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Euthanasia And Assisted Suicide In Psychiatric Patients: A Systematic Review Of The Literature
Abstract
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 used 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 selected 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 warrented as well as the involvement of mental health professionals.
... Psychiatric euthanasia constitutes 3% of total euthanasia cases in countries where it has been allowed for the longest periods. However, these cases exhibit distinct characteristics compared to euthanasia for organic diseases, such as being more prevalent among younger individuals, predominantly women (Alacreu-Crespo, Giner, & Courtet, 2021;Calati et al., 2021;Deschepper, Distelmans, & Bilsen, 2014;Dierickx, Deliens, Cohen, & Chambaere, 2017;Kim, De Vries, & Peteet, 2016;Lemmens, 2023;Nicolini, Kim, Churchill, & Gastmans, 2020;Nicolini, Peteet, Donovan, & Kim, 2020;Pullman, 2023). This profile shares similarities with individuals who attempt suicide, although not necessarily resulting in completed suicides. ...
... Regarding the types of disorders motivating the requests, various studies highlight the prevalence of individuals with personality or conduct disorders, accounting for up to 45%, often with a history of prior suicide attempts and life experiences involving significant stressors such as sexual abuse. A smaller percentage is attributed to severe mental disorders such as depression or bipolar disorder (Alacreu-Crespo et al., 2021;Calati et al., 2021;Deschepper et al., 2014;Dierickx et al., 2017;Kim et al., 2016;Lemmens, 2023;Mehlum et al., 2020;Nicolini, Peteet, et al., 2020;Pullman, 2023). A Dutch study (Kim et al., 2016) revealed that 20% of patients seeking psychiatric euthanasia had never been psychiatrically hospitalized, and in 56% of cases, reported social isolation or loneliness. ...
... However, we observe that the fundamental ethical questions associated with this issue have not been thoroughly explored. The requirements established are, in our view, still subject to deeper debate and broader consideration (Calati et al., 2021;Deschepper et al., 2014;Favron-Godbout & Racine, 2023;Grassi et al., 2022;Kious & Battin, 2019a;Lemmens, 2023; Ley Orgánica 3/2021, de 24 de marzo, de regulación de la eutanasia. BOE núm. ...
... 51 Dahası bazı psikiyatristler, hekim yardımlı intihar talebinin kendisinin karar verme kapasitesinin eksikliğini düşündürdüğünü ve hatta göstergesi olduğunu öne sürmektedir. 52 Bu eleştiriler, psikiyatri alanına köklü bir şekilde yerleşen intiharı önleme geleneğinden kaynaklanabilir. 51 Psikiyatristlerin intiharı psikopatolojinin bir semptomu olarak görmesi ve psikiyatrik tedavi ile önlenmesi gereken bir bozuklukla ilişkili olabileceğine dair bakış açısı, intihar ve psikiyatrik bozukluk arasındaki yüksek korelasyonla ilişkilidir. ...
... 44,49 Örneğin depresif bozukluğa bağlı umutsuzluğa ilişkin duygu ve inançlar, bireyin tedaviye yanıt verme olasılığına ilişkin algısını çarpıtabilir. 52 Genel olarak tıbbi karar alma süreçlerinde bilişsel çarpıtmaların resmîleştirilmiş bir yasal gereklilikle değerlendirilme metodu yoktur. 50 Tıpkı herhangi bir kişinin intihar eylem planını net değerlendirecek hiçbir kriter olmadığı gibi hastanın hekim yardımlı intihara rıza göstermesi konusunda mental bir kapasiteye sahip olup olmadığına karar vermenin profesyonel standartları ve eşikleri bilimsel olarak belirlenememektedir. 44,50 Ayrıca psikiyatri eğitimi ve öğretiminde intihar için risk faktörlerini değerlendirmenin, intiharı hızlandırabilecek psikiyatrik sorunları taramanın ve intiharı önlemek için müdahale etmenin dikkatle öğretilmesi de ironiktir. ...
... 68,70 Çoğu yargı bölgesi, fiziksel hastalığı olmayan ciddi psikiyatrik bozukluğu olan hastalar için hekim yardımlı intihara izin verme konusunda isteksizdir. 44 Ancak Benelüks ülkelerinde, "hafifletilemeyen" ve makul alternatiflerin yokluğunda tıbbi (somatik veya psikiyatrik) bir durumdan kaynaklanan "dayanılmaz ıstırap" hekim yardımlı intihar için uygun olarak değerlendirilebilmektedir. 52 Psikiyatrik bozukluğa dayalı hekim yardımlı intihar başvuruları, fiziksel hastalıkların ve psikiyatrik bozuklukların biyolojik temeline ilişkin artan kanıtlarla ilişkilidir. Bununla birlikte, fiziksel ve mental hastalıklar arasındaki benzerlikler güçlü olsa da net değildir. ...
Günümüzde ölümler tipik olarak kademeli fiziksel ve işlevsel bir düşüş döneminden sonra ileri bir yaşta meydana gelmektedir. Bu durum yaşamın son aşamasındaki hastalara yönelik yüksek kaliteli bakımı, XXI. yüzyılın sağlık hizmetlerinin temel zorluklarından birisi hâline getirmektedir. Biyomedikal araştırmalardaki ilerlemeler ve biyoetikte yeni disiplinlerin kurulması yaşam sonu bakımı, ötanazi ve hekim yardımlı intihar konusunda güncel tartışmaları beraberinde getirmektedir. Geçmişten günümüze gelen tartışmalar hâlâ güncelliğini korurken, ötanazi ve hekim yardımlı intihar dünya çapında giderek daha fazla yasallaşmaktadır. Bu tür düzenlemelerin temel amaçları; uygulamaları netliğe kavuşturmak, hekimlere yasal zemini açık bir şekilde sunmak ve hastaları korumaktır. Buna rağmen ölümde tıbbi yardım konusu, paradoksik unsurlar içeren çok boyutlu ciddi tartışmaları gündeme getirerek kamunun dikkatini çekmektedir. Bu uygulamaların evrimi ile ilgili tarihsel yönlerin ve ilgili literatürün araştırılması geçmişten günümüze gelen tartışmaları aydınlatabilir. Bu terimlerin evrimi ve olgularla biçimlenen yasal düzenlemeler, multidisipliner bir yaklaşımın gerekliliğini vurgulamaktadır. Metinde uygulamaların lehindeki ve aleyhindeki yaygın argümanlar literatür verileri ışığında sunulmaktadır. Ayrıca ölümde tıbbi yardım konusunu adli boyutları ve uygulanma biçimleriyle karşılaştırmak klinisyenlere farklı görüşler sunabilir. Derleme ötanazi ve hekim yardımlı intihar uygulamaları sürecinde yer alan ve genellikle ihmal edilen hekimin profesyonel yükümlülükleriyle çelişen gerilimini ortaya koymaktadır. Gözden geçirme, ötanazi ve hekim yardımlı intihar talebinde bulunan hastaların değerlendirilmesinde rol alan psikiyatristlerin ikilem içeren görüşlerinin tartışılmasıyla sona ermektedir.
... Psychological research on assisted suicide is still scant. In a recent review (Calati et al., 2021), the authors note that characteristics of people requesting PAS are similar to ones committing 'conventional' suicide. The majority of people applying for assistance have an intractable somatic illness (cancer being the most prevalent), and a minority suffer from a psychiatric illness. ...
... The main motivator for requesting assistance was identified as unbearable psychological suffering (Dierickx et al., 2017). One of the Calati review's conclusion was, "People dying from medical illnesses who receive EAS [PAS] tend to be empowered people who value self-determination and control" (Calati et al., 2021), p. 170). Interestingly, a significant percent (37%) withdrew their applications and 69% of those denied assistance remained alive at the time of the survey, which led the authors to suggest that the act of requesting assistance may have triggered a change in the decision-making. ...
... That policy can be enacted through increased precision of self-efficacy in regaining control through self-destruction. The suicidal GM does not have a point of no return, as the above mentioned data on withdrawal from PAS request and survival when such a request is denied show (Calati et al., 2021). Indeed, psychological autopsy studies show that the suicidal mind remains ambivalent till the very last moment (Shneidman, 1996), which in AIF terms, means that the suicidal GM's precision balance hovers near an equilibrium between pro-survival and self-destructive policies. ...
Suicide presents an apparent paradox as a behavior whose motivation is not obvious since its outcome is non-existence and cannot be experienced. To address this paradox we propose to frame suicide in the integrated theory of stress and active inference. We present an active inference-based cognitive model of suicide as a type of stress response hanging in cognitive balance between predicting self-preservation and self-destruction. In it, self-efficacy emerges as a meta-cognitive regulator that can bias the model toward either survival or suicide. The model suggests conditions under which cognitive homeostasis can override physiological homeostasis in motivating self-destruction. We also present a model proto-suicidal behavior, programmed cell death (apoptosis), in active inference terms to illustrate how an active inference model of self-destruction can be embodied in molecular mechanisms and to offer a hypothesis on another puzzle of suicide: why only humans among brain-endowed animals are known to practice it.
Keywords: suicide, active inference, free energy, apoptosis, self-efficacy, stress response
... Medical assistance in dying (MAiD), which encompasses euthanasia and physician-assisted suicide [1], raises debate in several countries. Belgium, The Netherlands, Luxembourg, and Switzerland have allowed people living with mental disorders to access some forms of MAiD for years [2]. More recently, Spain has passed a MAiD law making people living with mental disorders eligible for MAiD under certain conditions [3]. ...
... Gaining this understanding is a first step towards identifying ways of addressing them so that MAiD-MD can be successfully introduced and implemented, where legislations allow it. Thus, this article aims (1) to better understand the moral concerns regarding MAiD-MD, and (2) to highlight potential solutions that have been suggested by others to promote stakeholders' well-being (namely people living with mental disorders, their relatives, and their healthcare professionals). Hence, although highly relevant, moral concerns relating to not allowing MAiD for people with psychiatric suffering are not covered by this literature review. ...
... This qualitative thematic review allowed us to identify various moral concerns and possible solutions, which are related to how MAiD-MD is introduced into the following 5 contexts of emergence: (1) societal context, (2) ...
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.
... Euthanasia, defined as the intentional ending of a patient's life through the administration of life-ending drugs by a physician at the explicit patient's request (1)(2)(3), is only permitted by law in a small number of countries or regions worldwide. Moreover, the legal framework in these places mainly applies to terminally physically ill patients (4). ...
... Moreover, the legal framework in these places mainly applies to terminally physically ill patients (4). Medical Aid In Dying (MAID) (defined as voluntary euthanasia and/or physicianassisted suicide) for people who are not terminally ill, such as those suffering from psychiatric disorders, is only permitted by law in Belgium, Luxembourg, the Netherlands, Switzerland, and Spain (1,(5)(6)(7)(8)(9)(10). 1 Patients receiving MAID on the grounds of unbearable suffering caused by a psychiatric disorder mostly are women and often have multiple diagnoses, in most cases including a depressive disorder or a personality disorder (1,11,12). ...
... Moreover, the legal framework in these places mainly applies to terminally physically ill patients (4). Medical Aid In Dying (MAID) (defined as voluntary euthanasia and/or physicianassisted suicide) for people who are not terminally ill, such as those suffering from psychiatric disorders, is only permitted by law in Belgium, Luxembourg, the Netherlands, Switzerland, and Spain (1,(5)(6)(7)(8)(9)(10). 1 Patients receiving MAID on the grounds of unbearable suffering caused by a psychiatric disorder mostly are women and often have multiple diagnoses, in most cases including a depressive disorder or a personality disorder (1,11,12). ...
Background
Belgium is one of the few countries worldwide where euthanasia on the grounds of unbearable suffering caused by a psychiatric disorder is legally possible. In April 2010 euthanasia was carried out on a 38-year-old Belgian woman with borderline personality disorder and/or autism. After a complaint by the family, three physicians were referred to the Court of Assizes on the charge of “murder by poisoning”.
Methods
A content analysis of print and online news coverage of the euthanasia case in a selected sample of Flemish newspapers and magazines, published between December 1, 2019 and March 1, 2020, was conducted to analyze the prominence and framing of the euthanasia case, as well as the portrayal of key figures in this case. A quantitative analysis, as well as an in-depth qualitative analysis (with the aid of NVivo 1.0 software) was performed.
Results
One thousand two hundred fifteen news articles were identified through database searching. Of these, 789 articles were included after screening for relevance and eligibility. Mean prominence scores were moderate and did not statistically significantly differ between newspapers with a different historical ideological background or form (elite versus popular). The most frequent headline topics featured legal aspects (relating to the Belgian Euthanasia Law or the course of the trial). Headlines and content of most articles (90 and 89%, respectively) did not contain an essential standpoint on the euthanasia case itself or, if they did, were neutral. Historical ideological background, nor form of newspaper (elite versus popular) significantly influenced headline tone or article direction toward the euthanasia case. Despite this, our qualitative analysis showed some subtle differences in selection, statement or tonality of reports between certain newspapers with a different historical ideological background.
Conclusion
Although major Flemish newspapers and magazines generally were neutral in their coverage of the judicial case, major points of contention discussed were: the need for an evaluation and possible amendments to the existing Euthanasia Law, including a revision of the Belgian Control Commission and the system of penalties for physicians, and the absence of any consensus or guidance on how to define psychological suffering.
... Characteristics of the group that died by MAID coincide largely with those described previously in adult samples, including female sex, psychiatric multimorbidity, and the predominance of major depressive disorder, autism spectrum disorders, and personality disorders. 22,[25][26][27][28][29] Detailed descriptions of treatment histories of patients who died by MAID, by contrast, are scarce. Despite the patients' young age, we found extensive histories of many psychological and pharmacotherapeutic treatments, including intensive second-and third-line treatments, such as electroconvulsive therapy, lithium, and inpatient psychotherapy. ...
... These percentages are remarkably high compared with prior studies among adults. 25 While acute suicidal behaviors typically fluctuate, 31,32 patients need to prove a well-considered and recurrent death wish to be eligible for MAID. In a recent qualitative report, patients with persistent death wishes described those as stable and well-considered, while they described their suicidality as a loss of control related to entrapment. ...
Importance
In the Netherlands, a growing group of young people request medical assistance in dying based on psychiatric suffering (MAID-PS). Little is known about this group, their characteristics, and outcomes.
Objective
To assess the proportion of requests for and deaths by MAID-PS among young patients, outcomes of their application and assessment procedures, and characteristics of those patients who died by either MAID or suicide.
Design, Setting, and Participants
This retrospective cohort study included Dutch individuals younger than 24 years requesting MAID-PS between January 1, 2012, and June 30, 2021, whose patient file had been closed by December 1, 2022, at the Expertisecentrum Euthanasie, a specialized health care facility providing MAID consultation and care.
