Euthanasia and physician-assisted suicide in patients suffering from psychiatric disorders: a cross-sectional study exploring the experiences of Dutch psychiatrists

Ethical perspectives regarding Euthanasia, including in the context of adult psychiatry: a qualitative interview study among healthcare workers in Belgium

INTRODUCTION

Previous research has explored euthanasia's ethical dimensions, primarily focusing on general practice and, to a lesser extent, psychiatry, mainly from the viewpoints of physicians and nurses. However, a gap exists in understanding the comprehensive value-based perspectives of other professionals involved in both somatic and psychiatric euthanasia. This paper aims to analyze the interplay among legal, medical, and ethical factors to clarify how foundational values shape the ethical discourse surrounding euthanasia in both somatic and psychiatric contexts. It seeks to explore these dynamics among all healthcare professionals and volunteers in Belgium.

METHODS

Semi-structured interviews were conducted with 30 Dutch-speaking healthcare workers who had encountered patients requesting euthanasia for psychiatric conditions, in Belgium, from August 2019 to August 2020. Qualitative thematic analysis was applied to the interview transcripts.

FINDINGS

Participants identified three pivotal values and virtues: religious values, professional values, and fundamental medical values encompassing autonomy, beneficence, and non-maleficence, linked to compassion, quality care, and justice. These values interwove across four tiers: the patient, the patient's inner circle, the medical realm, and society at large. Irrespective of their euthanasia stance, participants generally displayed a blend of ethical values across these tiers. Their euthanasia perspective was primarily shaped by value interpretation, significance allocation to key components, and tier weighting. Explicit mention of varying ethical values, potentially indicating distinct stances in favor of or against euthanasia, was infrequent.

CONCLUSION

The study underscores ethical discourse's central role in navigating euthanasia's intricate landscape. Fostering inclusive dialogue, bridging diverse values, supports informed decision-making, nurturing justice, and empathy. Tailored end-of-life healthcare in psychiatry is essential, acknowledging all involved actors' needs. The study calls for interdisciplinary research to comprehensively grasp euthanasia's multifaceted dimensions, and guiding policy evolution. While contextualized in Belgium, the implications extend to the broader euthanasia discourse, suggesting avenues for further inquiry and cross-cultural exploration.

Medical assistance in dying for mental illness: a complex intervention requiring a correspondingly complex evaluation approach

Medical assistance in dying for mental illness as a sole underlying medical condition (MAiD MI-SUMC) is a controversial and complex policy in terms of psychosocial and ethical medical practice implications. We discuss the status of MAiD MI-SUMC in Canada and argue for the use of the UK Medical Research Council's framework on complex interventions in programme evaluations of MAiD MI-SUMC. It is imperative to carefully and rigorously evaluate the implementation of MAiD MI-SUMC to ensure an understanding of the multiple facets of implementation in contexts permeated by unique social, economic, cultural and historical influences, with a correspondingly diverse array of outcomes. This requires a complexity-informed programme evaluation focused on context-dependent mechanisms and stakeholder experiences, including patients, service providers and other people affected by the policy. It is also important to consider the economic impact on health and social welfare systems. Such evaluations can provide the data needed to guide evidence-informed decision-making that can contribute to safer implementation and refinement of MAiD MI-SUMC.

What medical conditions lead to a request for euthanasia? A rapid scoping review

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.

Searching for relief from suffering: A patient-oriented qualitative study on medical assistance in dying for mental illness as the sole underlying medical condition

Medical assistance in dying (MAiD) was introduced into Canadian legislation in 2016. Mental illness as the sole underlying medical condition (MI-SUMC) is excluded from eligibility; this is expected to change in 2024. Incurability, intolerable suffering, capacity to make healthcare decisions, and suicidality have been publicly debated in connection with mental illness. Few studies have explored the views of persons with mental illness on the introduction and acceptability of MAiD MI-SUMC; this study aimed to fill this gap. Thirty adults, residing in Ontario, Canada, who self-identified as living with mental illness participated. A semi-structured interview including a persona-scenario exercise was designed to discuss participants' views on MAiD MI-SUMC and when it could be acceptable or not. Reflexive thematic analysis was used to inductively analyze data. Codes and themes were developed after extensive familiarization with the dataset. A lived-experience advisory group was engaged throughout the study. We identified six themes: The certainty of suffering; Is there a suffering threshold to be met? The uncertainty of mental illness; My own limits, values, and decisions; MAiD MI-SUMCas acceptable when therapeutic means, and othersupports, have been tried to alleviate long-term suffering; and Between relief and rejection. These themes underline how the participants' lived experience comprised negative impacts caused by long-term mental illness, stigma, and in some cases, socioeconomic factors. The need for therapeutic and non-therapeutic supports was highlighted, along with unresolved tensions about the links between mental illness, capacity, and suicidality. Although not all participants viewed MAiD MI-SUMC as acceptable for mental illness, they autonomously embraced limits, values, and decisions of their own along their search for relief. Identifying individual and contextual elements in each person's experience of illness and suffering is necessary to understand diverse perspectives on MAiD MI-SUMC.

