A new review of patients in the Netherlands is shedding light on the controversial practice of euthanasia or assisted suicide among patients with psychiatric disorders, as the practice is increasing in certain jurisdictions. The review comes at a time when the Canadian government is crafting new legislation to address the euthanasia in this country.
The review, published Wednesday in the journal JAMA Psychiatry, looked at 66 cases of euthanasia or assisted suicide (EAS) among patients with psychiatric disorders. The cases were from 2011 to 2014.
The new review found that in most of the 66 psychiatric EAS cases, the patients had chronic, severe conditions, with histories of attempted suicides or hospitalizations.
EAS has been practised in the Netherlands for decades, however formal legislation was only enacted in 2002. Although the numbers remain small, psychiatric EAS is becoming more frequent, the review authors note.
The researchers who wrote the review cite a Dutch study from 1997 that estimated the number of psychiatric EAS cases was between two and five. In 2013, there were 42 reported psychiatric EAS cases, the authors say.
The review comes as the Canadian government crafts doctor-assisted death legislation. In January, the Supreme Court of Canada granted the federal government a four-month extension to come up with laws outlining assisted suicide and euthanasia in Canada.
Majority of patients had depressive disorders
The study found that most of the 66 patients had more than one psychiatric condition, and depressive disorders were the primary issue in 55 per cent of those cases.
Other conditions observed in the patients included psychosis (26 per cent), PTSD or anxiety (42 per cent), and cognitive impairment (6 per cent). Eating disorders, as well as prolonged grief and autism were also observed.
The review found that 41 per cent of the patients had a psychiatric history spanning between 11 and 30 years, and in 27 per cent of the patients, the history exceeded 30 years. It also found that 58 per cent of the patients had at least one other illness, including cancer, heart disease or diabetes.
In 56 per cent of the case reports, there was mention of the patients' social isolation or loneliness.
The researchers found the following characteristics among the 66 patients:
• 70 per cent were women;
• 52 per cent had attempted suicide;
• 80 per cent had been hospitalized for psychiatric reasons;
Treatment and refusal
The study noted that patients with difficult-to-treat depression had sought different types of therapy, including electroconvulsive therapy and deep brain stimulation.
However, in one EAS case, a woman in her 70s without health problems had decided, with her husband, that they would not live without each other. After her husband died, she lived a life described as a "living hell" that was "meaningless."
A consultant reported that this woman "did not feel depressed at all. She ate, drank, and slept well. She followed the news and undertook activities."
The review found that 32 per cent of the patients had been refused EAS at some point, but in three cases the physicians later changed their mind and performed EAS. The remaining 18 patients had physicians who were new to them perform EAS.
In 41 per cent of the cases the physician performing EAS was a psychiatrist, but in the rest of the cases it was usually a general practitioner, the review found.
Consultation with other doctors was "extensive," the review found. But in 11 per cent of the cases, there was no independent psychiatric input. In 24 per cent of the cases, there were disagreements among the physicians.
The authors of the review note that the aim of their study was to examine the cases of EAS in psychiatric patients in the Netherlands. “Whether the system provides sufficient regulatory oversight remains an open question that will require further study,” they said.
A separate editorial says the review of the Dutch cases raises "serious concerns."
Dr. Paul Appelbaum, of the New York State Psychiatric Institute, says there are particular concerns that come with the practice of EAS in psychiatric patients.
He notes that, in many such patients, a desire to die is often part of their disorder. As well, their response to treatment is less certain, meaning it's "much more difficult" for doctors to assess patients’ competence to decide to end their lives.
Appelbaum points to many troubling trends observed in the Dutch data, including the finding that 56 per cent of the cases included reports in which "social isolation or loneliness was important enough to be mentioned."
This "evokes the concern that (EAS) served as a substitute for effective psychosocial intervention and support," he said.
He also noted that it was also troubling that, in 12 per cent of cases, the "psychiatrist involved believed that the criteria for EAS were not met, but assisted death took place anyway."
There are several moral implications to consider as well, including the concern that psychiatrists may conclude from the legalization of EAS that it is acceptable to give up on treating some patients, he said.
Appelbaum noted, however, that it is important to keep in mind the limitation of the Dutch data.
In particular, the available sample did not reflect all cases involving psychiatric disorders. As well, the cases only included cases where EAS took place, which does not allow any conclusions to be drawn about the effectiveness of the screening process.