Main Outcomes and Measures
Outcomes of the MAID-PS assessment procedure (discontinued, rejected, or MAID-PS) and clinical characteristics of patients who died by MAID or suicide.
Results
The study included 397 processed applications submitted by 353 individuals (73.4% female; mean [SD] age, 20.84 [1.90] years). Between 2012 and the first half of 2021, the number of MAID-PS applications by young patients increased from 10 to 39. The most likely outcome was application retracted by the patient (188 [47.3%]) followed by application rejected (178 [44.8%]). For 12 applications (3.0%), patients died by MAID. Seventeen applications (4.3%) were stopped because the patient died by suicide during the application process and 2 (0.5%) because the patient died after they voluntarily stopped eating and drinking. All patients who died by suicide or MAID (n = 29) had multiple psychiatric diagnoses (most frequently major depression, autism spectrum disorder, personality disorders, eating disorder, and/or trauma-related disorder) and extensive treatment histories. Twenty-eight of these patients (96.5%) had a history of suicidality that included multiple suicide attempts prior to the MAID application. Among 17 patients who died by suicide, 13 of 14 (92.9%) had a history of crisis-related hospital admission, and 9 of 12 patients who died by MAID (75.0%) had a history of self-harm.
Conclusions and Relevance
This cohort study found that the number of young psychiatric patients in the Netherlands who requested MAID-PS increased between 2012 and 2021 and that applications were retracted or rejected for most. Those who died by MAID or suicide were mostly female and had long treatment histories and prominent suicidality. These findings suggest that there is an urgent need for more knowledge about persistent death wishes and effective suicide prevention strategies for this high-risk group.
... This term of disability is likely to involve doubts on doctors when they have to urgently evaluate a patient that ask for EAS, considering that previous literature found similar profiles between patients who requested it and psychiatric patients who commit suicide [2,3]. Moreover, studies support that 40% of suicide patients had no previous psychiatric condition and 37% of suicides had no axis I diagnosis [4][5][6]. ...
... Once the psychological stress has been reduced, it would be the optimal time to reassess whether the patient understands the risks and benefits of starting a euthanasia process, both in the short and medium term, to avoid interference from possible acute suffering in making decisions [4][5][6]. ...
Introduction
Suicide in people without a mental health diagnosis pose a clinical challenge that is still poorly understood by psychiatrists, generating the debate between respecting the patient’s autonomy right or supporting involuntary admissions after a lethal gesture to rule out psychopathology.
Aims and Methods
The authors take a case of an 81-year-old man without mental health history who, after his first suicide attempt by ingesting floor cleaners, presented acute kidney failure that required to initiate haemodialysis to preserve his life. Despite being aware of the fatal outcome in case of rejecting it, he denied the dialysis and verbalize the persistence of suicide ideation. This publication complies with the agreements of the Declaration of Helsinki and the informed consent was obtained from his wife.
Results
It was finally considered that the patient maintained his capacity for judgment and no involuntary measures were taken, with family consent. Finally, he passed away ten days after carrying out the suicide attempt.
Discussion
He was evaluated up to three times by mental health professionals and, after deciding that he had preserved judgment, his decision was respected. The patient passed away ten days later.
Conclusions
This approach could help psychiatrics better understand suicide behaviour in cases we don’t make a mental health diagnosis.
... Recent uptakes in requests by those with intractable mental illness(es) for euthanizing services in Benelux nations: Belgium, The Netherlands, and Luxembourg (Calati et al., 2021) begets a critical analysis of psychiatric euthanasia and assisted suicide (pEAS) in the Canadian context given that our sunset clause expires soon, after which Canada will become the most Procknow, Necropolitics of Psychiatric Euthanasia CJDS 13.1 (April 2024) 52 MAiD-permissive jurisdiction the world over. Critical research on pEAS addressing the legal and ethical concerns germane to Canadian MAiD law is lacking (Trachsel et al., 2022). ...
... This recalls an analogy of the dancing dead: patients swap one deathly dance partner out for another -exposure to one dance with death, e.g., a chemicalized death-in-life, and partly alive with another, e.g., pEAS, and end-oflife service access. Psychiatrized patients who do swap death-in-life out for pEAS will riddle the remainder of their days with death-making assessments and different forms of assaultive violence in the form of treatment pushed on them, for instance, through a two-track approach, that is, while on a recovery track, patients are enlisted in recovery-oriented programs that run parallel with the euthanasia track, evaluating requests for pEAS access (Calati et al., 2021), until their end-of-life request is approved and they are scheduled for death. ...
The thrust of this conceptual piece is to critique the State granting medical assistance in dying (MAiD) access to those whose sole underlying medical condition is a mental disorder through a necropolitical lens. First, I introduce Mbembe’s (2003) Necropolitics as this paper’s theoretical framework. Second, I argue how the State grants the psy-profession free rein to deploy its armory of necropolitical tactics to entangle the psychiatrized in its death-making, identity-devouring deathworlds. This paper will demonstrate how the MAiD process for pEAS keeps suicidal aspirants suspended in death-in-life involving silence, sacrifice, and stillness and waiting in protracted states of injury; additionally, it gives rise to a ‘necroeconomy’ demanding irregular mad body/minds be killed off so sane people can thrive and multiply.
... Persons with mental illness as their sole underlying medical condition are currently eligible to access MAiD in a small number of countries whose laws consider irremediable chronic health conditions, including Belgium, the Netherlands, Luxemburg and Switzerland. The reported number of such MAiD deaths in these countries remains small, but has been increasing over time [1,2]. It is estimated that in 2021, 0.9% and 1.5% of all MAiD deaths in Belgium and the Netherlands respectively were of people with a mental illness as their sole underlying medical condition [3,4]. ...
... We generated six themes from the patient and family narratives: (1) Raising MAiD MI-SUMC awareness -Public information and patient psychoeducation; (2) 3 Past or present use of alcohol, including problematic use 6 (20.0) n/a Past or present use of other substances, including problematic use, or substance not specified 2 Stergiopoulos et al. BMC Psychiatry (2024) 24:120 illness or family participant, respectively. ...
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.
... The prognosis of psychiatric disorders and the efficacy of treatment are not predictable compared with neurological ones. 4 Even more important, also in terms of alternative options and resistance to treatment, is the case of some mental disorders, such as mood disorders and personality disorders, in which we see very low age compared with a median age at death of 77 (42e93) years. 1 Moreover, socio-economic conditions play a crucial role for mental disorder prediction and treatment. If lower age in amyotrophic lateral sclerosis and other neurodegenerative diseases is associated with early onset, poor prognosis, and severe disability, lower age in mood and personality disorders is not clinically sustained. ...
... If lower age in amyotrophic lateral sclerosis and other neurodegenerative diseases is associated with early onset, poor prognosis, and severe disability, lower age in mood and personality disorders is not clinically sustained. 4 The symptomatic parameter is subjective and depends on how the patient sees his/her own living in his/her milieu. The evolving understanding of mental capacity as a continuum rather than an all-or-nothing criterion recognizes situations of partial or diminished capacity and could empower trustees or proxies to support health choices (i.e. ...
... (2) No obstante, presenta ciertos dilemas éticos, morales e incluso religiosos donde existe el argumento que la eutanasia va en contra del derecho a la vida. (3) A nivel mundial, la legalización de la eutanasia ha sido realizada en algunos países europeos, siendo España su mayor representante. (1) En ciertos países que tratan de evitar el sufrimiento intolerable han aprobado la eutanasia, así, Colombia, Argentina, Chile, Estados Unidos y México los de mayor importancia dentro del continente americano. ...
... Con respecto a la economía, se ha comprobado que las enfermedades irreversibles y cuidados paliativos requieren de gastos excesivos, donde muchas de las veces los familiares tienden a endeudarse o vender pertenencias valiosas. (20,3) De igual manera, Runzer et al. (35) identificaron que dentro de la mayor parte de enfermedades terminales se genera gastos que afectan a los familiares, quienes muchas de las veces no se encuentran en capacidad de solventarlos. Además, muchas de las veces se disminuye los recursos económicos gracias a que los pacientes y cuidadores no cuentan con la capacidad de trabajar. ...
Euthanasia or good death is a medical procedure that causes the death of a patient with chronic and incurable diseases. In Ecuador, despite having high rates of chronic and terminal diseases, Euthanasia is not legal; This is because the Constitution of the Republic guarantees the right to a dignified life. The objective of this research was to determine the attitudes towards euthanasia on the part of health professionals. We worked under a quantitative approach and descriptive research, where the questionnaire for evaluating attitudes towards euthanasia (CAE) was applied to 110 teachers from the Medicine, Nursing, Nutrition, Clinical Psychology, Laboratory and Physiotherapy Careers of the Faculty of Life Sciences. Health of the Technical University of Ambato. The results reflected that the majority of teachers accept the practice of euthanasia, the Nursing, Medicine and Clinical Laboratory careers have an incidence greater than 60%. 68.18% of teachers are not influenced by ethical, moral and religious aspects, and the use of palliative care. 50.91% of teachers feel motivated to apply euthanasia in order to reduce pain, physical deterioration and suffering. 53.64% support euthanasia due to family issues that affect the economy and well-being. Finally, through Spearman's Rho coefficient, it was determined that there is a direct relationship between the professional study career and the acceptance of euthanasia.
... In all countries, the unbearable suffering of the involved patients must be of a kind that cannot be alleviated anymore by drugs or alternative therapies (Calati et al., 2021). Most countries in which medical-assisted dying is legal further impose that the unbearable suffering must be caused by a terminal disease. ...
... The constitution of these countries clearly states that medical-assisted death can also be requested by patients unbearably suffering due to a non-terminal disease. Such disease may be of a physical and/or mental nature (Calati et al., 2021). This paper specifically focuses on euthanasia because of unbearable mental suffering due to a mental disease (UMS-euthanasia). ...
Aim
To explore final year nursing students' attitudes towards euthanasia due to unbearable mental suffering by using the adapted and validated Euthanasia Attitude Scale.
Design
Cross‐sectional survey.
Methods
Explorative, descriptive cross‐sectional study conducted using an e‐mail survey between October 2020 and March 2021 by a sample of final‐year baccalaureate nursing students (n = 273) from eight of the eleven Flemish university colleges. The actual questionnaire contains 21 questions and was developed based on a consensus reached following independent translations. The psychometric properties of the Euthanasia Attitude Scale were assessed, including reliability and validity. Independent‐sample Mann–Whitney U‐test was used to investigate relation between demographic and education‐related data, and domain and total score of the UMS‐EAS‐NL. This study received ethical approval from the Ethical Committee of the University Hospital Brussels, Belgium.
Results
McDonald's omega was 0.838 for the total Euthanasia Attitude Scale scores, supporting the validity of the questionnaire. A statistically significant difference in ‘Naturalistic beliefs’ score was found relating to the year of birth. There are clinically important results between those students who have been involved in euthanasia and those who have not.
Conclusions
Most of the final‐year nursing students supported the probability of patients' access to euthanasia due to unbearable mental suffering. To monitor adequate care, it is necessary to prepare nursing students adequately for this complex matter.
Impact
To date, no large‐scale study has examined nursing students' attitudes towards euthanasia because of unbearable mental suffering. It is expected that nursing students may be confronted with such a euthanasia request during an internship, or later in their professional career, in countries where euthanasia is legal. Students showed a high acceptability towards UMS‐euthanasia. Clinically significant differences were found for students who had ever been involved in euthanasia.
... Previous and current studies confirm that both nurses and GPs play crucial roles in guiding euthanasia [2,5,23]. Multidisciplinary collaboration offers better quality of care and leads to a better support network for the patient and their family [24]. ...
Background: The legalization of euthanasia in Belgium in 2002 positioned nurses as possible participants in the euthanasia process. However, ethical and legal dilemmas necessitate clear definitions of their roles and competencies in this context. Given that general practitioners (GPs) are the primary medical professionals performing euthanasia, understanding their perspectives on the roles of nurses is crucial. Aim: This study aims to describe GPs’ perceptions of the roles and competencies of nurses during the euthanasia process. The research question addressed is as follows: “What are GPs’ views on the roles and competencies of nurses in euthanasia?”. Methods: A quantitative cross-sectional survey was conducted among licensed GPs in Flanders, Belgium. Data were collected via an online survey using Qualtrics and analyzed with SPSS Statistics. Ethical approval was obtained from the Medical Ethics Committee of the university. Results: The study included responses from 237 GPs. GPs value the roles and competencies of nurses, recognizing euthanasia as a multidisciplinary process. They acknowledge the critical support nurses provide to patients and their families. GPs assert that the administration of euthanasia medication should remain the exclusive responsibility of the GP. The analysis further indicated that demographic factors did not significantly influence the results. Discussion/Conclusions: GPs in Belgium generally rated the roles and competencies of nurses positively. Enhancing multidisciplinary collaboration, legislating the roles of nurses, and incorporating practical euthanasia training in nursing curricula, e.g., via simulations, are recommended.
... Palliative psychiatric care, however, might not be achievable for SPMI patients due to the level of their psychiatric suffering. For patients with the capacity to make informed decisions about their own medical treatment, euthanasia or assisted suicide is possible for unbearable and irremediable psychiatric suffering in some countries, provided specific due care criteria are met (3,4). ...
... The latest official data indicates that since its implementation, 651 euthanasia procedures have been performed, with oncological and neurological diseases being the most common (Ministerio de Sanidad, 2022). Little is known about euthanasia for mental health issues compared to other countries where it is decriminalized (Calati et al. 2021;Evenblij et al. 2019;Verhofstadt M., et al., 2017). ...
This article examines the assessment of mental capacity in the context of euthanasia, particularly when requested by patients with mental illnesses. It proposes a holistic alternative approach to the traditional functional model, arguing that the latter is insufficient to capture the complexity of these patients’ decisions. Using approaches based on narrative, hermeneutic, and dialogical ethics, it offers an evaluation that considers the patient’s life story, values, and context. Shared decision-making and empathy are identified as fundamental components to ensure informed and consensual decisions, promoting an environment of respect and mutual understanding. The article reviews Spanish legislation on euthanasia, highlighting the need to include medical ethics experts in the Guarantee and Evaluation Commissions. These experts provide a comprehensive ethical perspective essential for addressing the ethical complexities in euthanasia requests and ensuring fair decisions that reflect the patient’s true will. It recommends reviewing and expanding current protocols, as well as including continuous ethics training to improve medical practice in this context. The conclusions suggest that an assessment of mental capacity based on ethical principles and an integrated narrative can significantly improve medical practice and decision-making in euthanasia, especially for these patients. Furthermore, the inclusion of ethics experts in the commissions can provide a more humane and just perspective, ensuring that decisions respect the patient’s dignity and autonomy.