Patients requesting and receiving euthanasia for psychiatric disorders in the Netherlands

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.

Assisted Suicide and Euthanasia in Mental Disorders: Ethical Positions in the Debate between Proportionality, Dignity, and the Right to Die

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.

Characteristics and outcomes of peer consultations for assisted dying request assessments: Cross-sectional survey study among attending physicians

Background

In most jurisdictions where assisted dying practices are legal, attending physicians must consult another practitioner to assess the patient's eligibility. Consequently, in some jurisdictions, they can rely on the expertise of trained assisted dying consultants (trained consultants). However, these peer consultations remain under-researched. We examined the characteristics and outcomes of peer consultations to assess an assisted dying request with trained consultants, and explored how these characteristics influence the performance of assisted dying.

Methods

We conducted a cross-sectional survey in 2019–2020 in Belgium among attending physicians who had consulted a trained consultant for an assisted dying request assessment (N = 904).

Results

The valid response rate was 56% (502/903). The vast majority of attending physicians (92%) who had consulted a trained consultant were general practitioners. In more than half of the consultations (57%), the patient was diagnosed with cancer. In 66%, the patient was aged 70 or older. Reported as the patients' most important reasons to request assisted dying: suffering without prospect of improving in 49% of the consultations, loss of dignity in 11%, pain in 9%, and tiredness of life in 9%. In the vast majority of consultations (85%), the attending physician consulted the trained consultant because of the expertise, and in nearly half of the consultations (46%) because of the independence. In more than nine out of ten consultations (91%), the consultant gave a positive advice: i.e., substantive requirements for assisted dying were met. Eight out of ten consultations were followed by assisted dying. The likelihood of assisted dying was higher in consultations in which loss of dignity, loss of independence in daily living, or general weakness or tiredness were reasons for the request.

Conclusion

Our findings indicate that the peer consultation practice with trained consultants is most often embedded in a primary care setting. Moreover, our study corroborates previous research in that assisted dying is performed relatively less frequently in patients with cancer and more often in patients with general deterioration. Our findings suggest that attending physicians hold peer consultations with trained consultants to endorse their own decision-making and to request additional support.

Persons with mental disorders and assisted dying practices in Spain: An overview

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.

Eutanasia y Psicología. Algunas claves para la intervención en Procesos Adelantados de Muerte

Los países que han optado por regular los Procesos Adelantados de Muerte (PAM) van en aumento en los últimos años. Este tipo de legislaciones implican directamente a los equipos sanitarios.Los psicólogos incluidos en estos equipos están en contacto con estos procesos, por lo que se torna imprescindible dilucidar, mediante la escasa literatura existente, si los PAM presentan variables diferenciales con otros procesos de muerte, que sean necesarias tener en cuenta durante la asistencia psicológica. Esta recopilación de literatura pretende plantear las diferencias que en la actualidad están contrastadas y plantear qué opciones de intervención psicológica están a nuestra disposición para realizar el acompañamiento a estas personas, sus cuidadores y los equipos sanitarios que los asisten.

Investigating the relationship between euthanasia and/or assisted suicide and rates of non-assisted suicide: systematic review

BACKGROUND

Euthanasia and assisted suicide (EAS) are practices that aim to alleviate the suffering of people with life-limiting illnesses, but are controversial. One area of debate is the relationship between EAS and suicide rates in the population, where there have been claims that availability of EAS will reduce the number of self-initiated deaths (EAS and suicide combined). Others claim that legislation for EAS makes it acceptable to end one's own life, a message at variance with that of suicide prevention campaigns.

AIMS

To examine the relationship between the introduction of EAS and rates of non-assisted suicide and self-initiated death.

METHOD

We conducted a systematic review to examine the association between EAS and rates of non-assisted suicide and of self-initiated death. We searched PubMed, Scopus, PsycINFO and Science Direct, until 20 December 2021. Studies that examined EAS and reported data on population-based suicide rates were included.

RESULTS

Six studies met the inclusion criteria; four reported increases in overall rates of self-initiated death and, in some cases, increased non-assisted suicide. This increase in non-assisted suicide was mostly non-significant when sociodemographic factors were controlled for. Studies from Switzerland and Oregon reported elevated rates of self-initiated death among older women, consistent with higher rates of depressive illnesses in this population.

CONCLUSIONS

The findings of this review do not support the hypothesis that introducing EAS reduces rates of non-assisted suicide. The disproportionate impact on older women indicates unmet suicide prevention needs in this population.

