence.

[Is psychiatry ready to let patients review their own files? Inventory of initial experiences]

BACKGROUND

Dutch patients will be granted the right to digitally access their own medical records, an option already available to the patients at the University Medical Center Utrecht since 2015.

AIM

To start a conversation about the development of readily accessible online patient records. METHODS Describe the experiences of a University department of psychiatry with an online patient portal, obtained through discussions and questionnaires.

RESULTS

During the next few years three legal developments will enable patients to acquire direct, remote, digital access to their medical files. Immediate online review of medical records improves accessibility and empowers the patient. Some therapists experienced a change in patient interaction. Furthermore, during documentation psychiatrists took into account that patients could review the contents at a later point.

CONCLUSION

Patients' accessibility of online records will influence the patient-therapist dynamic. More research on the patient perspective and a discussion among professionals are necessary to further streamline broad implementation of online patient portals.