... Taking the rationale for individual autonomy in decisions about one's body a step further, a growing number of jurisdictions around the world have adopted statutes or simply implemented practices that allow physician assistance in bringing about one's death 218 . Initially, patients with untreatable conditions that were likely to result in death in the foreseeable future (e.g., within six months) were eligible to receive prescriptions from physicians for lethal doses of medication. ...
Psychiatry shares most ethical issues with other branches of medicine, but also faces special challenges. The Code of Ethics of the World Psychiatric Association offers guidance, but many mental health care professionals are unaware of it and the principles it supports. Furthermore, following codes of ethics is not always sufficient to address ethical dilemmas arising from possible clashes among their principles, and from continuing changes in knowledge, culture, attitudes, and socioeconomic context. In this paper, we identify topics that pose difficult ethical challenges in contemporary psychiatry; that may have a significant impact on clinical practice, education and research activities; and that may require revision of the profession's codes of ethics. These include: the relationships between human rights and mental health care, research and training; human rights and mental health legislation; digital psychiatry; early intervention in psychiatry; end-of-life decisions by people with mental health conditions; conflicts of interests in clinical practice, training and research; and the role of people with lived experience and family/informal supporters in shaping the agenda of mental health care, policy, research and training. For each topic, we highlight the ethical concerns, suggest strategies to address them, call attention to the risks that these strategies entail, and highlight the gaps to be narrowed by further research. We conclude that, in order to effectively address current ethical challenges in psychiatry, we need to rethink policies, services, training, attitudes, research methods and codes of ethics, with the concurrent input of a range of stakeholders, open minded discussions, new models of care, and an adequate organizational capacity to roll-out the implementation across routine clinical care contexts, training and research.
... There have been several such cases heard in the Court of Protection in England and Wales, where the general outcome has been that these people with lived experience lack the capacity to make decisions about their treatment because of the severe and entrenched nature of their disorder; yet the judges have often not found it in their best interests to continue to be compulsorily treated [84]. In other jurisdictions, individuals with lived experience have been allowed to avail themselves to Medically Assisted Dying [85,86]. In such and similar cases, there could come a time when there should be honest consideration of whether a temporary pausing of active or aggressive treatment or even consideration of how to help people to be comfortable and maintain dignity when facing the prospect or possibility of decline and death [87]. ...
Decisions about the treatment of eating disorders do not occur in a socio-political vacuum. They are shaped by power relations that produce categories of risk and determine who is worthy of care. This impacts who gets access to care and recognition of rights in mental health services. Globally, there are calls for more human rights-based approaches in mental health services to reduce coercion, improve collaborative decision making and enhance community care. Treating individuals with longstanding, Severe and Enduring Eating Disorders (SEED) or Severe and Enduring Anorexia Nervosa (SE-AN) can be particularly problematic when it involves highly controversial issues such as treatment withdrawal and end-of-life decisions and, where legally permissible, medically assisted dying. In this article, we argue that the socio-political context in which clinical decision making occurs must be accounted for in these ethical considerations. This encompasses considerations of how power and resources are distributed, who controls these decisions, who benefits and who is harmed by these decisions, who is excluded from services, and who is marginalised in decision making processes. The article also presents tools for critically reflective practice and collaborative decision-making that can support clinicians in considering power factors in their practice and assisting individuals with longstanding eating disorders, SEED and SE-AN to attain their rights in mental health services.
... These thoughts are critical, as they have to be able to make a well-considered decision that they alone can make. 9 First, they need to evaluate their illness and their degree of suffering, for which they need to know whether their illness can be treated and what is its likely prognosis. They then have to decide whether they can live with the level of suffering that they may need to endurein other words, to determine to what extent it is bearable. ...
With assisted dying becoming increasingly available to people suffering from somatic diseases, the question arises whether those suffering from mental illnesses should also have access. At the heart of this difficult and complex matter are values such as equality and parity of esteem. These issues require humane deliberation.
... 11 Although PAS was initially intended for those suffering from physical illness or in palliative care, the international debate has gradually expanded to include people with mental illness as eligible for PAS. [12][13][14] Suicide and suicidal ideation form a distinct syndrome that is found in a variety of mental illnesses, with major depression being the most prevalent. Suicidal tendencies are often reported during depressive episodes, with a risk of suicide of around 15%. 15,16 Owing to the frequent co-occurrence, suicidality is also a diagnostic criterion for severe depression. ...
Background
Physician-assisted suicide (PAS) is typically associated with serious physical illnesses that are prevalent in palliative care. However, individuals with mental illnesses may also experience such severity that life becomes intolerable. In February 2020, the previous German law prohibiting PAS was repealed. Patients with severe mental illnesses are increasingly likely to approach physicians with requests for PAS.
AimsTo explore the ethical and moral perspectives of medical students and physicians when making individual decisions regarding PAS.
Method
An anonymised digital survey was conducted among medical students and physicians in Germany. Participants were presented with a case vignette of a chronically depressed patient requesting PAS. Participants decided on PAS provision and assessed theoretical arguments. We employed generalised ordinal regression and qualitative analysis for data interpretation.
ResultsA total of N = 1478 participants completed the survey. Of these, n = 470 (32%) stated that they would refuse the request, whereas n = 582 (39%) would probably refuse, n = 375 (25%) would probably agree and n = 57 (4%) would definitely agree. Patient-centred arguments such as the right to self-determination increased the likelihood of consent. Concerns that PAS for chronically depressed patients might erode trust in the medical profession resulted in a decreased willingness to provide PAS.
Conclusions
Participants displayed relatively low willingness to consider PAS in the case of a chronically depressed patient. This study highlights the substantial influence of theoretical medical-ethical arguments and the broader public discourse, underscoring the necessity of an ethical discussion on PAS for mental illnesses.
... Researchers have examined the experiences of physicians, patients, and families involved in euthanasia cases. Their findings contribute to the ongoing discourse and inform policymakers about the practical implications of the legislation [54]. As debates continue and society grapples with the ethical implications, it is essential to maintain a dialogue that respects diverse perspectives and promotes the well-being of all individuals involved. ...
Since many years ago, people have been debating whether or not euthanasia should be regarded as a basic right. Supporters contend that everyone has the right to decide how they want to die, while detractors contend that euthanasia undermines the importance of protecting human life. Mercy killing or assisted suicide is a highly controversial issue not just in India but in many other nations. The ending-of-life practice poses fundamental, ethical, religious, and moral problems associated with it. It is still a matter of question in bioethics and lacks a legal framework. The word euthanasia has been derived from the Greek word "Eu" means good and "Thanatos" means death. There has been great advancement in our legal system but a few issues are yet to be addressed, out of which is "the legality of euthanasia". This paper deals with the history, types, and arguments related to the right to euthanasia as a fundamental right in view with the ethical, moral, and legal principles/perspectives. Further, this paper provides a comparative and analytical study of legalization regarding euthanasia in India with respect to foreign countries including those based on morality, ethics, and the risk of misuse.
... In the Netherlands, the number of deaths where euthanasia was permitted due to dementia or mental illness increased to 201 in 2016 as compared to 25 in 2010 (Preston, 2018). A Dutch systematic review (Calati et al., 2021) found that within psychiatric disorders, Mood disorders followed by Personality disorders were the commonest reasons for requesting euthanasia. Between 2015 and 2016, an estimated total of 1100-1150 psychiatric patients explicitly sought euthanasia and assisted suicide (EAS) from Dutch Psychiatrists, common reasons for which were "suffering without prospect of improvement", "desperate situations in various aspects of life" and "feelings of depression." ...
... 32 An analysis of trends of 25 years of VAD practice in Oregon showed that the proportion referred for psychiatric assessment remains low (1), 33 which corresponds with a greater acceptance of VAD for mental health disorders. 34 The danger is that VAD is seen as the patient's choice for an outcome, without reconsidering other active mental health treatments that could improve quality of life again. ...
Objectives
We aimed to explore the relationship between the pursuit of voluntary assisted dying (VAD) and the delivery of quality palliative care in an Australian state where VAD was newly available
Methods
We adopted a retrospective convergent mixed-methods design to gather and interpret data from records of 141 patients who expressed an interest in and did or did not pursue VAD over 2 years. Findings were correlated against quality domains.
Results
The mean patient age was 72.4 years, with the majority male, married/partnered, with a cancer diagnosis and identifying with no religion. One-third had depression, anxiety or such symptoms, half were in the deteriorating phase, two-thirds required help with self-care and 83.7% reported moderate/severe symptoms. Patients sought VAD because of a desire for autonomy (68.1%), actual suffering (57.4%), fear of future suffering (51.1%) and social concerns (22.0%). VAD enquiries impacted multiple quality domains, both enhancing or impeding whole person care, family caregiving and the palliative care team. Open communication promoted adherence to therapeutic options and whole person care and allowed for timely access to palliative care. Patients sought VAD over palliative care as a solution to suffering, with the withholding of information impacting relationships.
Significance of results
As legislation is expanded across jurisdictions, palliative care is challenged to accompany patients on their chosen path. Studies are necessary to explore how to ensure the quality of palliative care remains enhanced in those who pursue VAD and support continues for caregivers and staff in their accompaniment of patients.
... Less than 20% suffer from schizophrenia and less than 10% each from anxiety disorders, trauma sequelae, addictive disorders, bipolar disorders or others. Comorbidities are common (25)(26)(27). ...
Persons with mental disorders have the same right to self-determination as patients with somatic diseases, also regarding death and dying. However, there are several challenges that render persons with mental disorders especially vulnerable to inappropriate conduct of assisted suicide: their wish to die may be a symptom of their mental disease and not an autonomous choice, decision-making competence may be compromised by their illness and more difficult to assess, the severity of suffering may be more difficult to evaluate from an external perspective, the wish to die may be more variable over time and the prognostic uncertainty in mental illness makes it more difficult to determine whether the severe suffering is, in fact, treatment-resistant. After reviewing the clinical and ethical background of assisted suicide in persons with mental disorders, we assess each of these challenges to a medically and ethically justified practice of assisted suicide in mentally ill persons, based on relevant clinical and ethical literature. We conclude that the only ethically valid argument to exclude persons with mental disorders from suicide assistance is their potential inability to make a free, autonomous decision. However, the mentioned challenges should be taken into account in evaluating a person's request for assisted suicide and for promoting her well-informed and deliberated decision-making. In addition to assessing the person's decision-making capacity, the evaluation process should be guided by the goal to empower the person to make an autonomous choice between the available options. We conclude the paper with perspectives for a clinically and ethically justified practice of evaluating requests for assisted suicide in persons with mental disorders.
... Belgium, the Netherlands and Switzerland are the countries where assisted dying is currently possible for people having an irremediable psychiatric illness as underlying reason for the request. Statistics show that the number of cases in these countries is steadily increasing but remain a very small minority of all cases (around 2% of all cases; predominantly long-standing treatment-resistant depression) (Calati et al., 2021). Nonetheless, public health debate focuses particularly on this group. ...
... 22,23 Various physical and mental conditions can increase the likelihood of requesting euthanasia among patients. 24,25 Contrary to the increasing number of euthanasia requests around the world, no consensus about criteria for recognizing conditions in which patients can request euthanasia as palliative care has been reached around the world. Informing about all medical conditions that increase the likelihood of requesting euthanasia can help health policymakers as well as clinicians to reach a more precise decision about the acceptance or the rejection of requests made by patients when face by such requests. ...
Background and Aims
Euthanasia is a controversial issue related to the right to die. Although euthanasia is mostly requested by terminally sick individuals, even in societies where it is legal, it is unclear what medical conditions lead to euthanasia requests. In this scoping review, we aimed to compile medical conditions for which euthanasia has been requested or performed around the world.
Methods
The review was preferred reporting items for systematic reviews and meta‐analysis for scoping reviews (PRISMA‐ScR) checklist. Retrieved search results were screened and unrelated documents were excluded. Data on reasons for conducting or requesting euthanasia along with the study type, setting, and publication year were extracted from documents. Human development index and euthanasia legality were also extracted. Major medical fields were used to categorize reported reasons. Group discussions were conducted if needed for this categorization. An electronic search was undertaken in MEDLINE through PubMed for published documents covering the years January 2000 to September 2022.
Results
Out of 3323 records, a total of 197 papers were included. The most common medical conditions in euthanasia requests are cancer in a terminal phase (45.4%), Alzheimer's disease and dementia (19.8%), constant unbearable physical or mental suffering (19.8%), treatment‐resistant mood disorders (12.2%), and advanced cardiovascular disorders (12.2%).
Conclusion
Reasons for euthanasia are mostly linked to chronic or terminal physical conditions. Psychiatric disorders also lead to a substantial proportion of euthanasia requests. This review can help to identify the features shared by conditions that lead to performing or requesting euthanasia
... Assisted dying is legally permitted in a number of jurisdictions, such as Canada, the Netherlands, Belgium, Luxemburg, Switzerland, and several American states. 1 To be eligible for medical assistance in dying (MAiD) in Canada, the requester has to be aged 18+, eligible for government-funded health services, capable of making healthcare decisions, make a voluntary request, have a "grievous and irremediable" medical condition, give informed consent, and have been informed of the means available to relieve their suffering. 2 If natural death is reasonably foreseeable, 3 the patient must undergo two independent assessments; if not reasonably foreseeable, there must also be a consultation with a healthcare professional with expertise in the condition leading to the MAiD request if one of the assessors does not have this expertise; a minimum 90-day period should lapse between the start of the first assessment and the provision of MAiD; the provider, assessor, and patient must all agree that serious consideration has been given to any treatments and services available for the patient's condition. ...
Objective
This lived experience-engaged study aims to understand patient and family perspectives on the relationship between suicidality and medical assistance in dying when the sole underlying medical condition is mental illness (MAiD MI-SUMC).
Method
Thirty individuals with mental illness (age M = 41.8 years, SD = 14.2) and 25 family members (age M = 47.5 years, SD = 16.0) participated in qualitative interviews examining perspectives on MAiD MI-SUMC and its relationship with suicide. Audio recordings were transcribed and analysed using reflexive thematic analysis. People with lived experience were engaged in the research process as team members.
Results
Four main themes were developed, which were consistent across individuals with mental illness and family members: (a) deciding to die is an individual choice to end the ongoing intolerable suffering of people with mental illness; (b) MAiD MI-SUMC is the same as suicide because the end result is death, although suicide can be more impulsive; (c) MAiD MI-SUMC is a humane, dignified, safe, nonstigmatized alternative to suicide; and (4) suicidality should be considered when MAiD MI-SUMC is requested, but suicidality's role is multifaceted given its diverse manifestations.
