Study examines euthanasia, assisted suicide of patients with psychiatric disorders

The practice of EAS has been around for decades in the Netherlands, although formal legislation was not unacted until 2002. Scott Y.H. Kim, M.D., Ph.D., of the National Institutes of Health, Bethesda, Md., and coauthors describe the characteristics of patients receiving EAS for psychiatric conditions and how the practice is regulated in the Netherlands. Summaries of cases of EAS for psychiatric conditions were made available online by Dutch regional euthanasia review committees. The study authors reviewed 66 cases for 2011 to 2014.

Of the 66 cases, 46 of them were women (70 percent); 32 percent of patients (n=21) were 70 or older; 44 percent (n=29) were 50 to 70 years old; and 24 percent (n=16) were 30 to 50 years old. Among the patients, 52 percent (n=34) had attempted suicide and 80 percent (n=53) had been hospitalized for psychiatric reasons.

Most patients had more than one psychiatric condition and depressive disorders were the primary psychiatric issue in 55 percent (n=36) of cases. Some patients had undergone electroconvulsive therapy for difficult-to-treat depression. However, in the case of one woman in her 70s with no health problems, she and her husband had decided years earlier that they would not live without each other. After he died, she described her life as a "living hell" and "meaningless," although the women reportedly "did not feel depressed at all" and ate, drank, and slept well, according to the study.

About 52 percent (34 of 66) of patients had personality-related problems, although sometimes without a formal diagnosis and more than a majority of patients had at least one coexisting illness, including cancer, cardiac disease, diabetes, stroke and others.

Reports on 37 patients (56 percent) mentioned social isolation and loneliness, including one patient who "indicated that she had a life without love and therefore had no right to exist" and another described as "an utterly lonely man whose life had been a failure."

Some of the patients had a history of EAS refusal. Among them, 21 patients (32 percent) had been refused EAS at some point but physicians later changed their mind about three of them and performed EAS, while the remaining 18 patients had physicians who were new to them perform the EAS. In 14 cases, the new physician was affiliated with a mobile euthanasia practice End-of-Life Clinic.

In 27 cases (41 percent), the physician performing EAS was a psychiatrist but in the rest of the cases it was usually general practitioners. Consultation with other physicians was extensive but in 11 percent (n=7) of cases there was no independent psychiatric input and 24 percent (n=16) of cases involved disagreements among physicians. Euthanasia review committees found only one case failed to meet the criteria for legal due care among all 110 reported psychiatric EAS cases during 2011 to 2014, the study reports.

"The retrospective oversight system in the Netherlands generally defers to the judgments of the physicians who perform and report EAS. Whether the system provides sufficient regulatory oversight remains an open question that will require further study," the study concludes.

Editorial: Physician-Assisted Deaths for Patients with Mental Disorders

"Although the data by Kim and colleagues can serve as indicators of problems with the Dutch system, it would be good to keep their data limitations in mind. Based as they are on reports filed by the physicians most directly involved in these cases, the accuracy of the information reported is unknown. For many variables, data had to be abstracted from narrative summaries translated from another language. The available sample did not reflect all cases involving psychiatric disorders. It is unclear why some reports were either not filed or not made publicly available or how the data might have differed if they were. Finally, because these cases are exclusively drawn from instances in which assisted death took place, we cannot conclude anything about the effectiveness of the screening process in excluding inappropriate cases. At the least, however, these data suggest the desirability of a more thorough examination of the Dutch process where patients with psychiatric disorders are concerned," writes Paul S. Applebaum, M.D., of the New York State Psychiatric Institute, New York.