Four American states, Canada, and four European nations legally permit assisted death, where a physician prescribes or directly administers life-ending drugs. Assisted suicide of psychiatric patients remains controversial: An investigation of such cases in the Netherlands finds 70 percent were women, while more than a quarter received the procedure from physicians new to them, generally doctors working at a mobile euthanasia clinic.

“In the United States, the trend of legalizing physician-assisted death is already accompanied by discussions about broadening the practice beyond individuals with terminal illness,” wrote the researchers from Maastricht and Harvard Universities.

Since 1997, Oregon has allowed assisted suicide. After a Supreme Court ruling in 2006, Washington and Vermont approved the practice, while Montana and New Mexico permit physician-assisted suicide via court rulings. Soon, California will also allow the practice. Worldwide, euthanasia is legal in the Netherlands, Belgium, and Luxembourg, while in Switzerland, assisted suicide is permitted as long as there are no "self-seeking motives" involved. Other countries, including France, contemplate similar laws.

In Belgium and the Netherlands, psychiatric patients have been increasingly seeking euthanasia. For the current study, researchers performed an extensive analysis of publicly available records in order to characterize the patients and describe the process as practiced in the Netherlands.

The Dutch Experience

In 2012, the research team explains, a new organization called the End-of-Life Clinic began to provide euthanasia or assisted suicide to patients whose own physicians had declined to perform the intervention. The clinic consists of physician and nurse teams funded by a euthanasia advocacy organization. A review of their activity was included in the current investigation, which also reviewed psychiatric case summaries from Dutch regional euthanasia review committees. To begin this analysis, two senior psychiatrists reviewed and coded the reports.

They discovered 70 percent of patients were women. Nearly a third were over 70, 44 percent were between the ages of 50 and 70, and about a quarter were 30 to 50. More than half had attempted suicide, while 80 percent had been psychiatrically hospitalized in the past. Many had multiple attempts or admissions.

Depression was the primary psychiatric issue in more than half (55 percent) the cases, though most patients had more than one condition such as psychosis. Post-traumatic stress disorder and other anxiety disorders were the complaints of 28 out of 66 patients. Cognitive impairment was present in 4 patients and this same number of patients struggled with a long-term eating disorder.

Nearly one-third of the patients had been refused assisted suicide at some point. For 18 patients, the physician performing the procedure was new to them. The physician performing assisted suicide was a general practitioner or other doctor for 59 percent of these mentally disordered patients; a psychiatrist performed the service for the rest.

Disagreements among the consulting doctors occurred in nearly a quarter of the cases. One dispute focused on the unbearable suffering criterion, while in half the cases, the physicians argued about a patient's competence to make the decision.
In an accompanying editorial, Psychiatrist Paul S. Applebaum recalls the practice of helping patients to die began with patients suffering from a terminal illness; all were experiencing severe pain and had a limited life span. Application of the criteria for suicide assistance is relatively straightforward for such patients, Applebaum says.

“For psychiatric patients, however, for whom a desire to die is often part of the disorder and whose response to additional treatment is less certain, the competence of their decision and the intractability of their suffering are much more difficult to assess,” he writes. Among the possible consequences of legalizing assisted suicide for people with mental disorders is removal of the pressure to improve psychiatric services, he says.

Source: Kim SYH, DeVries RG, Peteet JR. Euthanasia and Assisted Suicide of Patients With Psychiatric Disorders in the Netherlands 2011 to 2014. JAMA Psychiatry. 2016.