Conclusion
For patient-oriented mental health policy and treatment, it is critical that the voices of people with lived experience be heard on the issue of MAiD MI-SUMC. Given the important intersections between MAiD MI-SUMC and suicidality and the context of suicide prevention, the role that suicidality should play in MAiD MI-SUMC is multifaceted. Future research and policy development are required to ensure that patient and family perspectives guide the development and implementation of MAiD MI-SUMC policy and practice.
... There are many difficult medical ethical dilemmas that confront clinicians in evaluating whether a patient can be legally granted the right to EAS. [16][17][18] It is necessary for instance to distinguish a patient's well-considered wish to die from the Table 2 Age categorisation and gender per group of patients wish to no longer live, which may be a treatable symptom of a patient's mental disorder. Many patients who withdrew their requests for EAS (34%, n=84) did so because they no longer wished to die. ...
Background
Euthanasia and assisted suicide (EAS) for patients with psychiatric disorders occupies a prominent place in the public debate, but little is known about the psychiatric patients requesting and receiving EAS.
Objective
To compare the social demographic and psychiatric profile of the patients who make a request for EAS and those who receive it.
Method
We carried out a review of records from 1122 patients with psychiatric disorders who have filed a potentially eligible request for EAS at Expertise Centrum for Euthanasia (EE) in the period 2012–2018.
Findings
The majority of the patients requesting EAS were single females, living independently with a comorbid diagnosis of depression with a history of undergoing psychiatric treatment for more than 10 years. From the small number of patients who went on to receive EAS in our sample, the majority were also single women, with a diagnosis of depressive disorder. A small subgroup of patients whose diagnoses included somatic disorders, anxiety disorders, obsessive-compulsive disorders and neurocognitive disorders were over-represented in the group of patients receiving EAS compared with the applicant group.
Conclusion
The average demographic and psychiatric profile of patients requesting and receiving EAS were found to be broadly similar. The majority of patients requesting EAS had received a comorbid diagnosis, making this a difficult-to-treat patient group. Only a small number of patients requesting had their requests granted. Patients from different diagnostic groups showed patterns in why their requests were not granted.
Clinical implications
Many of the patients who withdrew their requests for EAS benefited from being able to discuss dying with end of life experts at EE. Health professionals can make a difference to a vulnerable group of patients, if they are trained to discuss end of life.
... Debates coupled with mental disorders question and challenge how to distinguish euthanasia/MAS from ordinary suicide (Miller & Appelbaum, 2018;Vandenberghe, 2018), and revolve around the role of mental illness in motivating euthanasia requests, patients' decision-making capacities, and what constitutes 'incurable' in the context of psychiatric and mental illnesses (Sheehan et al., 2017). Euthanasia/MAS requests from patients with disorders known to potentially impair decision-making capacity (e.g., psychiatric disorders, dementia) are less likely to be accepted (Bolt et al., 2015;Calati et al., 2021). This may also be related to cautiousness in relation to eugenic ideology, when considering decisions about euthanasia/MAS, as such ideas can still be part of the cultural heritage (Grue, 2010;Kim, 2019) and represent a 'slippery slope' to walk (Grodin et al., 2018;Grue, 2010). ...
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.
... A similar trend was also recorded by the End-of-Life Clinic between 2013 and 2017, with an increase from 9 to 65 cases [23]. ...
The admission of people suffering from psychiatric and neurocognitive disorders to euthanasia and physician-assisted suicide (E/PAS) in some European and non-European countries represents a controversial issue. In some countries, the initial limitation of E/PAS to cases of severe physical illness with poor prognosis in the short term has been overcome, as it was considered discriminatory; thus, E/PAS has also been made available to subjects suffering from mental disorders. This decision has raised significant ethical questions regarding the capacity and freedom of self-determination; the family, social, and economic contexts; the social consideration of the sense of dignity and the pressure on the judgment of one's personal value; the contextual therapeutic possibilities; the identification of figures involved in the validation and application; as well as the epistemological definitions of the clinical conditions in question. To these issues must be added the situation of legislative vacuum peculiar to different countries and the widespread lack of effective evaluation and control systems. Nonetheless, pessimistic indicators on global health status, availability of care and assistance, aging demographics, and socioeconomic levels suggest that there may be further pressure toward the expansion of such requests. The present paper aims to trace an international overview with the aim of providing ethical support to the debate on the matter. Precisely, the goal is the delimitation of foundations for clinical practice in the complex field of psychiatry between the recognition of the irreversibility of the disease, assessment of the state of physical and mental suffering, as well as the possibility of adopting free and informed choices.
... In the countries of the world in which euthanasia is decriminalized, individuals presenting problems of mental health can also request assistance in dying. Although statistically they represent relatively few cases, requests of this nature are increasing (Calati et al., 2021;Evenblij, Pasman, Pronk, & Onwuteaka, 2019;Perreault, Benrimoh, & Fielding, 2019;Verhofstadt, Van Assche, Sterckx, Audenaert, & Chambaere, 2019). In Belgium, Thienpont et al. (2015) studied 100 euthanasia requests from patients with mental disorders, of which 48 were accepted, although only 35 were carried out. ...
On 25 June 2021, the Law on Euthanasia in Spain came into force, providing for two modes of helping an individual end their life: euthanasia and/or medically assisted suicide. Among the requisites that a request for euthanasia has to fulfil are that the individual must be suffering a severe, chronic and debilitating condition or a
severe and incurable disease, at the same time as that person shows the necessary competence to decide. The possibility exists that a patient suffering mental health problems submits such a request; however, the specific characteristics of a mental health disorder make such a request considerably more complex. In this article, based on a narrative review of the law itself and the related literature, the requisites established under the law are analysed from an ethical-legal perspective with the aim of defining when a request for euthanasia from a person with a mental health disorder may be deemed legitimate and in line with legal provisions. This should help clinicians make rational, reasoned decisions when dealing with a request of this type.
... 59 Applying such care pathways on the basis of serious mental illness has been debated extensively; for example in relation to Canada's Medical Assistance in Dying law, 60 which includes extensions to the legal entitlement to voluntary palliative care or treatment refusal by the patient among those with severe and persistent mental illness. Although there is evidence to show an increasing rate of requests for assisted dying among psychiatric patients in countries where it is available, 61 there is currently no consensus among health-care providers around the applicability of assisted dying in patients with mental illness, as shown in a mixed-methods survey of Dutch general practitioners, 62 as well as little collaboration between palliative and mental health care services. 63 These factors and others, such as the need for more research to understand the over-representation of women among those who request and receive assisted dying in data from Belgium and the Netherlands, 64 suggest, in our view, that the many and complex risks presented by assisted dying based on serious mental illness are not yet able to be adequately mitigated with the confidence that ought to be required. ...
The evidence base for the treatment of severe eating disorders is limited. In addition to improving access to early intervention, there is a need to develop more effective treatments for complex presentations of eating disorders. For patients with long-standing and severe illnesses, particular difficulties might exist with their engagement with treatment and achieving treatment outcomes. Alarmingly, there is an emerging international discourse about a concept labelled as terminal anorexia and about the withdrawal of treatment for people with severe eating disorders, resulting in the death of patients, as a legitimate option. This concept has arisen in the context of vastly overstretched specialist services and insufficient research and funding for new treatments. This Personal View combines multiple perspectives from carers, patients, and mental health professionals based in the UK, highlighting how the risks of current service provision are best alleviated by increasing resources, capacity, and training, and not by a narrowing of the criteria according to which patients with eating disorders are offered the care and support they need.
Reakiro is a walk-in, care and expertise center for persons with severe, chronic psychiatric illness and a persisting death wish, leading to chronic suicidality and/or a euthanasia request. The aim is to introduce the Reakiro model, integrating principles from presence theory, recovery-oriented care, existential therapy, and palliative care, and to describe the population visiting Reakiro ( N = 505). 55.4% had not (or not yet) formally requested euthanasia. 13.9% were in a euthanasia evaluation procedure and a minority finished the procedure (2.0% granted, 2.2% denied). A majority (63.4%) matched with two or more categories in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-V). Depressive (54.3%), personality (35.4%), and trauma-related disorders (28.7%) were most prevalent. Compared with previous Belgian samples of persons requesting psychiatric euthanasia, the Reakiro sample shows similar distribution of sex, age, and prevalence of mood and personality disorders. The sample differs in showing a higher prevalence of trauma-related disorders.
Depressive disorders in older people are often accompanied by thoughts of their own death and the specific wish to die. Therefore, it can be assumed that depressive older people will express the wish for assisted suicide more frequently if legal provisions have been made. The following aspects must be taken into account when examining the decision-making capacity of those affected: depressive disorders can be reversible. Severe depressive disorders can be accompanied by an impaired capacity for judgment and making decisions, which rules out the possibility of making decisions of one′s own free will. Particularly in old age, somatic comorbidities and an increased risk of loneliness are often found, which can additionally promote suicidal ideation. Without comprehensive assessments it will not be possible to clarify the actual autonomy of the will and it will be difficult to assess the permanence of the decisions made. It is also conceivable that the legal expert opinion could come to a different conclusion than the treating physician, who has followed the course of the illness during various phases of the patient′s life and observed many changes in the patients will. In summary, it is currently not clearly recognizable in what form the assessment of free will could be organized in connection with possible legal regulations on assisted suicide, as long observation periods would be required for an adequate assessment.
El texto reflexiona sobre el impacto de la Ley de la Eutanasia (LORE) en España en el papel del médico y en la sociedad. El autor examina cómo la ley requiere que los profesionales médicos reconsideren sus prácticas, adaptándose no solo a nuevas técnicas y medicamentos, sino también a la necesidad de hablar abiertamente sobre la muerte. Se compara la aprobación de la LORE con la implementación de los cuidados paliativos en los años noventa, que transformaron la atención al final de la vida.El autor comparte experiencias personales que muestran los desafíos de acompañar a personas en situación terminal y las dificultades emocionales que conlleva enfrentar situaciones como el suicidio o la eutanasia. Recuerda cómo fue percibido como un "médico raro" por su enfoque en el cuidado de los incurables, y cómo la sociedad, influida por la tradición cristiana, ha condenado históricamente el suicidio. También señala las tensiones morales y legales que surgen ante la solicitud de eutanasia, y ante los diferentes tipos de muerte que configuran el panorama actual. Finalmente, el autor destaca que la LORE ofrece nuevas opciones para elegir una muerte asistida, pero plantea preguntas éticas sobre el papel del profesional de la medicina en estos casos y los límites que la profesión enfrenta.
This paper explores recently emerging challenges in Medical Assistance in Dying on Psychiatric Grounds (MAID-PG), focusing on ethical, clinical, and societal perspectives. Two themes are explored. First, the growing number of young MAID-PG requestors and the public platform given to MAID-PG requests. Ethically, media portrayal, particularly of young patients’ testimonials, requires scrutiny for oversimplification, acknowledging the potential for a Werther effect alongside the absence of a Papageno effect. This highlights the need for better communication policies for media purposes. Second, cautionary considerations regarding psychiatric care adequacy are addressed. In MAID-PG this includes reasons underlying psychiatrist reluctance to engage in MAID-PG trajectories, leading to growing waiting lists at end-of-life-care centers. Addressing current shortages in psychiatric care adequacy is crucial, necessitating less narrow focus on short-term care trajectories and recovery beside transdiagnostic treatment approaches, expanded palliative care strategies, and integrated MAID-PG care.
Background
Assisted dying for reasons solely related to an eating disorder (ED) has occurred in multiple countries, including those which restrict the practice to individuals with a terminal condition. The aims of this systematic review were to (1) identify all known cases of assisted deaths among patients with EDs and (2) describe the clinical rationales used to grant patients’ requests for assisted death.
Methods
We conducted a systematic search of peer-reviewed studies and publicly available government reports to identify cases of assisted death in patients with EDs. In reports that included qualitative data about the case, clinical rationales were extracted and grouped into domains by qualitative content analysis.
Results
We identified 10 peer-reviewed articles and 20 government reports describing at least 60 patients with EDs who underwent assisted dying between 2012 and 2024. Clinical rationales were categorized into three domains: irremediability, terminality, and voluntary request. Reports emphasized that patients with EDs who underwent assisted death had terminal, incurable, and/or untreatable conditions and had adequate decision-making capacity to make a life-ending decision. Most government reports did not include descriptive-enough data to verify psychiatric conditions.
Conclusion
The results of our systematic review underscore considerable gaps in the reporting of assisted death in patients with psychiatric conditions, posing substantial concerns about oversight and public safety. In many cases, the clinical rationales that were used to affirm patients with EDs were eligible for assisted death lack validity and do not cohere with empirical understanding.
Borderline personality disorder is a common condition characterized by numerous comorbid conditions, frequent use of clinical services, and an elevated lifetime risk for suicide. Good psychiatric management (GPM) was developed for patients with borderline personality disorder with the purpose of supporting wider community adoption and dissemination compared with existing therapies. The authors aimed to review the foundations and development of GPM, in particular the initial Canadian study assessing the therapy. They then reviewed the progress in research arising from the initial study and explored the research and educational opportunities needed to further the development of GPM for patients with borderline personality disorder. Research has indicated that patients with borderline personality disorder with complex comorbid conditions and impulsivity may benefit from GPM. Future research needs include noninferiority and equivalence studies comparing GPM with another evidence-based treatment; studies demonstrating that evidence-based therapies for borderline personality disorder improve functioning; and research on more accessible therapies, mechanisms of action for evidence-based therapies, extending therapies to patients with borderline personality disorder and significant comorbid conditions, and modifying therapies for men with borderline personality disorder. Attention should be directed toward testing stepped care models and integrating therapies such as GPM into psychiatric training programs. GPM is in development but shows promise as a therapy that is effective and accessible and that can be widely disseminated.
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.
Background:
Medical aid in dying (MAID) is legal in a number of countries, including some states in the U.S. While MAID is only permitted for terminal illnesses in the U.S., some other countries allow it for persons with psychiatric illness. Psychiatric MAID, however, raises unique ethical concerns, especially related to its effects on mental illness stigma and on how persons with psychiatric illnesses would come to feel about treatment and suicide. To explore those concerns, we conducted several focus groups with persons with lived experience of mental illness.
Methods:
We conducted three video-conference-based focus groups involving adults residing in the U.S. who reported a prior diagnosis of any psychiatric illness. Only participants who reported thinking that MAID for terminal illness was morally acceptable were included. Focus group participants were asked to respond to a series of four questions. Groups were facilitated by a coordinator who was independent of the research team.
