Reading of the Week: Euthanasia, Psychiatry, and the Thienpont et al. paper

The Belgian Euthanasia Law (2002) defines euthanasia as the physician’s “act of deliberately ending a patient’s life at the latter’s request,” by administering life-ending drugs.In Europe, psychological suffering stemming from either a somatic or mental disorder is acknowledged as a valid legal basis for euthanasia only in Belgium, the Netherlands and Luxembourg.In the Netherlands and Luxembourg, the term ‘assisted suicide’ is used when the life-ending drugs are taken orally, but in Belgium, the term ‘euthanasia’ is used whether the drugs are received orally or intravenously.

So begins a new paper on euthanasia in Belgium.

The topic is fascinating and it’s also highly relevant in Canada. As you will recall, Carter v. Canada – the Supreme Court ruling made earlier this year – speaks directly to the right to doctor-assisted suicide. (I’ll return to this point in a moment.)

This week’s Reading: “Euthanasia requests, procedures and outcomes for 100 Belgian patients suffering from psychiatric disorders: a retrospective, descriptive study” by Dr. Lieve Thienpont et al., which was just published online at BMJ Open.

Though much has been written about Belgium and euthanasia (a June Reading considered a New Yorker essay on the topic), little data has been analyzed. And that’s what makes the Thienpont et al. paper interesting. A quick summary: in a first-of-it-kind paper, the authors consider 100 psychiatric patients requesting euthanasia – from their diagnosis to their final outcome. It should be noted that the first author is a leading proponent of euthanasia and was actively involved in the care and decision making of these patients.

You can find the paper here:

Dr. Lieve Thienpont

The paper opens with background on the euthanasia law in Belgium. It notes the important legal phrase: euthanasia is allowed for “unbearable and untreatable” conditions.

Thienpont et al. explain:

‘Unbearable’ suffering can be understood as a subjective term. By its nature, the extent to which the suffering is unbearable must be determined from the perspective of the patient himself or herself, and may depend on his or her physical and mental strength and personality. According to the Law, a physician has to come to a level of mutual understanding with the patient about the extent of his or her unendurable suffering.

‘Untreatable’ is a more objective term. According to the guidelines of the Dutch Psychiatric Association (NVvP), any therapeutic option for a particular condition must meet the following three requirements: (1) it must offer a real prospect of improvement, (2) it must be possible to administer adequate treatment within a reasonable period of time and (3) there must be a reasonable balance between the expected treatment results and the burden of treatment consequences for the patient.

“Unbearable and untreatable” clearly encompasses terminal illness – and over 91% of those receiving euthanasia are terminally ill, cancer is the most common diagnosis (77%). But “unbearable and untreatable” also includes people with psychiatric illness. This study is meant to shed light on these patients.

Here’s what they did:

· Essentially, the study authors consider 100 patients requesting euthanasia based on psychological suffering; it is a retrospective study.

· The patients presented to the outpatient clinic between October 2007 and December 2011.

· At the end of 2012, all 100 patients or their practitioners were contacted to establish whether the patients were still alive and, if not, how they had died.

· Demographical and medical information were drawn from patient records.

· Diagnoses were made by the first author, compatible with DSM-IV, as part of her care of these patients. (!)

· To safeguard against inappropriate euthanasia, the clinic follows the law including attempts to alleviate suffering and patient education (referred to as the “four-track” approach).

Here’s what they found:

· The patients included 23 men and 77 women. (!)

· The average age was 46 for men and 47 for women. Most were off work: retired (8), medially unfit for work (73), working or on leave (14). Most lived alone (59). See below for a graphical description of some of the demographics.

· Referrals came from a variety of sources, including psychiatrists (24) and psychotherapists (10).

· In terms of diagnoses, 90 out of 100 had more than one diagnosis. Most suffered from treatment-resistant mood disorder (58, mainly MDD). Personality disorders were seen in half the patients with borderline PD being the most common (27). Other diagnoses: PTSD, schizophrenia (14), eating disorders (10).

· Of the 35 who underwent euthanasia, the average number of counseling sessions was 3.49; the average time between the request and the procedure was 8.66 months (but with a big standard deviation of 9.55 months); the procedure was carried out largely by general practitioners (20); sodium thiopental was the life-ending drug in every case, overwhelmingly administered by IV (31 cases); 30 patients died with family present.

· 6 patients suicide, including 2 of 48 who had had their request approved.

The study authors note:

To the best of our knowledge, this is the first report on a relatively large series of requests for euthanasia based on psychological suffering due to psychiatric disorders.

And though the paper itself is quite neutral – for the most part, it’s a straightforward reporting of patients and outcomes – they close with concern:

A literature review made clear that the concept of ‘unbearable suffering’ has not yet been defined adequately, and that views on this concept are in a state of flux. It is generally accepted that this concept is considered to be subjective, dependent on personal values, and that it must be determined in the first place by the patient. Nevertheless, a psychiatrist should carefully evaluate this in the context of each patient’s psychopathology. Unfortunately, there are no guidelines for the management of euthanasia requests on grounds of mental suffering in Belgium.

A few thoughts:

1. The topic is clearly controversial. Some will consider the Belgian law as a natural extension of liberty; others will view it as part of a slippery slope to state-sanctioned death. The point of this Reading (like all Readings) is to promote discussion and debate, not to endorse a perspective.

2. The first author is very much tied to the work of the clinic. For the most part, the data presented is straightforward (age, working status, etc.). That said, diagnoses weren’t reviewed by independent researchers – a limitation of this study.

3. As I’ve already noted, the topic is clearly relevant. In Carter v. Canada, the Justices of the Supreme Court of Canada ruled that doctor-assisted suicide should be legal if “the person has a grievous and irremediable medical condition… that causes enduring suffering that is intolerable to the individual…” As with the phrase “unbearable and untreatable,” it’s difficult to see how this phrase would exclude those with psychiatric illness.

4. In other words, the larger debate about doctor-assisted suicide has the potential to re-shape psychiatry. (!!)

Reading of the Week. Every week I pick a reading — often an article or a paper — from the world of Psychiatry.

1 Comment

  1. Important paper. Hope all docs read it. Thx for the blog.