Physician assisted-dying in mentally and somatically ill individuals in Switzerland: Protocol for survey-based study

BACKGROUND

Article 115 of the Swiss Penal Code (StGB) permits physician-assisted dying (PAD), provided it is not performed for "selfish reasons," and thus, occupies a special role in international comparison. However, the Swiss federal law does not regulate who exactly is entitled to access PAD, and there is no universal agreement in the concerned professional societies. Additional uncertainty arises when assessing the wish for PAD of a mentally ill person compared to a somatically ill person.

OBJECTIVES

This study aims to contribute to the discussion of PAD among the mentally ill and to provide insight into the current situation in Switzerland.

METHODS

This is a monocentric prospective observational survey-based study. We will conduct an exploratory online/telephone survey about PAD in somatic vs. mental illness in Switzerland. The survey sample will comprise 10,000 Swiss residents of the general population from all three language regions (German, Italian, and French) as well as 10,000 medical professionals working in the seven states ("cantons") of Basel-Stadt, Basel-Landschaft, Aargau, Lucerne, Graubünden, Ticino, and Vaud. Opinions on PAD in mentally and somatically ill patients will be assessed using 48 different case vignettes. Each participant will be randomly assigned a somatic terminal, a somatic non-terminal, and a mental non-terminal case vignette. Furthermore, the attitude toward the ethical guidelines of the Swiss Medical Association of 2004, 2018, and 2022, as well as the stigmatization of mentally ill people will be assessed.

DISCUSSION

Physician-assisted dying in mentally ill persons is a highly relevant yet controversial topic. On the one hand, mentally ill persons must not be discriminated against in their desire for PAD compared to somatically ill persons while at the same time, their vulnerability must be considered. On the other hand, treating physicians must be protected in their ethical integrity and need security when judging PAD requests. Despite its relevance, data on PAD in the mentally ill is sparse. To regulate PAD for the mentally ill, it is therefore important for Switzerland-but also internationally-to gain more insight into the ongoing debate.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov, identifier: NCT05492461.

Holding on or letting go? Patient experiences of control, context, and care in oral esketamine treatment for treatment-resistant depression: A qualitative study

BACKGROUND

Ketamine and its enantiomer esketamine represent promising new treatments for treatment-resistant depression (TRD). Esketamine induces acute, transient psychoactive effects. How patients perceive esketamine treatment, and which conditions facilitate optimal outcomes, remains poorly understood. Understanding patient perspectives on these phenomena is important to identify unmet needs, which can be used to improve (es)ketamine treatments.

AIMS

To explore the perspectives of TRD patients participating in "off label" oral esketamine treatment.

MATERIALS AND METHODS

In-depth interviews were conducted with 17 patients (11 women) after a six-week, twice-weekly esketamine treatment program, and subsequently after six months of at-home use. Interviews explored participants' perspectives, expectations, and experiences with esketamine treatment. Audio interviews were transcribed verbatim and analysed following an Interpretative Phenomenological Analysis (IPA) framework.

RESULTS

Key themes included overwhelming experiences; inadequate preparation; letting go of control; mood states influencing session experiences; presence and emotional support, and supportive settings. Patients' attempts to let go and give into vs. attempts to maintain control over occasionally overwhelming experiences was a central theme. Multiple factors influenced patients' ability to give into the experience and appeared to impact their mood and anxiety about future sessions, including level of preparation and education, physical and emotional support, and setting during the session.

CONCLUSION

Better preparation beforehand, an optimized treatment setting, and emotional and psychological support during (es)ketamine sessions can help patients to "let go" and may lead to better quality of care and outcomes. Recommendations to improve quality of patient care in (es)ketamine treatment are provided, including suggestions for the training of nurses and other support staff.

Feeling Seen, Being Heard: Perspectives of Patients Suffering from Mental Illness on the Possibility of Physician-Assisted Death in the Netherlands

Physician-assisted death (PAD) for patients suffering from a mental illness is allowed in the Netherlands under certain conditions but is a very controversial topic, mainly discussed by ethicists and physicians. The voice of the patient is rarely included in the debate, so we know little about what their views on the topic are. We aim to understand the views of patients with mental illness and wish to die with regard to the possibility of PAD in the Netherlands. The data for this qualitative study were collected through 21 in-depth interviews with Dutch patients who have a wish for PAD as a result of suffering from a mental illness. We identified four themes in relation to the meaning of PAD for the patients suffering from mental illness and wish to die. These themes are (1) Autonomy and self-determination, (2) ending the suffering, (3) recognition, and (4) a dignified end-of-life. The option of PAD for patients suffering from mental illnesses was considered of great importance to the patients who have a wish to die. We highlight the importance of 'recognition' for the situation of the patient, as this could lead to new perspective. We argue that psychiatrists need to reflect on providing this recognition in earlier phases of treatment, taking seriously and discussing a wish for PAD in treatment is beneficial to patients. It provides space for the patient to discuss their wishes and could cause them not wanting to die anymore.