Results:
A total of 22 persons participated in the focus groups. The majority of participants had depression and anxiety disorders; no participants had psychotic disorders such as schizophrenia. Many participants strongly favored permitting psychiatric MAID, generally on the basis of respect for autonomy, its effects on stigma, and the severe suffering caused by mental illness. Others expressed concerns, typically related to difficulties in ensuring decision-making capacity and to the risk that MAID would be used in lieu of suicide.
Conclusions:
Persons with a history of psychiatric illness, as a group, have a diverse array of views about the permissibility of psychiatric MAID, reflecting nuanced consideration of how it relates to the public perception of mental illness, stigma, autonomy, and suicide risk.
Physician-assisted death (PAD) of patients whose suffering does not stem from terminal conditions has become more prevalent during the last few decades. This paper is focused on decision-making competence for PAD, specifically in situations in which PAD is related solely to psychiatric illness. First, a theoretical analysis presents the premises for the argument that competence for physician-assisted death for psychiatric patients (PADPP) should be determined based on a higher threshold in comparison to the required competence for conventional medical interventions. Second, the higher threshold for decision-making competence for PADPP is illustrated. Third, several real PADPP cases are critically discussed, as an illustration to decision-making competence evaluations that would not have met the higher standard. Finally, a short summary of practical suggestions regarding the assessment of decision-making competence for PADPP is presented. Psychiatrists are called to address the ethical, legal, societal and clinical challenges related to PADPP and should be prepared for its probable expansion.
ZUSAMMENFASSUNG
Gegenstand/Ziel: Mit dem Urteil des Bundesverfassungsgerichts von 2020 ist der rechtliche Rahmen für assistierten Suizid grundsätzlich gegeben; jedoch sind Fragen der Indikationsstellung bei Personen mit psychischer Störung noch ungeklärt. Der vorliegende Beitrag geht daher der Debatte nach, inwiefern der Forschungsstand den Zugang zu einem ärztlich assistierten Suizid auf Grundlage einer psychischen Störung als vertretbar bewertet.
Methode: Die Fragestellung wurde mittels einer selektiven Literaturrecherche in den Datenbanken PubPsych und PubMed sowie durch das Schneeballsystem gefundener Studien der Länder mit Legalisierung beantwortet.
Ergebnisse: Die psychiatrische Personengruppe kann anhand der gegenwärtigen Zugangsvoraussetzungen nicht kategorisch von ärztlich assistiertem Suizid ausgeschlossen werden. Der Rechtsanspruch sollte nur unter strengen Bewertungsverfahren im Rahmen zweier psychiatrischer unabhängiger Gutachten, professionellen Standards und zusätzlichen Sicherheitsvorkehrungen geltend gemacht werden.
Schlussfolgerung: Es sollten berufsrechtliche Regelungen und Standards im Sinne von Leit- und Richtlinien geschaffen werden. Zudem kann ein themenspezifischer Bedarf an Aus-, Fort- und Weiterbildung von (Fach-)Ärzten und (Fach-)Psychotherapeuten postuliert werden.
Klinische Relevanz: Das komplexe Unterfangen verlangt transparente Regelungen und Unterstützungsangebote für das Fachpersonal.
Assisted suicide has been the subject of controversial debates for years, particularly intensively since a ruling by the Federal Constitutional Court of Germany (BVerfG) in 2020, which postulated that the only prerequisite for the legitimacy of assistance is the free decision to commit suicide. This brings the issue into the focus of psychiatry. On the one hand, because people with mental illnesses can seek assisted suicide and on the other hand, because these illnesses often but not necessarily limit the ability to make a free decision on suicide. In the area of tension between the medical obligation to life and to suicide prevention on the one hand and the obligation to respect autonomous decisions of patients on the other hand, psychiatrists are not only personally challenged to develop a moral stance, but also as a profession to define the role and obligations of the discipline. This overview aims to contribute to this.
Unter dem Schlagwort der epistemischen Ungerechtigkeit wird seit knapp zwei Jahrzehnten diskutiert, inwiefern Personen in ihrer Rolle als Wissende benachteiligt werden können und welche moralisch relevanten Konsequenzen aus solchen Verletzungen möglicherweise folgen. Der Band versammelt Beiträge, die die Debatten um das Konzept epistemischer Ungerechtigkeit und seine Bedeutung maßgeblich geprägt haben, sowie aktuelle Beiträge zu seinen Implikationen und möglichen Konsequenzen von Situationen epistemischer Ungerechtigkeit.
Mit Beiträgen von
David Coady | Katharina Eisenhut | Miranda Fricker | Orsolya Friedrich | Agomoni Ganguli-Mitra | Axel Gelfert | Hilkje C. Hänel | Julia A. Harzheim | Lars Leeten | José Medina | Ruben Sakowsky | Ela Sauerborn | Sebastian Schleidgen | Katharina Trettenbach | Verina Wild | Andreas Wolkenstein
Belgium is one of very few countries where euthanasia on the basis of psychiatric illness is legally possible. Three physicians involved in the euthanasia of a 38-year-old woman suffering from psychiatric illness recently faced a criminal trial for “murder by poisoning”, for allegedly having failed to comply with several requirements of the Belgian Euthanasia Law. Although none of the physicians were convicted, the case generated extensive debate, in the media and the general public as well as in the medical profession and among policy makers. In this chapter, we take this trial as the starting point for a critical analysis of the clinical-psychiatric, ethical, and legal issues involved in evaluating euthanasia requests in cases of complex psychiatric disorders. In these cases, the requirements of the Belgian Euthanasia Law could be improved by mandating the advice of two psychiatrists, who are experts in the treatment of the specific condition of the person requesting euthanasia. Simultaneously with the process of evaluating the euthanasia request, there should be a parallel treatment track in which all therapeutic and recovery-oriented options are explored. These two tracks should not be in the hands of the same physician.KeywordsEuthanasiaBelgiumMental suffering
Psychiatric illness
Criminal law
The Belgian euthanasia law passes the human rights test, except for the a posteriori control Mortier versus Belgium (no. 78017/17) On several occasions, the European Court of Human Rights (ECtHR) has ruled on the human rights compliance of national regulations regarding medical assistance in dying. However, ‘Mortier versus Belgium’ is the first decision of the court on a case of euthanasia and, more specifically, euthanasia for unbearable mental suffering of a person with a psychiatric disorder. The court finds that the substantive and procedural requirements that must be observed by the concerned physicians under the Belgian euthanasia law, do not violate the European Convention on Human Rights (ECHR). By contrast, the way in which the a posteriori control by the Federal Control and Evaluation Commission is regulated, does violate the ECtHR as it cannot guarantee that all members are independent. Since a ruling of the court is binding, the legislature will need to amend the euthanasia law so that the independence of the members of this commission is always assured.
Voluntary Assisted Dying is a process whereby terminally ill patients are provided a lethal dose of medication for them to voluntarily ingest to end their life. Victoria, Australia, implemented legislation permitting Voluntary Assisted Dying for terminally ill adult patients with a life expectancy less than 6 months. Ethical dilemmas arise when terminally ill patients with a comorbid mental illness attempt to access Voluntary Assisted Dying because of the complex relationship between psychiatric conditions and suicidal ideation. This paper seeks to investigate the most ethical approach for doctors to respond to such a request by discussing objections raised in other literature to patients with a comorbid psychiatric illness aiming to access Voluntary Assisted Dying in Victoria. To answer this question, objections to terminally ill patients with a comorbid psychiatric illness accessing Voluntary Assisted Dying were found through review of literature. Discussion of these objections centred around unpacking the two historical ethical justifications for Voluntary Assisted Dying: respect for autonomy and relief of suffering. Regarding autonomy, contention focused on competency to make autonomous decisions. Not all psychiatric patients lack competency to decide about Voluntary Assisted Dying, and there are comparable competency assessments used in psychiatry today. Considering suffering, objections related to the authenticity of the intolerable nature of a patient's suffering out of concerns that it has been influenced by their condition, and that the psychiatric illness may still be treatable. However, given suffering is subjective, its perception is not lessened if the source is psychological in nature. Furthermore, it is challenging to justify a position where a patient is forced to spend the last months of their life enduring suffering that has been historically refractory to multiple, genuine treatment efforts. Not all terminally ill patients with a comorbid psychiatric disorder will lack competency to choose Voluntary Assisted Dying, and many will have genuine suffering for which they are requesting Voluntary Assisted Dying. Multidisciplinary, holistic assessments for these patients are not mandated, but would be useful to address the issues, overcome barriers to access and determine that applicants are making an authentic request.
Background:
The aim of this research project, part of a program initiated by the Swiss Federal Council, was to trace the development of organized assisted suicide in Switzerland, starting from the very first case in 1985.
Methods:
Retrospective data on 3666 death records from Swiss institutes of foren- sic medicine for the years 1985 to 2014 were systematically compiled, read into a database, and for the most part quantitatively evaluated.
Results:
Alongside a marked increase in the overall number of assisted suicides since the turn of the century, the number of people traveling to Switzerland from other countries-predominantly Germany-for this purpose has risen steadily. The proportion of women was 60%, and the age at death ranged from 18 to 105 years (median 73). The largest diagnostic category was malignancy overall, neurological disease for those from other countries. The next largest category was age-related functional limitation, e.g., sensory impairment (loss of sight and hearing), the conse- quences of which were stated in writing as the reason for the wish to die. Following the Swiss Federal Court's promulgation of binding requirements in 2006, the docu- mentation contained in the death records for the subsequent period up to 2014 is much more detailed, but still not uniform or even necessarily complete.
Conclusion:
The number of candidates for organized assisted suicide increased steadily during the study period, but no standard procedures were followed. The question therefore arises of whether further regulation or the introduction of a cen- tral registration office to maximize standardization and promote transparency would lead to improved quality assurance.
Background
Unbearable suffering is a key criterion in legally granting patients' euthanasia requests in Belgium yet a generally accepted definition of unbearable suffering remains elusive. The ability to understand and assess unbearable suffering is essential, particularly in patients with psychiatric conditions, as the underlying causes of these conditions are not always apparent. To enable research into when and why suffering experiences incite patients with psychiatric conditions to request euthanasia, and to help explore preventive and curative perspectives, the development of an assessment instrument is needed.
Aims
To improve the cognitive validity of a large initial item pool used to assess the nature and extent of suffering in patients with psychiatric conditions.
Method
Cognitive validity was established via two rounds of cognitive interviews with patients with psychiatric conditions with ( n = 9) and without ( n = 5) euthanasia requests.
Results
During the first round of cognitive interviews, a variety of issues relating to content, form and language were reported and aspects that were missing were identified. During the second round, the items that had been amended were perceived as sufficiently easily to understand, sensitive to delicate nuances, comprehensive and easy to answer accurately. Neither research topic nor method were perceived as emotionally strenuous, but instead as positive, relevant, comforting and valuable.
Conclusions
This research resulted in an item pool that covers the concept of suffering more adequately and comprehensively. Further research endeavours should examine potential differences in suffering experiences over time and in patients with psychiatric conditions with and without euthanasia requests. The appreciation patients demonstrated regarding their ability to speak extensively and openly about their suffering and wish to die further supports the need to allow patients to speak freely and honestly during consultations.
Declaration of interests
None.
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.
Background
The medical-ethical dilemmas related to euthanasia and physician-assisted suicide (EAS) in psychiatric patients are highly relevant in an international context. EAS in psychiatric patients appears to become more frequent in the Netherlands. However, little is known about the experiences of psychiatrists with this practice. This study aims to estimate the incidence of EAS (requests) in psychiatric practice in The Netherlands and to describe the characteristics of psychiatric patients requesting EAS, the decision-making process and outcomes of these requests.
Methods
In the context of the third evaluation of the Dutch Euthanasia Act, a cross-sectional study was performed between May and September 2016. A questionnaire was sent to a random sample of 500 Dutch psychiatrists. Of the 425 eligible psychiatrists 49% responded. Frequencies of EAS and EAS requests were estimated. Detailed information was asked about the most recent case in which psychiatrists granted and/or refused an EAS request, if any.
Results
The total number of psychiatric patients explicitly requesting for EAS was estimated to be between 1100 and 1150 for all psychiatrists in a one year period from 2015 to 2016. An estimated 60 to 70 patients received EAS in this period. Nine psychiatrists described a case in which they granted an EAS request from a psychiatric patient. Five of these nine patients had a mood disorder. Three patients had somatic comorbidity. Main reasons to request EAS were ‘depressive feelings’ and ‘suffering without prospect of improvement’. Sixty-six psychiatrists described a case in which they refused an EAS request. 59% of these patients had a personality disorder and 19% had somatic comorbidity. Main reasons to request EAS were ‘depressive feelings’ and ‘desperate situations in several areas of life’. Most requests were refused because the due care criteria were not met.
Conclusions
Although the incidence of EAS in psychiatric patients increased over the past two decades, this practice remains relatively rare. This is probably due to the complexity of assessing the due care criteria in case of psychiatric suffering. Training and support may enable psychiatrists to address this sensitive issue in their work better.
Electronic supplementary material
The online version of this article (10.1186/s12888-019-2053-3) contains supplementary material, which is available to authorized users.
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.
Background: The Netherlands is one of the few countries in the world that allows euthanasia and assisted suicide (EAS) due to psychiatric suffering.
Methods: The Dutch regional euthanasia review committees published 43 case summaries online between 2015 and 2017, of which 35 were analyzed (22% of all psychiatric EAS cases) on patient characteristics and physician involvement.
Results: 77% of patients were women. 51% of patients were between 50 and 70. Major depression disorder and personality disorders were present in almost half of the patients. All patients were considered mentally competent.
Conclusions: The incidence of psychiatric EAS cases is rising, but 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 on several characteristics from patients dying through assisted suicide. The fact that all patients are considered competent suggest that they are unjustly seen as vulnerable or that the competence assessment lacks due diligence.
Key words: Euthanasia, assisted suicide, psychiatry, Dutch case summaries.
