End of life decision-making, euthanasia, and physician assisted suicide in persons with neuropsychiatric conditions

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Abstract

This project involves both empirical and normative analyses, initially focusing on a specific subset of practices in some European settings. In the past year, we have conducted the following projects. 1. We conducted a directed-content analysis of all psychiatric EAS cases involving personality and related disorders published by the Dutch regional euthanasia review committees (N=74, from 2011 to October 2017). We found that most patients were women (76%, n=52), often with long, complex clinical histories: 62% had physical comorbidities, 97% had at least 1 and 70% had 2 or more psychiatric comorbidities. They often had a history of suicide attempts (47%), selfharming behavior (27%) and trauma (36%). In 46%, a previous EAS request had been refused. Past psychiatric treatments varied: e.g., hospitalization and psychotherapy were not tried in 27% and 28% respectively. In 50%, the physician managing their EAS were new to them, a third (36%) did not have a treating psychiatrist at the time of EAS request, and most physicians performing EAS were non-psychiatrists (70%) relying on cross-sectional psychiatric evaluations focusing on EAS eligibility, not treatment. Physicians evaluating such patients appear to be especially emotionally affected compared to when personality disorders are not present. We concluded that the EAS evaluation of persons with personality disorders may be challenging and emotionally complex for their evaluators who are often nonpsychiatrists. These factors could influence the interpretation of EAS requirements of irremediability, raising issues that merit further discussion and research. 2. We are conducting a systematic review of reasons for and against psychiatric EAS. This is the first review review of its kind, and we anticipate completion during the next fiscal year. 3. We have completed an analysis of the relationship between gender and psychiatric EAS, and the ethical implications of overrepresentation of women in psychiatric EAS. The MS is under review. 4. We conducted an analysis of 75 cases of EAS in persons with dementia. We found that patients who make advance requests (AR) and concurrent requests (CR) for EAS differ in age, duration of illness, and past experiences. AR-EAS cases were complicated by ambiguous directives, patients being unaware of the EAS procedure, and physicians having difficulty assessing unbearable suffering. Both the physicians and the review committees deemed some quite impaired CR-EAS patients as competent by appealing to patients previous statements. We conclude that problems discussed in the literature about AR-EAS are indeed present in practice and the competence assessment model used in EAS for dementia does not seem be a functional capacity model; both findings will likely engender further ethical discussion about EAS in persons with dementia. Our manuscript has been accepted at the American Journal of Geriatric Psychiatry. Furthermore, our previous work on EAS and dementia, an extended case analysis, was published. 5. We wrote an overview and analysis of the most common argument used in the literature in favor of psychiatric EAS. This argument uses 'parity' or non-discrimination as a basis to expand EAS in jurisdictions that already have some form of end of life EAS. We point out the structure and the limits of this form of argumentation. This MS will be published as an overview commentary in an issue of Am J of Bioethics.