Suicide prevention efforts have increased in recent decades, along with rates of suicide in the United States. Findings reported by the Centers for Disease Control and Prevention show a 24% increase in suicides between 1999 and 2014 among males and females of all age groups.1 Concurrently, there has been expanding legalization of physician-assisted death (PAD) for mentally competent adults with terminal illness and a prognosis of ≤6 months to live. Maine is the most recent state to pass such legislation, becoming the ninth jurisdiction to allow the practice in addition to the District of Columbia, New Jersey, Vermont, Oregon, Washington, Hawaii, Colorado, California, and Montana.2,3

Although New Jersey’s law took effect on August 1, 2019, a state judge signed a temporary restraining order blocking the practice until further consideration, based on a lawsuit filed by a physician who argued that “being required to transfer medical records under the law is ‘not only a violation of the rights to practice medicine without breaching the fiduciary duties owing to those patients…but also violations of their First Amendment rights under the United States Constitution to freely practice their religions in which human life is sacred and must not be taken.’ “4

This scenario is reflective of the broader, ongoing debate about the ethics of PAD and whether, and how, physicians should be involved in the process.5 The American Medical Association and the American College of Physicians have essentially expressed opposition to the practice, whereas the American Association of Hospice and Palliative Medicine takes a position of “studied neutrality” on the topic.6 The American Psychiatric Association (APA) opposes the practice for non-terminally ill patients.7

Relevant to the mental health realm specifically, patients must sometimes undergo evaluation to determine their mental competence to opt for PAD, and this may be viewed as contradictory to clinicians’ typical goal and efforts to prevent suicide.6 However, even mental health clinicians who are not directly involved in this process may encounter patients who are on the path to PAD, highlighting the importance of clinician awareness and competence regarding this topic.

The manner in which psychiatrists interact with “decisionally capable patients with advanced medical illness who wish to end their own lives” in states where PAD has been legalized may be “influenced by contradictory and even incompatible ethical, psychological, social, cultural, and professional biases,” Joel Yager, MD, professor in the Department of Psychiatry at the University of Colorado School of Medicine, Denver, and colleagues wrote in a review published in May 2018 in the Journal of Clinical Psychiatry.6

Dr Yager’s article focuses on the role of the psychiatrist when working with patients who desire assisted death, not as prescribers of lethal medications but in the context of assessing competency or working with these individuals in a supportive role. Although there may be conflict “between patients’ autonomous preferences regarding their wish to die and psychiatrists’ usual approaches to suicide prevention…. harms might result if suicide prevention becomes the only focus of treatment plans for these patients.”6

In response to Dr Yager and colleagues, a letter by Mark S. Komrad, MD, DFAPA, FACP, a physician on the faculty of psychiatry at Johns Hopkins, Baltimore, Maryland, and colleagues expressed opposition to the practice of PAD in general, asserting that it is inherently unethical and contrary to the tenets of Hippocratic medicine.8 Among other concerns, Dr Komrad has written elsewhere about the potential for a slippery slope from PAD for terminal illness to an ever-expanding range of conditions and circumstances.9 In the Netherlands, for example, some patients with apparently untreatable psychiatric illnesses are now eligible for PAD, and the Dutch government has proposed legislation that would legalize assisted suicide for older adults who may be otherwise healthy but feel as if they have “completed life” and may be dealing with issues such as loneliness, loss of independence, and reduced mobility.10

Another criticism of PAD is that it is based on the assumption that death is the only means of escape from extreme suffering. “This is not consistent with state-of-the-art palliative care, which includes a number of techniques, including…’terminal sedation,’ in which consciousness is suppressed to the point where suffering is not experienced…and many other measures [that] are quite effective at relieving suffering in a dignified and compassionate manner,” wrote Dr Komrad in a submission to the New Zealand Parliamentary Committee examining euthanasia and assisted suicide.9

For these and other reasons, Dr Komrad and coauthors believe it is also unethical for psychiatrists to perform competency assessments in this context.8 Instead, they propose that the role of the psychiatrist, in settings in which PAD is legal, should be “limited to (1) determining if the patient is at immediate risk of self-harm, in which case emergency procedures could be initiated, and (2) alleviating acute suffering, such as panic attacks or extreme emotional distress, using appropriate psychiatric interventions. We also envision the possibility that a connection with a psychiatrist may help the patient work through existential and psychosocial issues that may underlie the wish for death or assisted suicide,” they added.8

Although some patients with terminal illnesses may benefit from palliative and hospice care, there are “limits in the ability of even excellent palliative care to mitigate all patient concerns,” noted Yager et al.6 “Faced with individuals determined to die, clinicians are pushed to think outside their usual comfort zones and boundaries.”

Psychiatry Advisor explored the topic in interviews with Dr Yager and Kamalika Roy, MBBS, MD, an assistant professor of psychiatry at Oregon Health and Science University in Portland.11

Psychiatry Advisor: What is the role of psychiatrists in the process of PAD, and should it even be called “assisted suicide”?