Debating Euthanasia and Physician-Assisted Death in People with Psychiatric Disorders

PURPOSE OF REVIEW

Over the last 30 years, medical assistance in dying (MAiD) including euthanasia (EU) and physician-assisted death (or suicide, PAS) has become the center of a large debate, particularly when these practices have involved people with psychiatric illness, including resistant depression, schizophrenia, personality, or other severe psychiatric disorders. We performed a review utilizing several databases, and by including the most relevant studies in full journal articles investigating the problem of MAiD in patients with psychiatric disorders but not in physical terminal conditions (non-terminal, MAiD-NT).

RECENT FINDINGS

Literature has shown that a small percentage of people with psychiatric disorders died by MAiD-NT in comparison with patients with somatic diseases in terminal clinical conditions (e.g., cancer, AIDS). However, the problem in the field is complex and not solved yet as confirmed by the fact that only a few countries (e.g., the Netherlands, Belgium, Luxemburg) have legalized MAiD-NT for patients with psychiatric disorders, while most have maintained the practices accessible only to people with somatic disease in a terminal phase. Also, how to make objective the criterion of irremediability of a mental disorder; how to balance suicide prevention with assisted suicide; how to avoid the risk of progressively including in requests for MAiD-NT vulnerable segments of the population, such as minors, elderly, or people with dementia, in a productive-oriented society, are some of the critical points to be discussed. The application of MAiD-NT in people with psychiatric disorders should be further explored to prevent end-of-life rights from contradicting the principles of recovery-oriented care.

What About Us? Experiences of Relatives Regarding Physician-Assisted Death for Patients Suffering from Mental Illness: A Qualitative Study

Physician-assisted death (PAD) for patients suffering from mental illness is legally permitted in the Netherlands. Although patients' relatives are not entrusted with a legal role, former research revealed that physicians take into account the patient's social context and their well-being, in deciding whether or not to grant the request. However, these studies focussed on relatives' experiences in the context of PAD concerning patients with somatic illness. To date, nothing is known on their experiences in the context of PAD concerning the mentally ill. We studied the experiences of relatives with regard to a PAD request by patients suffering from mental illness. The data for this study were collected through 12 interviews with relatives of patients who have or had a PAD request because of a mental illness. We show that relatives are ambivalent regarding the patient's request for PAD and the following trajectory. Their ambivalence is characterised by their understanding of the wish to die and at the same time hoping that the patient would make another choice. Respondents' experiences regarding the process of the PAD request varied, from positive ('intimate') to negative ('extremely hard'). Some indicated that they wished to be more involved as they believe the road towards PAD should be a joint trajectory. To leave them out during such an important event is not only painful, but also harmful to the relative as it could potentially complicate their grieving process. Professional support during or after the PAD process was wanted by some, but not by all.

[The right to die and assisted suicide: Review and critical analysis]

OBJECTIVES

In the context of the present re-examination of the French bioethical laws by the National Advisory Ethics Committee ("Comité consultatif national d'éthique": CCNE), a recent survey indicated a request of the public opinion to obtain a medical aid in end of life and a so-called "assisted suicide". This led psychiatrists to re-consider their role and deontological position which usually led them to consider a request for an assistance in suicide as - a priori - a pathological demand, occurring within a suicidal crisis. The present article intends to: 1) describe the laws and practices of countries which allow medically assisted end of life help procedures; 2) clarify the definitions of "assisted suicide", "assistance to suicide" and "euthanasia"; 3) consider available epidemiological data and the roles given to doctors and, more specifically psychiatrists, in these procedures; 4) analyse the rationale behind these demands. These considerations should enable French psychiatrists to clarify their position when facing requests for a medical aid in dying.

METHODS

Four European countries (Switzerland, the Netherlands, Belgium, Luxemburg) and Oregon (the first US state to introduce legislation) were considered, since they accumulated and published a large amount of experiences and data about "assisted suicide" and medical help in dying. In total, 127 articles were selected, mainly from PubMed and Cairn databases, published between 1997 and 2020. These articles deal with legal considerations, epidemiological data, ethical and sociological considerations.

RESULTS

Laws and practices differ notably according to the state/country. In Belgium, the Netherlands and Luxemburg, as in Oregon, the medical help in dying has been de-criminalized, as long as certain legal criteria are met. In Switzerland, where no specific law exists in the penal code, non-governmental associations have benefited from the legal vacuum and organized the practice of "assisted suicide" for "altruistic motives". In the scientific and legal literature, the terms used to describe and define the medical help in dying upon request differ greatly. In France, the National Advisory Ethics Committee defines euthanasia ("euthanasie"), assisted suicide ("suicide assisté") and suicide assistance ("assistance au suicide"). Available epidemiological data, whatever the country considered, indicate that requests for a medical aid in dying are expressed mainly by patients aged over 60 years and suffering from cancer. Psychiatric diseases account for only 1% to 3%. Most often, systematic assessment by a psychiatrist is neither requested nor made, when the demand does not occur during a primary psychiatric illness. In the case of an existing primary psychiatric pathology, a psychiatrist assesses the case against formal legal predefined criteria. This latter practice was only recently introduced, after some feedback and after legal actions had been brought to Court. When the underlying motivations of the request are considered, it appears that, even in the absence of an evolving psychiatric condition, several psychological or psychopathological reasons prevail such as spirituality, attachment style, social isolation, despair, depression… which should greatly benefit psychiatric exploration, investigation and expertise.