Suicide is a worldwide phenomenon. This review is based on a literature search of the World Health Organization (WHO) databases and PubMed. According to the WHO, in 2015, about 800,000 suicides were documented worldwide, and globally 78% of all completed suicides occur in low- and middle-income countries. Overall, suicides account for 1.4% of premature deaths worldwide. Differences arise between regions and countries with respect to the age, gender, and socioeconomic status of the individual and the respective country, method of suicide, and access to health care. During the second and third decades of life, suicide is the second leading cause of death. Completed suicides are three times more common in males than females; for suicide attempts, an inverse ratio can be found. Suicide attempts are up to 30 times more common compared to suicides; they are however important predictors of repeated attempts as well as completed suicides. Overall, suicide rates vary among the sexes and across lifetimes, whereas methods differ according to countries. The most commonly used methods are hanging, self-poisoning with pesticides, and use of firearms. The majority of suicides worldwide are related to psychiatric diseases. Among those, depression, substance use, and psychosis constitute the most relevant risk factors, but also anxiety, personality-, eating- and trauma-related disorders as well as organic mental disorders significantly add to unnatural causes of death compared to the general population. Overall, the matter at hand is relatively complex and a significant amount of underreporting is likely to be present. Nevertheless, suicides can, at least partially, be prevented by restricting access to means of suicide, by training primary care physicians and health workers to identify people at risk as well as to assess and manage respective crises, provide adequate follow-up care and address the way this is reported by the media. Suicidality represents a major societal and health care problem; it thus should be given a high priority in many realms.
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.
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.
Background
The concept of ‘unbearable suffering’ is central to legislation governing whether euthanasia requests may be granted, but remains insufficiently understood, especially in relation to psychiatric patients.
Aims
To provide insights into the suffering experiences of psychiatric patients who have made a request for euthanasia.
Method
Testimonials from 26 psychiatric patients who requested euthanasia were analysed using QualiCoder software.
Results
Five domains of suffering were identified: medical, intrapersonal, interpersonal, societal and existential. Hopelessness was confirmed to be an important contributor. The lengthy process of applying for euthanasia was a cause of suffering and added to experienced hopelessness, whereas encountering physicians who took requests seriously could offer new perspectives on treatment.
Conclusions
The development of measurement instruments to assess the nature and extent of suffering as experienced by psychiatric patients could help both patients and physicians to better navigate the complicated and sensitive process of evaluating requests in a humane and competent way. Some correlates of suffering (such as low income) indicate the need for a broad medical, societal and political debate on how to reduce the burden of financial and socioeconomic difficulties and inequalities in order to reduce patients' desire for euthanasia. Euthanasia should never be seen (or used) as a means of resolving societal failures.
Objective:
Perform a meta-analysis to quantify the association between psychological pain and current or lifetime history of suicidal ideation or suicide attempt.
Data sources:
Search MEDLINE, Web of Science, and PsycINFO from 1965 to 2015 for (psychache OR mental pain OR psychological pain) AND (suicid*).
Study selection:
Observational case-control studies addressing the difference in psychological pain between individuals with and without current or lifetime history of suicidal ideation or suicide attempt.
Data extraction:
Data were independently extracted into a standard electronic form. All authors were contacted for unpublished data related to current or lifetime history of suicide ideation or attempt.
Data synthesis:
Twenty studies were included. Comparisons concerned 760 subjects with versus 8,803 subjects without lifetime history of suicide attempt; 344 subjects with versus 357 patients without current suicide attempt; 262 patients with versus 64 patients without lifetime history of suicidal ideation; and 551 subjects with versus 7,383 subjects without current suicidal ideation. The intensity of psychological pain was higher (1) in both subjects with lifetime history of suicide attempts and subjects with current suicide attempts versus without (effect sizes = 0.72, P < 10-2 and 0.66, P < 10-2, respectively) and (2) in both subjects with lifetime history of suicide ideation and subjects with current suicidal ideation versus without (effect sizes = 1.49, P = .01 and 1.15, P < 10-2, respectively). Association between psychological pain and suicidality remained significant even when depression levels were not different between subjects.
Conclusions:
Higher psychological pain levels are associated with suicidal ideation and acts. Considering psychological pain to be at the core of suicidality is important for daily clinical practice and for the promotion of innovative therapeutic strategies for suicide prevention.
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
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.
Electronic supplementary material
The online version of this article (doi:10.1186/s12888-017-1369-0) contains supplementary material, which is available to authorized users.
Received: April 29, 2016
Accepted: September 06, 2016
Published online: February 10, 2017
Issue release date: February 2017
Background:
In 2002, the Belgian Act on Euthanasia came into effect, regulating the intentional ending of life by a physician at the patient's explicit request. We undertook this study to describe trends in officially reported euthanasia cases in Belgium with regard to patients' sociodemographic and clinical profiles, as well as decision-making and performance characteristics.
Methods:
We used the database of all euthanasia cases reported to the Federal Control and Evaluation Committee on Euthanasia in Belgium between Jan. 1, 2003, and Dec. 31, 2013 (n = 8752). The committee collected these data with a standardized registration form. We analyzed trends in patient, decision-making and performance characteristics using a χ2 technique. We also compared and analyzed trends for cases reported in Dutch and in French.
Results:
The number of reported euthanasia cases increased every year, from 235 (0.2% of all deaths) in 2003 to 1807 (1.7% of all deaths) in 2013. The rate of euthanasia increased significantly among those aged 80 years or older, those who died in a nursing home, those with a disease other than cancer and those not expected to die in the near future (p < 0.001 for all increases). Reported cases in 2013 most often concerned those with cancer (68.7%) and those under 80 years (65.0%). Palliative care teams were increasingly often consulted about euthanasia requests, beyond the legal requirements to do so (p < 0.001). Among cases reported in Dutch, the proportion in which the person was expected to die in the foreseeable future decreased from 93.9% in 2003 to 84.1% in 2013, and palliative care teams were increasingly consulted about the euthanasia request (from 34.0% in 2003 to 42.6% in 2013). These trends were not significant for cases reported in French.
Interpretation:
Since legalization of euthanasia in Belgium, the number of reported cases has increased each year. Most of those receiving euthanasia were younger than 80 years and were dying of cancer. Given the increases observed among non-terminally ill and older patients, this analysis shows the importance of detailed monitoring of developments in euthanasia practice.
Between 10 and 20 million people attempt suicide every year worldwide, and suicide attempts represent a major economic burden. Suicide attempters suffer from high rates of comorbidity, and comorbidity is the rule in suicide re-attempters. Comorbidity complicates treatment and prognosis and causes a more protracted course. In the present narrative review, we included these patterns of comorbidity: intra-Axis I disorders, intra-Axis II disorders, Axis I with Axis II disorders, and psychiatric with physical illnesses. We also briefly reviewed the patterns of comorbidity in suicide re-attempters. We concluded that comorbidity at different levels appears to be the rule in suicide attempters, particularly in those who re-attempt. However, several issues deserve further research regarding the patterns of comorbidity in suicide attempters.
Background:
Cognitive behavioural therapy (CBT) is an effective treatment for people whose depression has not responded to antidepressants. However, the long-term outcome is unknown. In a long-term follow-up of the CoBalT trial, we examined the clinical and cost-effectiveness of cognitive behavioural therapy as an adjunct to usual care that included medication over 3-5 years in primary care patients with treatment-resistant depression.
Methods:
CoBalT was a randomised controlled trial done across 73 general practices in three UK centres. CoBalT recruited patients aged 18-75 years who had adhered to antidepressants for at least 6 weeks and had substantial depressive symptoms (Beck Depression Inventory [BDI-II] score ≥14 and met ICD-10 depression criteria). Participants were randomly assigned using a computer generated code, to receive either usual care or CBT in addition to usual care. Patients eligible for the long-term follow-up were those who had not withdrawn by the 12 month follow-up and had given their consent to being re-contacted. Those willing to participate were asked to return the postal questionnaire to the research team. One postal reminder was sent and non-responders were contacted by telephone to complete a brief questionnaire. Data were also collected from general practitioner notes. Follow-up took place at a variable interval after randomisation (3-5 years). The primary outcome was self-report of depressive symptoms assessed by BDI-II score (range 0-63), analysed by intention to treat. Cost-utility analysis compared health and social care costs with quality-adjusted life-years (QALYs). This study is registered with isrctn.com, number ISRCTN38231611.
Findings:
Between Nov 4, 2008, and Sept 30, 2010, 469 eligible participants were randomised into the CoBalT study. Of these, 248 individuals completed a long-term follow-up questionnaire and provided data for the primary outcome (136 in the intervention group vs 112 in the usual care group). At follow-up (median 45·5 months [IQR 42·5-51·1]), the intervention group had a mean BDI-II score of 19·2 (SD 13·8) compared with a mean BDI-II score of 23·4 (SD 13·2) for the usual care group (repeated measures analysis over the 46 months: difference in means -4·7 [95% CI -6·4 to -3·0, p<0·001]). Follow-up was, on average, 40 months after therapy ended. The average annual cost of trial CBT per participant was £343 (SD 129). The incremental cost-effectiveness ratio was £5374 per QALY gain. This represented a 92% probability of being cost effective at the National Institute for Health and Care Excellence QALY threshold of £20 000.
Interpretation:
CBT as an adjunct to usual care that includes antidepressants is clinically effective and cost effective over the long-term for individuals whose depression has not responded to pharmacotherapy. In view of this robust evidence of long-term effectiveness and the fact that the intervention represented good value-for-money, clinicians should discuss referral for CBT with all those for whom antidepressants are not effective.
Funding:
National Institute for Health Research Health Technology Assessment.
Systematic reviews and meta-analyses have become increasingly important in health care. Clinicians read them to keep up to date with their field [1],[2], and they are often used as a starting point for developing clinical practice guidelines. Granting agencies may require a systematic review to ensure there is justification for further research [3], and some health care journals are moving in this direction [4]. As with all research, the value of a systematic review depends on what was done, what was found, and the clarity of reporting. As with other publications, the reporting quality of systematic reviews varies, limiting readers' ability to assess the strengths and weaknesses of those reviews.
Several early studies evaluated the quality of review reports. In 1987, Mulrow examined 50 review articles published in four leading medical journals in 1985 and 1986 and found that none met all eight explicit scientific criteria, such as a quality assessment of included studies [5]. In 1987, Sacks and colleagues [6] evaluated the adequacy of reporting of 83 meta-analyses on 23 characteristics in six domains. Reporting was generally poor; between one and 14 characteristics were adequately reported (mean = 7.7; standard deviation = 2.7). A 1996 update of this study found little improvement [7].
In 1996, to address the suboptimal reporting of meta-analyses, an international group developed a guidance called the QUOROM Statement (QUality Of Reporting Of Meta-analyses), which focused on the reporting of meta-analyses of randomized controlled trials [8]. In this article, we summarize a revision of these guidelines, renamed PRISMA (Preferred Reporting Items for Systematic reviews and Meta-Analyses), which have been updated to address several conceptual and practical advances in the science of systematic reviews (Box 1).
Box 1: Conceptual Issues in the Evolution from QUOROM to PRISMA
Completing a Systematic Review Is an Iterative Process
The conduct of a systematic review depends heavily on the scope and quality of included studies: thus systematic reviewers may need to modify their original review protocol during its conduct. Any systematic review reporting guideline should recommend that such changes can be reported and explained without suggesting that they are inappropriate. The PRISMA Statement (Items 5, 11, 16, and 23) acknowledges this iterative process. Aside from Cochrane reviews, all of which should have a protocol, only about 10% of systematic reviewers report working from a protocol [22]. Without a protocol that is publicly accessible, it is difficult to judge between appropriate and inappropriate modifications.
To identify patterns in euthanasia requests and practices relating to psychiatric patients; to generate recommendations for future research.
Retrospective analysis of data obtained through medical file review.
Outpatient psychiatric clinical setting in the Dutch-speaking region of Belgium, between October 2007 and December 2011; follow-up at the end of December 2012.
100 consecutive psychiatric patients requesting euthanasia based on psychological suffering associated with psychiatric disorders (77 women, 23 men; mean age 47 years; age range 21-80 years).
Patient sociodemographic characteristics; diagnoses; decisions on euthanasia requests; circumstances of euthanasia procedures; patient outcomes at follow-up.
Most patients had been referred for psychiatric counselling by their physician (n=55) or by LEIF (Life End Information Forum) (n=36). 90 patients had >1 disorder; the most frequent diagnoses were depression (n=58) and personality disorder (n=50). 38 patients required further testing and/or treatment, including 13 specifically tested for autism spectrum disorder (ASD); 12 received an ASD diagnosis (all Asperger syndrome). In total, 48 of the euthanasia requests were accepted and 35 were carried out. Of the 13 remaining patients whose requests were accepted, 8 postponed or cancelled the procedure, because simply having this option gave them enough peace of mind to continue living. In December 2012, 43 patients had died, including 35 by euthanasia; others died by suicide (6), palliative sedation (1) and anorexia nervosa (1).
Depression and personality disorders are the most common diagnoses in psychiatric patients requesting euthanasia, with Asperger syndrome representing a neglected disease burden. Further research is needed, especially prospective quantitative and qualitative studies, to obtain a better understanding of patients with psychiatric disorders who request euthanasia due to unbearable psychological suffering.
Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.
While assisted suicide (AS) is strictly restricted in many countries, it is not clearly regulated by law in Switzerland. This imbalance leads to an influx of people-'suicide tourists'-coming to Switzerland, mainly to the Canton of Zurich, for the sole purpose of committing suicide. Political debate regarding 'suicide tourism' is taking place in many countries. Swiss medicolegal experts are confronted with these cases almost daily, which prompted our scientific investigation of the phenomenon. The present study has three aims: (1) to determine selected details about AS in the study group (age, gender and country of residence of the suicide tourists, the organisation involved, the ingested substance leading to death and any diseases that were the main reason for AS); (2) to find out the countries from which suicide tourists come and to review existing laws in the top three in order to test the hypothesis that suicide tourism leads to the amendment of existing regulations in foreign countries; and (3) to compare our results with those of earlier studies in Zurich. We did a retrospective data analysis of the Zurich Institute of Legal Medicine database on AS of non-Swiss residents in the last 5 years (2008-2012), and internet research for current legislation and political debate in the three foreign countries most concerned. We analysed 611 cases from 31 countries all over the world. Non-terminal conditions such as neurological and rheumatic diseases are increasing among suicide tourists. The unique phenomenon of suicide tourism in Switzerland may indeed result in the amendment or supplementary guidelines to existing regulations in foreign countries.
Suicidal behavior results from a complex interplay between stressful events and vulnerability factors, including cognitive deficits. However, it is not clear which cognitive tests may best reveal this vulnerability. The objective was to identify neuropsychological tests of vulnerability to suicidal acts in patients with mood disorders.
A search was made of Medline, EMBASE and PsycINFO databases, and article references. A total of 25 studies (2323 participants) met the selection criteria. A total of seven neuropsychological tests [Iowa gambling task (IGT), Stroop test, trail making test part B, Wisconsin card sorting test, category and semantic verbal fluencies, and continuous performance test] were used in at least three studies to be analysed.