Dr Yager: These days the preferred terms seem to be Medical Aid (or Medical Assistance) in Dying (MAID). Currently, the formal role of the psychiatrist in places where MAID is legal is to serve as a consultant to examine the patient when the attending physicians have concerns or doubts regarding the patient’s competence to request MAID. The psychiatrist is called on to make a determination about the patient’s decisional capacity. Beyond that, psychiatrists can be called on to provide psychological support for patients, families, and even health providers.

Dr Roy: Regarding the terminology, physician-assisted suicide (PAS) and PAD are used interchangeably to refer to this entity. One can argue that PAS is more appropriate, as the person is requesting to end their own life. The other side of the argument emphasizes that the process of assistance should be the focus, and that process takes away the essence of “suicide” from the term. Both of these terms are very different from euthanasia, which is not legal in this country, in which a physician can actively engage in the process of ending one’s life. 

At this time, in the United States, psychiatric consultation is not mandatory before a physician can approve a patient’s request for PAS. Oregon was the first state to have PAS on their legislation, and it probably has the biggest database of approved cases. From that database, it is evident that less than 10% of the approved cases were seen by a psychiatrist during the process. 

Psychiatrists can play 2 types of role in the process of PAS. They can treat any symptoms of mental illness or subclinical symptoms of depression or anxiety. Here I would like to mention that PAS is not legally available in this country exclusively for the reason of “terminal” mental illness. This provision or lack of it is a contrast to the availability of PAS for mental illness diagnoses in many European countries. However, the patients that are requesting PAS for their nonpsychiatric terminal disease often might have psychiatric symptoms of depression and anxiety. A psychiatrist can effectively evaluate such symptoms.

The other role psychiatrist can very effectively play is to evaluate these patients for their capacity to consent for a life-ending medication. (PAS is done through ingesting such medications.) Any physician who is [familiar with] their patient should be able to assess their capacity to consent; however, psychiatrists might be better equipped to administer this tool. Especially the consultation-liaison psychiatrists are extensively trained in the nuances of capacity evaluation. However, as capacity is an attributed construct, incapacity needs to be identified to make that referral to psychiatry in relevant cases. 

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Psychiatry Advisor: What are some of the main points of controversy surrounding this role?

Dr Yager: Because MAID is currently legal in only 9 states and the District of Columbia, controversy obviously exists as to the entire enterprise of medical assistance in dying. On one hand, some health professionals, medical societies, and jurisdictions believe it’s unethical for physicians, including psychiatrists, to participate in these end-of-life activities. At the other extreme, for example, in the Netherlands and Belgium, physicians (including psychiatrists) may prescribe for patients who self-administer lethal medications, not only for terminally ill patients who request such assistance but even for some carefully vetted patients with severe, chronic psychiatric conditions that are unresponsive to treatment.

Dr Roy: There was a recent debate among 2 schools of psychiatrists about the potential role of psychiatrists in PAS. The group in support highlighted the above the 2 points I mentioned in the earlier question. The most important concern was a potential underrecognition of incapacity in the requesting person when the request is fulfilled by a nonpsychiatric physician, as they might not have extensive training in the area of capacity evaluation and, even with training, might not have a good understanding of the nuances involved. It is a routine process to consult a psychiatrist when a patient refuses even a nonlifesaving form of treatment, as this is a psychiatrist’s area of expertise. The same or even higher threshold should be used in requests for PAS, as the event is irreversible.

There is also an interesting trend of individuals asking for a prescription for PAS medications but never using them. The reason for this change in status has not been researched. Ambivalence, resolution of anxiety (about illness), and discussion with family and friends could be some potential reasons for such change in status. These areas can be effectively explored with a psychiatric consultation ahead of time. 

The school that debates against making psychiatric consultation mandatory for this purpose argues that the onus cannot be placed on the psychiatrist in the context of capacity evaluation, as a psychiatrist would not be the primary physician for these patients, and probably would see these patients only a limited number of times. Some psychiatrists from Oregon also argued that the mandatory nature of psychiatric consultation might undermine the fundamental rights of self-preservation or autonomy for these patients. 

Psychiatry Advisor: What would you recommend to clinicians who want to further explore this topic?

Dr Yager: Many resources are available. The online PDF of a recent article in JAMA, “Building a Better Death, One Conversation at a Time” contains…a number of contemporary resources.12

Dr Roy: I would definitely recommend reading and learning about the evolution of PAS/PAD and euthanasia, the process, the legislation (in the specific state where the psychiatrist practices and other states), the cases (hearings and case reports) that led to such legislation, the case series that were published from the European states on this topic, and the legal implications of such cases in the past. 