CONCLUSION

In some countries, the request for medically assisted help in dying has become a legal and social reality. In France, where the public debate is still open, it should be emphasized that a psychiatric assessment and interview should be systematically provided to any person requesting medical assistance to die or commit suicide. It is the commitment of psychiatrists to understand the implicit demands and unexpressed motives underlying this request which have strong links with the unique life-events and emotional experiences of the person. The psychiatrist has a unique role in the contextualization of such a request.

Request for euthanasia by a psychiatric patient with undetected intellectual disability

In the Netherlands, euthanasia or assisted suicide (EAS) in psychiatric disorders is legal in certain circumstances. Guidelines recommend a second opinion to independently check diagnosis and treatment resistance. A 68-year-old patient, diagnosed with bipolar I disorder, with a request for euthanasia because of tiredness, repeated falls and racing thoughts was seen for such a second opinion. Persisting in her wish, her reluctant family and psychiatrist became convinced of euthanasia. Our disagreement with the diagnosis of bipolar I disorder upset her, but she agreed with discontinuation of psychotropic drugs. Her mobility and tiredness improved, whereafter her request for euthanasia evolved into a death wish due to completed life. Intellectual disability and an attention deficit hyperactivity disorder could explain her struggle in life. This case report shows that extending the procedure regarding EAS with an independent psychiatric evaluation is important. For our patient, this second opinion supported her to find meaning in life.

Euthanasia in adults with psychiatric conditions: A descriptive study of the experiences of Belgian psychiatrists

To investigate the experience of psychiatrists who completed assessment procedures of euthanasia requests from adults with psychiatric conditions (APC) over the last 12 months. Between November 2018 and April 2019 a cross-sectional survey was sent to a sample of 753 psychiatrists affiliated with Belgian organisations of psychiatrists to gather detailed information on their latest experience with a completed euthanasia assessment procedure, irrespective of its outcome (i.e. euthanasia being performed or not). Information on 46 unique cases revealed that most APC suffered from comorbid psychiatric and/or somatic disorders, and had received different kinds of treatment for many years prior to their euthanasia request. Existential suffering was the main reason for the request. The entire procedure spanned an average of 14 months, and an average of 13.5 months in the 23 cases that culminated in the performance of euthanasia. In all cases, the entire procedure entailed multidisciplinary consultations, including with family and friends. Psychiatrists reported fewer difficulties in assessing due care criteria related to the APC's self-contemplation - for example, unbearable suffering on top of the due care criteria related to their medical condition; incurability due to lack of reasonable treatment perspectives. In a few cases in which euthanasia was the outcome, not all legal criteria were fulfilled in the reporting physicians' opinions. Both positive and negative experiences of the assessment procedure were reported: for example, reduced suicide risk for the APC; an emotional burden and a feeling of being pressured for the psychiatrist. This study confirms that euthanasia assessment in APC entails a lengthy process with diverse complexities, and psychiatrists require support in more than one respect if the assessments are to be handled adequately. Thorough evaluation of current guidelines is recommended: that is, to what extent the guidelines sufficiently address the complexities around (e.g.) assessing legal criteria or involving relatives. We formulate various avenues for further research to build on this study's insights and to fill remaining knowledge gaps.

Experiences and views of Dutch general practitioners regarding physician-assisted death for patients suffering from severe mental illness: a mixed methods approach

BACKGROUND

In the Netherlands, physician-assisted death (PAD) is allowed under certain conditions. Patients who suffer from mental illnesses are not excluded from this practice. In 2018, general practitioners (GPs) performed 20 out of a total of 67 cases of EAS for psychiatric suffering.

OBJECTIVE

More insight into GPs' experiences and views with regard to PAD in psychiatry.

DESIGN

The data for this study were obtained through a survey amongst 500 randomly selected Dutch GPs and by in-depth interviews with 20 Dutch GPs.

SETTING

A survey study and in-depth interviews.

SUBJECTS

Dutch GPs.

RESULTS

86 out of 101 GPs found it conceivable to perform EAS in case of somatic disease, and 51 out of 104 GPs found it conceivable in the case a patient suffered from a mental illness only. The main reason given for refusing an PAD request was that the criteria of due care were not met. Reasons for supporting psychiatric PAD related to responsibility, self-determination, compassion, fairness, and preventing suicide. Reasons for not supporting psychiatric PAD were related to the scope of medicine, a perceived lack of experience, uncertainties regarding the criteria of due care and life-expectancy.

