Monday, 7 March 2016

Patients with psychiatric disorders who request euthanasia (continued)

Once again the uncomfortable topic of euthanasia and assisted suicide (EAS) is covered on this blog (see here for the last entry) as I discuss the findings reported by Scott Kim and colleagues [1] who reported on the "characteristics of patients receiving EAS for psychiatric conditions and how the practice is regulated in the Netherlands."

Accompanied by some media interest (see here), the Kim paper provides an important overview of the: "Clinical and social characteristics of patients, physician review process of the patients’ requests, and the euthanasia review committees’ assessments of the physicians’ actions" in relation to EAS. As per other countries, certain legal protections are currently in place in the Netherlands when it comes to EAS. Although it is widely assumed that EAS is generally 'linked' to the presentation of physical conditions, either limiting life or causing extreme suffering, there is an increasing number of people turning to such options on the basis of the effects of psychiatric and/or behavioural conditions/labels/disorders. Before you form any snap opinions about the 'rights and wrongs' of this, it is worth bearing in mind the far-reaching effects that psychiatric conditions can have on a person and how this manifests in relation to issues such as suicide rates for example. I say that last sentence whilst making no personal value judgements on the provision of EAS.

Kim et al analysed data on 66 people who received EAS. 66 people who are no longer with us. Most were women (70%) and most had some history of 'psychiatric admission' (80%). About half of the cohort had a history of suicide attempt(s). The types of diagnoses/labels applied to the cohort ranged from depression (35%) to psychotic disorder(s) (8%). As per the last occasion when EAS was discussed on this blog, mention of the autism spectrum is made in 2 of the 66 cases reported on. Also: "In 37 patients (56%), the reports mentioned the patients’ social isolation or loneliness, some with striking descriptions such as the following: “The patient indicated that she had had a life without love and therefore had no right to exist” (case 2012-46), and “The patient was an utterly lonely man whose life had been a failure” (case 2013-21)." I might add that those are words actually included in the case reports analysed.

"The patients’ psychiatric conditions were chronic. In 10 patients (15%), the duration of their illness was described qualitatively (“years,” “decades,” or “longstanding”)." Alongside the psychiatric or behavioural presentation of cases, Kim and colleagues also report on the presence of various comorbid medical conditions. Many (58%) had a least one medical condition. Some (18%) had 3 or more including: "cancer, suspected malignancy, chronic obstructive pulmonary disease, cardiac disease, diabetes mellitus, stroke, prior brain tumor surgery, arthritis, orthopedic problems, chronic fatigue, fibromyalgia, migraines, neurological disorders (stroke, Meniere disease, pain syndrome, Parkinson disease, diaphragm paralysis, or gait disturbance), pancreatitis, medical complications of severe weight loss, vision loss, hearing loss, incontinence, and decubitus or other ulcers."

Various other points are covered in the Kim paper which I would encourage interested readers to peruse. The bottom line is that procedures pertinent to EAS in relation to psychiatric/behavioural manifestations are being utilised and a degree of diversity is present among those seeking such an extreme alternative. That social isolation and loneliness are part of the reasons why EAS is being sought is also an important point to reiterate.

The accompanying editorial on the Kim paper (see here) also makes for an important read. Questions are raised: "Will psychiatrists conclude from the legalization of assisted death that it is acceptable to give up on treating some patients? If so, how far will the influence of that belief spread?" that have some really important repercussions particularly in view of the discussions on a good death (see here).

I do finally want to pass comment specifically on the inclusion of autism or autism spectrum disorder (ASD) in amongst the Kim case files. My view is the same as it was the last time I discussed this topic:

'I know the idea of modifying the presentation of autism is not palatable for everyone, and that society also needs to play a role in how people with autism / autistic people are welcomed and supported. When however a label such as autism potentially leads, or is contributory, to a path whereby a person considers ending their own life by suicide or euthanasia, I find it difficult to say that we should just stand back and watch from the sidelines.'

More research on this uncomfortable topic is of course implied.


[1] Kim SYH. et al. Euthanasia and Assisted Suicide of Patients With Psychiatric Disorders in the Netherlands 2011 to 2014. JAMA Psychiatry. 2016. Feb 10.

---------- Kim, S., De Vries, R., & Peteet, J. (2016). Euthanasia and Assisted Suicide of Patients With Psychiatric Disorders in the Netherlands 2011 to 2014 JAMA Psychiatry DOI: 10.1001/jamapsychiatry.2015.2887