For psychiatrists, it will also be very useful to understand and practice the subtle complexities of capacity evaluation from ethical, moral, and legal perspectives besides the clinical perspective, which most of us are very comfortable with. There are many reports, presentations, and published papers on the topic of capacity evaluation. One such presentation was done by my team, in a debate form, in the APA annual meeting in 2018. 

Other resources include: 

· Appelbaum P. Physician-assisted death in psychiatry. World Psychiatry. 2018;17(2):145-146.

· Jones R, Simpson A. Medical assistance in dying: challenges for psychiatry. Front Psychiatry. 2018;9:678.

· Bourgeois JA, Mariano MT, Wilkins JM, Brendel RW, Kaplan L, Ganzini L. Physician-assisted death psychiatric assessment: a standardized protocol to conform to the California end of life option act. Psychosomatics. 2018;59(5):441-451.

· Kim SYH, Conwell Y, Caine ED. Suicide and physician-assisted death for persons with psychiatric disorders: how much overlap? JAMA Psychiatry. 2018;75(11):1099-1100.

The APA also has a resource document dedicated to physician-assisted suicide.7

Psychiatry Advisor: What are remaining needs in this area?

Dr Yager: Contemporary society, or at least increasingly large segments, [appears] ready to engage in serious conversations about end-of-life issues. Not only secular people but clergy, such as Bishop Desmond Tutu of South Africa, have increasingly endorsed compassionate attitudes and practices (“death with dignity”) regarding end-of-life care for the terminally ill.

Many television programs, films, and magazine articles have focused on the way in which terminally ill patients and others opt to take matters into their own hands, as well as the roles that families, their communities, and their health providers might take in these processes. A great deal of sociological and anthropological research, and research in empirical ethics, looking at how society and cultures evolve attitudes and practices, is called for.

Dr Roy: The most pressing missing information is previous patients’ data pertaining to their mental health. Some states (especially Oregon) have good data sets about the primary diagnosis, the reason for the request, hospice status, demography, etc. However, the patients’ psychiatric symptoms and mental well-being is often not captured in the data sets. This lack of information might be related to the generalized underrecognition and underexpression of a person’s emotional well-being when terminal diagnoses and complex treatment processes are discussed in a busy medical setting.

It is hard to imagine that these patients would not be overwhelmed by their physical distress during meetings with their physicians to discuss their terminal illness and PAS. So, there is a significant chance that, in the discussion about mental well-being, a potential influence of anxiety or an underlying psychiatric disorder may not be disclosed or explored.

Cases in which PAS medications were provided but the patient chose not to use them should be studied in a focused manner to explore potential contributions from anxiety, depression, and ethical, moral, and social variables. 

PAS/PAD should be integrated into formal didactic sessions in psychiatry and nonpsychiatry residency training programs, and an option should be given to rotate with physicians that took part in the process of PAS/PAD for all psychiatry and nonpsychiatry trainees.

References

1. Curtin SC, Warner M, Hedegaard H. Increase in suicide in the United States, 1999–2014. NCHS Data Brief. 2016;(241):1-8.

2. Death With Dignity. Frequently asked questions. https://www.deathwithdignity.org/faqs/. Accessed September 11, 2019.

3. CNN. Physician-assisted suicide fast facts. Updated August 1, 2019. Accessed September 11, 2019.

4. Catalini M. New Jersey’s medically assisted suicide law put on hold. The Philadelphia Tribune. https://www.phillytrib.com/news/state_and_region/new-jersey-s-medically-assisted-suicide-law-put-on-hold/article_80371337-dd0c-5ea7-93a0-85654c38d094.html. August 16, 2019. Accessed September 11, 2019.

5. Rodriguez T. Experts weigh in on ACP position statement on physician-assisted suicide. MedicalBag. https://www.medicalbag.com/home/medicine/experts-weigh-in-on-acp-position-statement-on-physician-assisted-suicide/. October 4, 2017. Accessed September 11, 2019.

6. Yager J, Ganzini L, Nguyen DH, Rapp EK. Working with decisionally capable patients who are determined to end their own lives. J Clin Psychiatry. 2018;79(4):17r11767.

7. American Psychiatric Association. APA resource document on physician-assisted death. 2017.

8. Komrad MS, Pies RW, Hanson AL, Geppert CMA. Assessing competency for physician-assisted suicide is unethical. J Clin Psychiatry. 2018;79(6):18lr12566.

9. Euthanasia Prevention Coalition. Dr Mark Komrad: Submission to New Zealand government committee. March 1, 2018. Accessed September 11, 2019.

10. Bilefsky D, Schuetze CF. Dutch law would allow assisted suicide for healthy older people. New York Times. October 13, 2016. Accessed September 11, 2019.

11. Roy K. Role of psychiatrists in assisted dying: a changing trend. Am J Psych Res. 2016;11(9):5-7.

12. Voelker R. Building a better death, one conversation at a time. JAMA. 2019;322(3):195-197.