CONCLUSION

GPs are less likely to perform PAD for suffering from a mental illness, compared to somatic suffering. Some GPs apply an extra criterion of 'life-expectancy' in case of PAD for suffering from a mental illness. Refusing PAD based on a long life expectancy keeps open the possibility of recovery, but may also just prolong the suffering and add to the unbearableness of it.KEY POINTSCurrently, there is no qualitative research on what the views are of general practitioners regarding the subject of physician-assisted death (PAD) for patients suffering from severe mental disorders.General practitioners are less likely to consider a request for physician-assisted death by a patient suffering from a psychiatric disorder, compared to somatic suffering. Reasons for supporting psychiatric PAD related to responsibility, self-determination, compassion, fairness, and preventing suicide.Reasons for not supporting psychiatric PAD were related to the scope of medicine, a perceived lack of experience, uncertainties regarding the criteria of due care and life-expectancy.Significance for the reader: Although allowed in the Netherlands, PAD in case of severe mental suffering remains a controversial topic. We need in-depth information about the actual practice of it to have an informed debate with regard to this subject.

The ongoing discussion on termination of life on request. A review from a German/European perspective

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 POINTSTermination 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.

Euthanasia and assisted suicide in psychiatric patients: A systematic review of the literature

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 searched 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 included 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 warranted as well as the involvement of mental health professionals.

"Nothing Hurts Less Than Being Dead": Psychological Pain in Case Descriptions of Psychiatric Euthanasia and Assisted Suicide from the Netherlands: « Rien ne fait moins mal qu'être mort »: La douleur psychologique dans les descriptions de cas d'euthanasie et de suicide assisté psychiatrique aux Pays-Bas

OBJECTIVES

Euthanasia and assisted suicide (EAS) of individuals with mental disorders is a growing practice in several countries, including the Netherlands. Here, we aimed to identify the most frequent dimensions of and associated factors to psychological pain, which has been associated with suicidality, in individuals undergoing psychiatric EAS.

METHODS

An exploratory retrospective content analysis of the English translation of 66 digital case records of individuals who died by EAS in the Netherlands between 2011 and 2014 was performed. Nine standard psychological pain dimensions (irreversibility, loss of control, emptiness, emotional flooding, freezing, social distancing, narcissistic wounds, confusion, and self-estrangement), illness, and sociodemographic variables were evaluated by 2 independent raters using a premade data abstraction form (Kohen κ > 0.8 in all cases).

RESULTS

The mean number of dimensions was 4.64 ± 1.20 (median = 5), out of 9. The most frequent dimensions were irreversibility, loss of control, emptiness, and emotional flooding, in decreasing order. Past treatment refusal and the mention of social connections in case descriptions were related to the higher number of psychological pain dimensions (4.89 ± 1.24 vs. 4.31 ± 1.07, P = 0.03 and 5.05 ± 1.17 vs. 4.43 ± 1.17, P = 0.03, respectively). Emotional flooding was the only dimension specifically associated with specific psychiatric conditions, namely posttraumatic phenomena and personality disorders.

CONCLUSIONS

Numerous psychological pain dimensions were detected in case descriptions of individuals who underwent EAS before the procedure. Subjective nature of the study precludes definite conclusions but suggest that future studies should explore psychological pain and the role of interventions targeting it in patients requesting EAS.

Medico-legal and bioethical perspectives following the constitutional legitimacy of assisted suicide in Italy

Assisted suicide is the subject of much debate throughout the world. In Italy, on 24 September 2019, the Italian Constitutional Court legitimised assisted suicide under certain conditions: self-determination capacity, irreversible illness and intense physical/psychological suffering of the patient. This historic judgement surely paved the way for an evolution of the Italian legal framework on the matter but also raised some challenging medico-legal and bioethical questions. This study aims at analysing two of the most controversial among them: the inclusion of psychiatric patients among eligible patients for assisted suicide and the position of physicians related to their right to conscientious objection.

The engagement of psychiatrists in the assessment of euthanasia requests from psychiatric patients in Belgium: a survey study

BACKGROUND

Since its legalisation in 2002, the number of times euthanasia has been carried out in response to requests from adults with psychiatric conditions (APC) has continued to increase. However, little is known about why and how psychiatrists become engaged in the assessment of such euthanasia requests.

METHODS

A cross-sectional survey study was conducted between November 2018 and April 2019 of 499 psychiatrists affiliated with the Flemish Psychiatry Association. Chi square/Fisher's exact tests were performed to examine if, and to what extent, psychiatrists' backgrounds relate to their concrete experiences. The answers to the open question regarding motives for (non-) engagement were thematically coded.

