Opening Assisted Dying to Psychiatric Patients a Bad Idea?

Pam Harrison

June 29, 2016

Extending Canada's new legislation on assisted dying to include psychiatric patients will lead to early and unnecessary deaths, experts say.

"A policy for access to assisted dying by nonterminally ill patients with psychiatric conditions will put many vulnerable and stigmatized people at risk," write Scott Kim, MD, PhD, National Institutes of Health, Bethesda, Maryland, and Tudo Lemmens, LLM, DCL, University of Toronto Faculty of Law and the Dalla Lana School of Public Health, Ontario, Canada.

"We believe there is a serious gap between the idealized basis upon which assisted dying for patients with psychiatric conditions is advocated and the reality of its practice, as reflected in evidence from Belgium and the Netherlands," they add.

Their editorial was published online June 21 in the Canadian Medical Association Journal.

Assessing Competence

The Supreme Court of Canada recently ruled that competent, consenting adults who have a "grievous and irremediable" medical condition should have access to medical assistance in dying.

In response to this ruling, the Parliamentary Special Joint Committee on Physician-Assisted Dying posited that a "grievous and irremediable" condition could include a nonterminal medical condition, such as a psychiatric disorder.

However, in the recently passed Bill C-14, the Canadian government did not extend this criterion to psychiatric conditions, confining assisted dying to those patients for whom "natural death has become reasonably foreseeable."

Dr Kim and Dr Lemmens argue that the passing of Bill C-14 may not lay to rest the argument to extend assisted dying to the non–terminally ill, inasmuch as Canada's Liberal government has given notice that it will continue to study the issue.

The editorialists' first concern centers around the question of which mentally ill patients would be considered for assisted dying.

"Arguments for including mental illness as an eligible condition for assisted dying almost always focus on severe depression," Dr Kim and Dr Lemmens note.

But this assumes physicians are skilled at determining whether a psychiatric condition, such as severe depression, is indeed hopeless and that these patients are competent to choose assisted dying.

A recent review of euthanasia cases from the Netherlands and Belgium, where assisted dying for patients with mental illness is legal, brings the whole issue of mental capacity into question.

In the Netherlands, most assessments of a patient's mental capacity are based on a simple global judgment of capacity, "even for patients with disorders that increase the risk of incapacity," Dr Kim and Dr Lemmens point out.

Case studies from Belgium also indicate that physicians do not always agree on a patient's capacity to make exacting decisions and that criteria upon which to judge a patient's mental capacity are not rigorous enough.

"Most people who request [assisted dying]...have characteristics that compromise their ability to cope with adversity, including personality disorders," they write.

Lack of Treatment?

The issue of how to evaluate such patients is difficult to discuss, let alone make decisions on evidence-based guidelines, they note.

A key eligibility criterion in the Canadian legislation is that a patient's suffering be "grievous and irremediable." Dr Kim and Dr Lemmens argue that the term "irremediable" is "inherently vague and unreliable."

"Consider a patient who has been suffering from chronic depression for 20 years, has tried more than a dozen different medications as well as electroconvulsive therapy [ECT] and is currently in a depressive episode that has lasted several years," they write.

According to published guidelines in Belgium and the Netherlands, a patient such as this would likely meet the "irremediable" criterion.

However, a study published in the British Journal of Psychiatry found that more than 60% of a sample of 118 patients with confirmed treatment-resistant depression attained full remission following intensive treatment in a specialized mood disorder center. Almost half of these patients achieved remission lasting for at least 6 months.

Findings such as these support the commentators' contention that most patients with "irremediable" conditions can achieve remission if given high-quality treatment.

They also suggest that the recommendation by the Parliamentary Special Joint Committee on Physician-Assisted Dying that patients whose conditions are considered "irremediable" not be required to accept treatments that they find untenable could be "particularly consequential" for those with psychiatric disorders.

"It is one thing for a patient with a terminal illness to refuse a last-ditch effort, but quite another to set aside a core clinical imperative in psychiatric treatment: compassionately and skillfully helping patients even through periods of sustained suffering during which people often lose the will to live and despair about whether things will get better," the editorialists write.