IGT and category verbal fluency performances were lower in suicide attempters than in patient controls [respectively, g = -0.47, 95% confidence interval (CI) -0.65 to -0.29 and g = -0.32, 95% CI -0.60 to -0.04] and healthy controls, with no difference between the last two groups. Stroop performance was lower in suicide attempters than in patient controls (g = 0.37, 95% CI 0.10-0.63) and healthy controls, with patient controls scoring lower than healthy controls. The four other tests were altered in both patient groups versus healthy controls but did not differ between patient groups.
Deficits in decision-making, category verbal fluency and the Stroop interference test were associated with histories of suicidal behavior in patients with mood disorders. Altered value-based and cognitive control processes may be important factors of suicidal vulnerability. These tests may also have the potential of guiding therapeutic interventions and becoming part of future systematic assessment of suicide risk.
In most Western countries females have higher rates of suicidal ideation and behavior than males, yet mortality from suicide is typically lower for females than for males. This article explores the gender paradox of suicidal behavior, examines its validity, and critically examines some of the explanations, concluding that the gender paradox of suicidal behavior is a real phenomenon and not a mere artifact of data collection. At the same time, the gender paradox in suicide is a more culture-bound phenomenon than has been traditionally assumed; cultural expectations about gender and suicidal behavior strongly determine its existence. Evidence from the United States and Canada suggests that the gender gap may be more prominent in communities where different suicidal behaviors are expected of females and males. These divergent expectations may affect the scenarios chosen by females and males, once suicide becomes a possibility, as well as the interpretations of those who are charged with determining whether a particular behavior is suicidal (e.g., coroners). The realization that cultural influences play an important role in the gender paradox of suicidal behaviors holds important implications for research and for public policy.
Research needs to be reported transparently so readers can critically assess the strengths and weaknesses of the design, conduct, and analysis of studies. Reporting guidelines have been developed to inform reporting for a variety of study designs. The objective of this study was to identify whether there is a need to develop a reporting guideline for survey research.
We conducted a three-part project: (1) a systematic review of the literature (including "Instructions to Authors" from the top five journals of 33 medical specialties and top 15 general and internal medicine journals) to identify guidance for reporting survey research; (2) a systematic review of evidence on the quality of reporting of surveys; and (3) a review of reporting of key quality criteria for survey research in 117 recently published reports of self-administered surveys. Fewer than 7% of medical journals (n = 165) provided guidance to authors on survey research despite a majority having published survey-based studies in recent years. We identified four published checklists for conducting or reporting survey research, none of which were validated. We identified eight previous reviews of survey reporting quality, which focused on issues of non-response and accessibility of questionnaires. Our own review of 117 published survey studies revealed that many items were poorly reported: few studies provided the survey or core questions (35%), reported the validity or reliability of the instrument (19%), defined the response rate (25%), discussed the representativeness of the sample (11%), or identified how missing data were handled (11%).
There is limited guidance and no consensus regarding the optimal reporting of survey research. The majority of key reporting criteria are poorly reported in peer-reviewed survey research articles. Our findings highlight the need for clear and consistent reporting guidelines specific to survey research.
Background
Interest in the topic of termination of life has been growing for 2 decades. After legalisation of active euthanasia and assisted suicide (EAS) in the Netherlands in 2002, movements to implement similar laws started in other European countries. However, many people objected to legalisation on the basis of the experiences in the Netherlands and as a matter of principal.
Methods
This selected and focussed review presents the theoretical discussions about EAS and describes the respective parliamentary discussions in Germany and the data and experiences in the Netherlands. It also considers people with mental disorders in the context of termination-of-life services.
Results
So far, only a few European countries have introduced legislation on EAS. Legalisation of EAS in the Netherlands resulted in an unexpectedly large increase in cases. The number of people with mental disorders who terminate their lives on request remains low.
Conclusions
Experience from the Netherlands shows that widening criteria for EAS has problematic consequences.
•
KEY POINTS
• Termination of life on request, which a subgroup of people support, is a matter of ongoing debate.
• Because of several problematic aspects, including ethical considerations, only a few countries in the world allow active euthanasia or assisted suicide.
• Even if euthanasia is well regulated, legalising it can have problematic consequences that are difficult to control, such as an unwanted excessive increase in euthanasia cases.
• The well-documented experiences with the euthanasia law in the Netherlands serve as an example of what is to be expected when euthanasia is legalised.
• We need to pay close attention to the relationship between suicide and suicide prevention on the one hand and euthanasia acts and promotion of euthanasia on the other.
• Further ethical, psychological and legal research is needed. In particular, the role of palliative medicine in societies’ approach to end-of-life care must be explored in much more detail.
The odds ratio (OR) for gender differences in major depression is 1.95, averaged meta-analytically over all ages and nations. The gender difference appears by age 12, OR = 2.37, and peaks at OR = 3.02 for ages 13-15. Using the ABC (affective, biological, cognitive) model as a framework within a vulnerability-stress approach, we consider the evidence for biological vulnerabilities (genes, pubertal hormones, and pubertal timing), affective vulnerabilities (temperament), and cognitive vulnerabilities (negative cognitive style, objectified body consciousness, and rumination). The impact of stress is central to the vulnerability-stress model, and we review evidence on gender differences in stress exposure, emphasizing gender differences in sex-related traumas such as child sexual abuse and rape. Finally, we examine sociocultural factors that may contribute to the gender difference, including the media and gender inequality. An implication for research methods is that single-gender designs should be questioned. Regarding clinical implications, the vulnerabilities and stressors identified in this review should contribute to personalized interventions with depressed individuals, especially depressed women.
The Canadian province of Quebec enacted in 2014 a legislation that permitted medical assistance in dying (MAID) under specific conditions and the rest of Canada followed suit in June 2016. In this article, which is the second in a set of case series of requests for MAID in Canadian psychiatry, we present the cases of two patients who made a request for MAID to their treating psychiatrist in an outpatient clinic. While one is advanced in age and suffering from intense physical and psychic pain with little if any psychiatric comorbidity, the other is a young and medically healthy woman who nonetheless suffers from extensive psychiatric comorbidity. This article discusses both cases in light of recent scientific literature and case law that is slowly emerging in Canada, focusing on the concepts of the end of life and its legal definition as well as psychic suffering and its management in those wishing to receive physician-assisted dying. In our conclusion, we stress the need to clarify the definition of treatment resistance, the necessity to determine each physician's role when many are involved, as well as the importance of treating psychic pain holistically, which can sometimes require going beyond standard psychiatric care.
Background
The medical-ethical dilemmas related to euthanasia and physician-assisted suicide (EAS) in psychiatric patients are highly relevant in an international context. EAS in psychiatric patients appears to become more frequent in the Netherlands. However, little is known about the experiences of psychiatrists with this practice. This study aims to estimate the incidence of EAS (requests) in psychiatric practice in The Netherlands and to describe the characteristics of psychiatric patients requesting EAS, the decision-making process and outcomes of these requests.
Methods
In the context of the third evaluation of the Dutch Euthanasia Act, a cross-sectional study was performed between May and September 2016. A questionnaire was sent to a random sample of 500 Dutch psychiatrists. Of the 425 eligible psychiatrists 49% responded. Frequencies of EAS and EAS requests were estimated. Detailed information was asked about the most recent case in which psychiatrists granted and/or refused an EAS request, if any.
Results
The total number of psychiatric patients explicitly requesting for EAS was estimated to be between 1100 and 1150 for all psychiatrists in a one year period from 2015 to 2016. An estimated 60 to 70 patients received EAS in this period. Nine psychiatrists described a case in which they granted an EAS request from a psychiatric patient. Five of these nine patients had a mood disorder. Three patients had somatic comorbidity. Main reasons to request EAS were ‘depressive feelings’ and ‘suffering without prospect of improvement’. Sixty-six psychiatrists described a case in which they refused an EAS request. 59% of these patients had a personality disorder and 19% had somatic comorbidity. Main reasons to request EAS were ‘depressive feelings’ and ‘desperate situations in several areas of life’. Most requests were refused because the due care criteria were not met.
Conclusions
Although the incidence of EAS in psychiatric patients increased over the past two decades, this practice remains relatively rare. This is probably due to the complexity of assessing the due care criteria in case of psychiatric suffering. Training and support may enable psychiatrists to address this sensitive issue in their work better.
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.
Euthanasia was decriminalized in Quebec in December 2015, and Canada-wide in June 2016. Both the Provincial and Federal legislation have limited the right to medical assistance in dying (MAID) to end-of-life cases; which makes MAID inaccessible to most patients solely suffering from psychiatric illness. While some end-stage anorexia nervosa or elderly patients may meet the end-of-life criterion because of their medical comorbidities or their age (Kelly et al., 2003), repeated suicide attempts or psychotic disorganization would not qualify since they would not be seen as elements of an illness leading to a foreseeable "natural death" (Canada, 2016). This is in contradiction to other jurisdictions, such as Belgium and the Netherlands as well as the eligibility criteria stated in the Supreme Court of Canada's decision in Carter v. Canada (Supreme Court of Canada, 2015). Here we analyze three cases of patients who presented to a psychiatric emergency department and requested MAID for psychiatric reasons. While none of the patients were eligible for MAID under Canadian law, we find that their demographics match closely that of patients granted MAID for psychiatric reasons in jurisdictions where that practice is allowed. Based on these cases, we comment on potentially negative consequences that may come from decriminalizing MAID for psychiatric reasons (such as an increased assessment burden on ED staff) and potentially positive consequences (such as encouraging suffering patients who had not consulted to seek care). While it is by no means our intention to take a political or moral stand on this important issue, or to conclusively weigh the negatives and positives of allowing MAID for psychiatric reasons, we do stress the importance of an active voice for psychiatry in this ongoing public debate.
Examining the evidence from Belgium - one of only five countries where euthanasia is practised legally - an international panel of experts considers the implications of legalised euthanasia and assisted suicide. Looking at the issue from an international perspective, the authors have written an invaluable in-depth analysis of the ethical aspects of this complex area. The discussion forms a solid foundation for informed debate about assisted dying. With contributors from a broad range of disciplines, this book is ideal for students, academics, legislators and anyone interested in legal, medical, social and philosophical ethics. A vital and timely examination of a growing phenomenon and one of the most challenging ethical questions of our time.
In exceptional cases, suicide might be considered a rational choice of a competent person, even in the presence of psychiatric illness. But unless a truly rigorous prospective review system is in place for such cases, countries should not legalize the practice.
Self-injurious thoughts and behaviors (SITBs), including nonsuicidal self-injury, suicidal thoughts, suicide attempts, and suicide death exhibit substantial sex differences. Across most countries, men die by suicide more frequently than women; yet, women think about and attempt suicide more frequently than men. Research on sex differences in nonsuicidal self-injury is less developed; however, nonsuicidal self-injury is historically understood as a primarily female phenomenon. This review describes current research on sex differences across SITBs with a focus on factors that moderate these effects, such as age, race, geographic region, and time. Additionally, this review describes factors that may help to explain why sex differences across SITBs exist, including differences in culture, access to lethal suicide methods, rates of mental illness, and utilization of health care. The role of gender, and particularly non-binary gender, is also discussed. Current understanding of these sex differences is described with an eye toward future research on this topic.
Background
Evidence-based data on prevalence and risk factors of suicidal intentions and behavior in dementia are as scarce as the data on assisted dying. The present literature review aimed on summarizing the current knowledge and provides a critical discussion of the results.
Methods
A systematic narrative literature review was performed using Medline, Cochrane Library, EMBASE, PSYNDEX, PSYCINFO, Sowiport, and Social Sciences Citation Index literature.
Results
Dementia as a whole does not appear to be a risk factor for suicide completion. Nonetheless some subgroups of patients with dementia apparently have an increased risk for suicidal behavior, such as patients with psychiatric comorbidities (particularly depression) and of younger age. Furthermore, a recent diagnosis of dementia, semantic dementia, and previous suicide attempts most probably elevate the risk for suicidal intentions and behavior. The impact of other potential risk factors, such as patient's cognitive impairment profile, behavioral disturbances, social isolation, or a biomarker based presymptomatic diagnosis has not yet been investigated. Assisted dying in dementia is rare but numbers seem to increase in regions where it is legally permitted.
Conclusion
Most studies that had investigated the prevalence and risk factors for suicide in dementia had significant methodological limitations. Large prospective studies need to be conducted in order to evaluate risk factors for suicide and assisted suicide in patients with dementia and persons with very early or presymptomatic diagnoses of dementia. In clinical practice, known risk factors for suicide should be assessed in a standardized way so that appropriate action can be taken when necessary.
In Reply We agree with Ms Hodel and Dr Trachsel when they conclude, “With improvements in the quality of care, there might be fewer requests for EAS.” According to the article by Dr Kim and colleagues,¹ most patients receiving EAS for psychiatric conditions did not receive accurate treatment for their mental state and level of suffering that could have led to avoiding EAS. Dr Trachsel and colleagues² suggested palliative care in psychiatry for severe persistent mental illness, including long-term residential care patients with severe chronic schizophrenia and insufficient quality of life; those with therapy-refractory depression; and persons with severe, long-standing, therapy-refractory anorexia nervosa. Most EAS psychiatric patients in the series by Kim and colleagues did not meet these criteria.
Background:
Pain-related conditions have been reported to play a key role among risk factors for suicide. Headache in particular has been repeatedly associated with suicidal thoughts and behaviors. The aims of this study were: 1) to assess the association between lifetime headache (both non-migrainous headache and migraine) and lifetime suicide attempts (SA); 2) to differentiate, within subjects with lifetime SA, patients with and without lifetime headache in terms of socio-demographic and clinical features.
Methods:
We studied 1965 subjects from a cohort of community-dwelling persons aged 65 years and over without dementia (the ESPRIT study), divided in two groups: those with (n=75), and those without a lifetime SA (n=1890). Logistic regression analyses were used to compare these groups according to lifetime headache status.
Results:
After adjusting for gender, living alone, tobacco and alcohol consumption, and depressive, manic/hypomanic and anxiety disorders, lifetime headache frequency was significantly higher in subjects with a lifetime SA compared with controls (OR=1.92 [1.17-3.15]). Additionally, different factors were identified as being associated with lifetime SA in participants with lifetime headache (female gender, a lower level of high-density lipoprotein cholesterol, insomnia, lifetime major depression) versus participants without headache (glycemia and lifetime major depression).
Conclusions:
Lifetime headache was associated with lifetime SA. Subjects who are women and report the co-occurrence of headache and insomnia as well as lifetime major depression require higher attention and a careful screening for suicidal thoughts and behaviors.