RESULTS

Two hundred one psychiatrists participated, a response rate of 40%. During their careers, 80% of those responding have been confronted with at least one euthanasia request from an APC patient and 73% have become involved in the assessment procedure. Their engagement was limited to the roles of: referring physician (in 44% of the psychiatrists), attending physician (30%), legally required 'advising physician' (22%), and physician participating in the actual administration of the lethal drugs (5%). Within the most recent 12 months of practice, 61% of the respondents have been actively engaged in a euthanasia assessment procedure and 9% have refused at least once to be actively engaged due to their own conscientious objections and/or the complexity of the assessment. The main motive for psychiatrists to engage in euthanasia is the patient's fundamental right in Belgian law to ask for euthanasia and the psychiatrist's duty to respect that. The perception that they were sufficiently competent to engage in a euthanasia procedure was greater in psychiatrists who have already had concrete experience in the procedure.

CONCLUSIONS

Although the majority of psychiatrists have been confronted with euthanasia requests from their APC patients, their engagement is often limited to referring the request to a colleague physician for further assessment. More research is needed to identify the determinants of a psychiatrist's engagement in euthanasia for their APC patients and to discover the consequences of their non-, or their restricted or full engagement, on both the psychotherapeutic relationship and the course of the euthanasia request.

Belgian psychiatrists' attitudes towards, and readiness to engage in, euthanasia assessment procedures with adults with psychiatric conditions: a survey

BACKGROUND

Although the Belgian assessment pathway for legal euthanasia requires the engagement of at least one psychiatrist, little is known about psychiatrists' attitudes towards euthanasia for adults with psychiatric conditions (APC). This study aims to gauge psychiatrists' attitudes towards and readiness to engage in euthanasia assessment and/or performance procedures in APC.

METHODS

This cross-sectional survey study was performed between November 2018 and April 2019. The survey was sent to a sample of 499 eligible psychiatrists affiliated to the Flemish Association for Psychiatry, a professional association that aims to unite and represent all psychiatrists working in Flanders, the Dutch-speaking, northern part of Belgium. The Association's members comprise an estimated 80-90% of all psychiatrists active in Flanders. Only psychiatrists working with APC (83% of the association's total membership) were included. Factorial Anova and Chi Square tests were performed to examine if and to what extent psychiatrists' backgrounds were associated with, respectively, their attitudes and their readiness to play a role in euthanasia procedures concerning APC.

RESULTS

One hundred eighty-four psychiatrists completed the questionnaire (response rate 40.2%); 74.5% agree that euthanasia should remain permissible for APC. However, 68.9% question some of the approaches taken by other physicians during the euthanasia assessment and only half consider euthanasia assessment procedures compatible with the psychiatric care relationship. Where active engagement is concerned, an informal referral (68%) or preliminary advisory role (43.8%) is preferred to a formal role as a legally required advising physician (30.3%), let alone as performing physician (< 10%).

CONCLUSION

Although three quarters agree with maintaining the legal option of euthanasia for APC, their readiness to take a formal role in euthanasia procedures appears to be limited. More insight is required into the barriers preventing engagement and what psychiatrists need, be it education or clarification of the legal requirements, to ensure that patients can have their euthanasia requests assessed adequately.

Euthanasia, medically assisted dying or assisted suicide: time for psychiatrists to say no

OBJECTIVE

Euthanasia has been considered unethical for most of the history of medicine. Recently it has been legalised in some countries, including parts of Australasia. We describe the recent history of euthanasia, paying attention to the extension of criteria that impact on the poor, elderly and vulnerable members of society in countries that currently have legalised this. In four of the five countries where euthanasia is legalised, there have been extensions of its criteria, either by revision of legislation or changes in practice.

CONCLUSIONS

We suggest that this dynamic can be halted by international agreements of medical societies to shun involvement in euthanasia, as has been the case with other legal interventions that stigmatise. We may, as we have in the past, need to work collectively to meet this ethical challenge.

Complexities in consultations in case of euthanasia or physician-assisted suicide: a survey among SCEN physicians

BACKGROUND

In the Netherlands, euthanasia or physician-assisted suicide (EAS) is allowed if due care criteria are met. One criterion is consultation of a second independent physician, often SCEN physicians. The public debate about EAS focuses on patients with psychiatric disorders, dementia, and tired of living, as complex cases. What complexities SCEN physicians perceive during consultation is unknown. This study aims to assess the frequency of EAS consultations that are perceived difficult by SCEN physicians, to explore what complexities are perceived by SCEN physicians during consultation, and to assess what characteristics are associated with difficult consultations.

METHODS

Data from 2015 to 2017 from an annual cross-sectional survey among SCEN physicians was used. In 2015, the survey focused on the most difficult consultation that year and in 2016/2017 on the most recent consultation. Frequencies of coded answers to an open-ended question were done to explore what complexities SCEN physicians perceived during their most difficult consultation. Univariable and multivariable logistic regression analyses were used to assess what characteristics were associated with difficult consultations.