As evidence, the commentators cite a review of 66 euthanasia cases published by the Dutch in which reviewers found that most patients who were deemed eligible for assisted dying met the criteria after having refused a recommended treatment and that many had not received all possible treatments indicated for their particular condition.

The criteria for deciding whether a given case is medically futile are as vague as those for determing whether a case is irremediable.

Canadian Legislation Too Strict?

Belgium psychiatrist Joris Vandenberghe, MD, PhD, University Psychiatric Center, Katholieke Universiteit Leuven, in Belgium, partly agrees with the commentators but believes that some psychiatric patients should neverthess be considered for assisted death if all interventions have failed and the patient has requested assisted dying repeatedly, deliberately, and competently.

"I think the current approach taken by the Canadian government is a bit too strict because it doesn't fully recognize the enormous impact that psychiatric disorders can have on patients," Dr Vandenberghe told Medscape Medical News.

"Sometimes, even if rarely, we end up in a situation where we might be able to make things somewhat more bearable for patients, but if that's not sufficient for them, then I think it's important to have another option that is not provided now in the current legislation in Canada."

In Dr Vandenberghe's opinion, the uncertainty surrounding the issue of assisted dying arises from the inability of experts to predict how the course of any psychiatric illness might play out.

"In physical illnesses, we have to some extent a certainty that things will progress, that a cancer or a neurodegenerative disease will get worse, so we know how the disease will evolve, even though we may not know the exact time line it will take," Dr Vandenberghe observed.

Not so in psychiatry, he added.

There are hardly any long-term studies of prognoses of patients with psychiatric disorders. The few that are available show there is no single predictor or combination of predictors that accurately indicates individual outcomes.

"[I]f you have no way to predict the course of an illness, it's very difficult to say that the disorder is 'irremediable' and that nothing more can be done," said Dr Vandenberghe.

Need for More Safeguards

In the British Journal of Psychiatry study cited by the commentators, only 65% of patients received ECT.

"In my opinion, you would never consider euthanasia if a patient has not received ECT, because if patients respond to ECT, there is a good chance they will also respond to maintenance ECT, and we need to offer it to patients if they start to relapse," said Dr Vandenberghe.

He also knows from long experience how difficult it is to judge a patient's mental capacity to reach a decision regarding assisted suicide.

"It's not just a matter of being able to reason in a cognitive and coherent way. It's also a matter of the affective symptoms that psychiatric patients have," he said.

"If you are hopeless and you lack all perspective, the way you see reality is distorted by your illness, so some of the symptoms of a psychiatric disorder can blur a patient's decision-making capacity, and this is one of the many difficult aspects in evaluating a patient's capacity to reach a decision regarding euthanasia."

The inherent difficulty of determining prognoses for patients with psychiatric conditions, together with the problem of assessing a patient's ability to competently decide on a course of euthanasia, might be addressed with strict safeguards that are currently not part of euthanasia guidelines, at least not in Belgium, he said.

In a letter to the Canadian Special Joint Committee on Physician-Assisted Dying that was published in February 2016, Dr Vandenberghe shared his 13-year experience with assisted dying in Belgium.

"I am generally not opposed to our euthanasia legislation and agree that patients suffering from psychiatric conditions should not be excluded from our legislation. However, extra precautions are urgently needed.

"I'm not happy with the way things work here [in Belgium]. Sometimes euthanasia is used with insufficient reluctance on the part of the healthcare professionals involved. We're missing opportunities for treatment, and we need more safeguards," said Dr. Vandenberghe.

"So for me, the answer lies in a thorough evaluation of a patient prior to euthanasia. There really is no time pressure in psychiatric disorders, and if you have a multidisciplinary committee involved in the evaluation, you can take care of lot of the concerns we now have about euthanasia in the setting of psychiatric illness."

Dr Kim, Dr Lemmens, and Dr Vandenberghe have disclosed no relevant financial relationships.

CMAJ. Published online June 21, 2016. Full text

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