A main objective of legalization of euthanasia or physician-assisted suicide (EAS) is to ease suffering (ie, physical pain and loss of autonomy elicited by an irreversible serious disease), when a terminally ill patient's pain is overwhelming despite palliative care.¹ It implies that there is no reasonable alternative in the patient’s situation, with no prospect of improvement of a painful condition or global functioning. Because mental disorders are among the most disabling illnesses, requests for EAS based on unbearable mental suffering caused by severe psychiatric disease may possibly increase. EAS may be differentiated from suicide because EAS results in death without self-inflicted behavior, yet both are driven by a desire to end life. This raises the question: Should the management of patients with psychiatric disorders requesting EAS be considered for suicide prevention?
Importance:
The increasing legalization of euthanasia and physician-assisted suicide worldwide makes it important to understand related attitudes and practices.
Objective:
To review the legal status of euthanasia and physician-assisted suicide and the available data on attitudes and practices.
Evidence review:
Polling data and published surveys of the public and physicians, official state and country databases, interview studies with physicians, and death certificate studies (the Netherlands and Belgium) were reviewed for the period 1947 to 2016.
Findings:
Currently, euthanasia or physician-assisted suicide can be legally practiced in the Netherlands, Belgium, Luxembourg, Colombia, and Canada (Quebec since 2014, nationally as of June 2016). Physician-assisted suicide, excluding euthanasia, is legal in 5 US states (Oregon, Washington, Montana, Vermont, and California) and Switzerland. Public support for euthanasia and physician-assisted suicide in the United States has plateaued since the 1990s (range, 47%-69%). In Western Europe, an increasing and strong public support for euthanasia and physician-assisted suicide has been reported; in Central and Eastern Europe, support is decreasing. In the United States, less than 20% of physicians report having received requests for euthanasia or physician-assisted suicide, and 5% or less have complied. In Oregon and Washington state, less than 1% of licensed physicians write prescriptions for physician-assisted suicide per year. In the Netherlands and Belgium, about half or more of physicians reported ever having received a request; 60% of Dutch physicians have ever granted such requests. Between 0.3% to 4.6% of all deaths are reported as euthanasia or physician-assisted suicide in jurisdictions where they are legal. The frequency of these deaths increased after legalization. More than 70% of cases involved patients with cancer. Typical patients are older, white, and well-educated. Pain is mostly not reported as the primary motivation. A large portion of patients receiving physician-assisted suicide in Oregon and Washington reported being enrolled in hospice or palliative care, as did patients in Belgium. In no jurisdiction was there evidence that vulnerable patients have been receiving euthanasia or physician-assisted suicide at rates higher than those in the general population.
Conclusions and relevance:
Euthanasia and physician-assisted suicide are increasingly being legalized, remain relatively rare, and primarily involve patients with cancer. Existing data do not indicate widespread abuse of these practices.
Background:
Euthanasia or physician-assisted suicide (EAS) of psychiatric patients is legal in some countries but remains controversial.
Objective:
This study examined a frequently raised concern about the practice: how physicians address the issue of decision-making capacity of persons requesting psychiatric EAS.
Methods:
A review of psychiatric EAS case summaries published by the Dutch Regional Euthanasia Review Committees. Directed content analysis using a capacity-specific 4 abilities model (understanding of facts, applying those facts to self, weighing/reasoning, and evidencing choice) was used to code texts discussing capacity. A total of 66 cases from 2011-2014 were reviewed.
Results:
In 55% (36 of 66) of cases, the capacity-specific discussion consisted of only global judgments of patients' capacity, even in patients with psychotic disorders. Further, 32% (21 of 66) of cases included evidentiary statements regarding capacity-specific abilities; only 5 cases (8%) mentioned all 4 abilities. Physicians frequently stated that psychosis or depression did or did not affect capacity but provided little explanation regarding their judgments. Physicians in 8 cases (12%) disagreed about capacity; even when no explanation was given for the disagreement, the review committees generally accepted the judgment of the physician performing EAS. In one case, the physicians noted that not all capacity-specific abilities were intact but deemed the patient capable.
Conclusion:
Case summaries of psychiatric EAS in the Netherlands do not show that a high threshold of capacity is required for granting EAS. Although this may reflect limitations in documentation, it likely represents a practice that reflects the normative position of the review committees.
Importance: Euthanasia or assisted suicide (EAS) of psychiatric patients is increasing in some jurisdictions such as Belgium and the Netherlands. However, little is known about the practice, and it remains controversial.
Objectives: To describe the characteristics of patients receiving EAS for psychiatric conditions and how the practice is regulated in the Netherlands.
Design, Setting, and Participants: This investigation reviewed psychiatric EAS case summaries made available online by the Dutch regional euthanasia review committees as of June 1, 2015. Two senior psychiatrists used directed content analysis to review and code the reports. In total, 66 cases from 2011 to 2014 were reviewed.
Main Outcomes and Measures: Clinical and social characteristics of patients, physician review process of the patients’ requests, and the euthanasia review committees’ assessments of the physicians’ actions.
Results: Of the 66 cases reviewed, 70% (n = 46) were women. In total, 32% (n = 21) were 70 years or older, 44% (n = 29) were 50 to 70 years old, and 24% (n = 16) were 30 to 50 years old. Most had chronic, severe conditions, with histories of attempted suicides and psychiatric hospitalizations. Most had personality disorders and were described as socially isolated or lonely. Depressive disorders were the primary psychiatric issue in 55% (n = 36) of cases. Other conditions represented were psychotic, posttraumatic stress or anxiety, somatoform, neurocognitive, and eating disorders, as well as prolonged grief and autism. Comorbidities with functional impairments were common. Forty-one percent (n = 27) of physicians performing EAS were psychiatrists. Twenty-seven percent (n = 18) of patients received the procedure from physicians new to them, 14 of whom were physicians from the End-of-Life Clinic, a mobile euthanasia clinic. Consultation with other physicians was extensive, but 11% (n = 7) of cases had no independent psychiatric input, and 24% (n = 16) of cases involved disagreement among consultants. The euthanasia review committees found that one case failed to meet legal due care criteria.
Conclusions and Relevance: Persons receiving EAS for psychiatric disorders in the Netherlands are mostly women and of diverse ages, with complex and chronic psychiatric, medical, and psychosocial histories. The granting of their EAS requests appears to involve considerable physician judgment, usually involving multiple physicians who do not always agree (sometimes without independent psychiatric input), but the euthanasia review committees generally defer to the judgments of the physicians performing the EAS.
Background
In Switzerland assisted suicide is legal if no self-interest is involved.AimsTo compare the strength and direction of associations with sociodemographic factors between assisted and unassisted suicides.Method
We calculated rates and used Cox and logistic regression models in a longitudinal study of the Swiss population.ResultsAnalyses were based on 5 004 403 people, 1301 assisted and 5708 unassisted suicides from 2003 to 2008. The rate of unassisted suicides was higher in men than in women, rates of assisted suicides were similar in men and women. Higher education was positively associated with assisted suicide, but negatively with unassisted. Living alone, having no children and no religious affiliation were associated with higher rates of both.Conclusions
Some situations that indicate greater vulnerability such as living alone were associated with both assisted and unassisted suicide. Among the terminally ill, women were more likely to choose assisted suicide, whereas men died more often by unassisted suicide.
Although the relationship between physical pain and suicidal thoughts and behaviors has been explored
in multiple epidemiologic and clinical studies, it is still far from being well understood. Consequently, we
conducted a meta-analysis of studies comparing rates of suicidal thoughts and behaviors in individuals
with and without physical pain.
We searched MEDLINE and PsycINFO (May 2015) for studies comparing rates of current and lifetime
suicidal thoughts and behaviors (death wish, suicide ideation, plan, attempt and death: DW, SI, SP, SA,
SD) in individuals with any type of physical pain (headache, back, neck, chest, musculoskeletal,
abdominal and pelvic pains, arthritis, fibromyalgia, medically unexplained pain, and other not specified
pain) versus those without it. Data were analyzed with Cochrane Collaboration Review Manager Software
(RevMan, version 5.3). We assessed the methodological quality of the studies with the STROBE
statement.
Of the 31 included studies, three focused on lifetime DW, twelve focused on current SI (six lifetime), six
focused on current SP (two lifetime), nine focused on current SA (11 lifetime) and eight on SD. Individuals
with physical pain were more likely to report lifetime DW (p = 0.0005), both current and lifetime SI
(both p < 0.00001), SP (current: p = 0.0008; lifetime: p < 0.00001), and SA (current: p < 0.0001; lifetime:
p < 0.00001). Moreover, they were more likely to report SD (p = 0.02). In all analyses, the between study
heterogeneity was high. Moreover, the presence of publication bias has been detected in the main
outcomes.
Physical pain is a consistent risk factor for suicidal thoughts and behaviors. Further research is required
to investigate the specific impact of: 1) chronic versus acute pain, 2) different types of pain (e.g.,
medically unexplained pain), and 3) risk factors for suicide in chronic pain patients.
Suicide is a complex public health problem of global importance. Suicidal behaviour differs between sexes, age groups, geographic regions, and sociopolitical settings, and variably associates with different risk factors, suggesting aetiological heterogeneity. Although there is no effective algorithm to predict suicide in clinical practice, improved recognition and understanding of clinical, psychological, sociological, and biological factors might help the detection of high-risk individuals and assist in treatment selection. Psychotherapeutic, pharmacological, or neuromodulatory treatments of mental disorders can often prevent suicidal behaviour; additionally, regular follow-up of people who attempt suicide by mental health services is key to prevent future suicidal behaviour.
Right to Die NL, an organization in the Netherlands that advocates for the option of euthanasia, founded the End-of-Life Clinic in 2012 to provide euthanasia or physician-assisted suicide for patients who meet all legal requirements but whose regular physicians rejected their request. Many patients whose requests are rejected have less common situations, such as a psychiatric or psychological condition, dementia, or being tired of living.
To study outcomes of requests for euthanasia or physician-assisted suicide received by the clinic and factors associated with granting or rejecting requests.
Analysis of application forms and registration files from March 1, 2012, to March 1, 2013, the clinic's first year of operation, for 645 patients who applied to the clinic with a request for euthanasia or physician-assisted suicide and whose cases were concluded during the study period.
A request could be granted, rejected, or withdrawn or the patient could have died before a final decision was reached. We analyzed bivariate and multivariate associations with medical conditions, type of suffering, and sociodemographic variables.
Of the 645 requests made by patients, 162 requests (25.1%) were granted, 300 requests (46.5%) were refused, 124 patients (19.2%) died before the request could be assessed, and 59 patients (9.1%) withdrew their requests. Patients with a somatic condition (113 of 344 [32.8%]) or with cognitive decline (21 of 56 [37.5%]) had the highest percentage of granted requests. Patients with a psychological condition had the smallest percentage of granted requests. Six (5.0%) of 121 requests from patients with a psychological condition were granted, as were 11 (27.5%) of 40 requests from patients who were tired of living.
Physicians in the Netherlands have more reservations about less common reasons that patients request euthanasia and physician-assisted suicide, such as psychological conditions and being tired of living, than the medical staff working for the End-of-Life Clinic. The physicians and nurses employed by the clinic, however, often confirmed the assessment of the physician who previously cared for the patient; they rejected nearly half of the requests for euthanasia and physician-assisted suicide, possibly because the legal due care criteria had not been met.
Concerns about suicide risk in people with dementia have been increasing in recent years along with a discourse about rational suicide and assisted suicide.
A systematic narrative literature review of suicidal behavior and assisted suicide in persons with dementia.
Most studies that have examined the spectrum of suicidal ideation, attempted suicide and suicide in dementia have methodological limitations but the overall suicide risk does not appear to be increased. When suicidal behavior does occur, common themes include the presence of psychiatric comorbidity, mainly depression; occurrence early in the dementia course with preserved insight and capacity; and an increased risk in younger people. The emerging discourse on rational and assisted suicide has been spurred by early and pre-symptomatic diagnosis and poses a number of ethical challenges for clinicians including the role of proxy decision-makers.
Although dementia might not confer a significant overall risk for suicidal behavior, clinicians still need to consider the potential for suicide in vulnerable individuals particularly early in the dementia course.
Background
Assisted death and dementia is a controversial topic that, in recent years, has been subject to considerable clinical, ethical and political debate.Objective
This paper reviews the international literature on attitudes towards assisted dying in dementia and considers the factors associated with these.DesignA systematic literature search was conducted in Cumulative Index to Nursing and Allied Health Literature, Excerpta Medica Database, PsychINFO and Web of Science between 1992 and August 2013. Electronic and hand searches identified 118 potential relevant studies. Eighteen studies met the full inclusion criteria and were screened using a quality assessment tool.ResultsHealth professionals hold more restrictive views towards assisted dying, which appear less affected by their cultural background, than the public, patients and carers. However, opinions within each population vary according to dementia severity and issues of capacity, as well as differing according to factors such as age, ethnicity, gender and religion of those surveyed. There also appears to be a trend towards more accepting attitudes over time.Conclusions
Sociodemographic factors can influence attitudes towards assisted dying. The impact of these, however, may also differ according to the population surveyed. The findings from this review can contribute to current debates and inform clinical practice and future research in this area. Copyright © 2014 John Wiley & Sons, Ltd.
The objective of this study was to examine the interest of non-terminally ill hospitalized elderly patients in euthanasia and physician assisted suicide (PAS) and to determine the stability of these interests over time. Patients age 60 or older (n=158), including both a depressed sample and non-depressed control sample, underwent a structured interview evaluating their interest in euthanasia and PAS in the event of a series of hypothetical outcome scenarios. Substantial proportions of subjects (varying from 13.3%–42% depending on the scenario) expressed hypothetical acceptance of euthanasia and PAS. After six months a subset of patients changed their minds about euthanasia and PAS (8% - 26% depending on the scenario), most often in the direction of initial acceptance to later rejection. Patients depressed in the hospital and interested in PAS for the outcome of their current (non-terminal) condition were significantly more likely express unstable opinions, with most rejecting it six months later. Other correlations of instability, in specific scenarios, included being male, experiencing higher baseline suffering, poorer subjective health and lower instrumental support. Because euthanasia and PAS actions are irreversible, findings of instability have important implications both clinically and for design of PAS legislation.
Experiences of social rejection, exclusion or loss are generally considered to be some of the most 'painful' experiences that we endure. Indeed, many of us go to great lengths to avoid situations that may engender these experiences (such as public speaking). Why is it that these negative social experiences have such a profound effect on our emotional well-being? Emerging evidence suggests that experiences of social pain--the painful feelings associated with social disconnection--rely on some of the same neurobiological substrates that underlie experiences of physical pain. Understanding the ways in which physical and social pain overlap may provide new insights into the surprising relationship between these two types of experiences.