RESULTS

21.6% of cases consulted by SCEN physicians is perceived difficult. Complexities that SCEN physicians perceive were mainly in contact with patients (79.7%) and in the assessment of due care criteria (41.0%). Characteristics that were associated with a higher likelihood of a consultation being difficult are the attending physician being less certain to perform the EAS, patients staying in the hospital, main diagnosis heart failure/CVA, and accumulation of age-related health problems/psychiatry/dementia, and the presence of a psychiatric disorder, or psychosocial or existential problems besides the main diagnosis. Characteristics that were associated with a lower likelihood of a consultation being difficult are high patient's age and physical suffering as reason to request EAS.

CONCLUSION

Complexities perceived by SCEN physicians in EAS consultations are not limited to the 'complex' cases present in the current public debate about EAS, e.g. patients with psychiatric disorders, dementia, and tired of living. Attention for these complexities in intervision could indicate if there is a need among SCEN physicians to enhance knowledge and skills in training and to receive specific support in intervision on these complexities.

Physicians' experiences with euthanasia: a cross-sectional survey amongst a random sample of Dutch physicians to explore their concerns, feelings and pressure

Background

Physicians who receive a request for euthanasia or assisted suicide may experience a conflict of duties: the duty to preserve life on the one hand and the duty to relieve suffering on the other hand. Little is known about experiences of physicians with receiving and granting a request for euthanasia or assisted suicide. This study, therefore, aimed to explore the concerns, feelings and pressure experienced by physicians who receive requests for euthanasia or assisted suicide.

Methods

In 2016, a cross-sectional study was conducted. Questionnaires were sent to a random sample of 3000 Dutch physicians. Physicians who had been working in adult patient care in the Netherlands for the last year were included in the sample (n = 2657). Half of the physicians were asked about the most recent case in which they refused a request for euthanasia or assisted suicide, and half about the most recent case in which they granted a request for euthanasia or assisted suicide.

Results

Of the 2657 eligible physicians, 1374 (52%) responded. The most reported reason not to participate was lack of time. Of the respondents, 248 answered questions about a refused euthanasia or assisted suicide request and 245 about a granted EAS request. Concerns about specific aspects of the euthanasia and assisted suicide process, such as the emotional burden of preparing and performing euthanasia or assisted suicide were commonly reported by physicians who refused and who granted a request. Pressure to grant a request was mostly experienced by physicians who refused a request, especially if the patient was ≥80 years, had a life-expectancy of ≥6 months and did not have cancer. The large majority of physicians reported contradictory emotions after having performed euthanasia or assisted suicide.

Conclusions

Society should be aware of the impact of euthanasia and assisted suicide requests on physicians. The tension physicians experience may decrease their willingness to perform euthanasia and assisted suicide. On the other hand, physicians should not be forced to cross their own moral boundaries or be tempted to perform euthanasia and assisted suicide in cases that may not meet the due care criteria.

Public and physicians' support for euthanasia in people suffering from psychiatric disorders: a cross-sectional survey study

Background

Although euthanasia and assisted suicide (EAS) in people with psychiatric disorders is relatively rare, the increasing incidence of EAS requests has given rise to public and political debate. This study aimed to explore support of the public and physicians for euthanasia and assisted suicide in people with psychiatric disorders and examine factors associated with acceptance and conceivability of performing EAS in these patients.

Methods

A survey was distributed amongst a random sample of Dutch 2641 citizens (response 75%) and 3000 physicians (response 52%). Acceptance and conceivability of performing EAS, demographics, health status and professional characteristics were measured. Multivariable logistic regression analyses were performed.

Results

Of the general public 53% were of the opinion that people with psychiatric disorders should be eligible for EAS, 15% was opposed to this, and 32% remained neutral. Higher educational level, Dutch ethnicity, and higher urbanization level were associated with higher acceptability of EAS whilst a religious life stance and good health were associated with lower acceptability. The percentage of physicians who considered performing EAS in people with psychiatric disorders conceivable ranged between 20% amongst medical specialists and 47% amongst general practitioners. Having received EAS requests from psychiatric patients before was associated with considering performing EAS conceivable. Being female, religious, medical specialist, or psychiatrist were associated with lower conceivability. The majority (> 65%) of the psychiatrists were of the opinion that it is possible to establish whether a psychiatric patient’s suffering is unbearable and without prospect and whether the request is well-considered.

Conclusion

The general public shows more support than opposition as to whether patients suffering from a psychiatric disorder should be eligible for EAS, even though one third of the respondents remained neutral. Physicians’ support depends on their specialization; 39% of psychiatrists considered performing EAS in psychiatric patients conceivable. The relatively low conceivability is possibly explained by psychiatric patients often not meeting the eligibility criteria.

Supplementary information

Supplementary information accompanies this paper at 10.1186/s12910-019-0404-8.