Death with Dignity Act: screening for mental disorders may be lacking

One in six who received lethal drugs was clinically depressed.

Issue: November 25, 2008

Oregon’s Death with Dignity Act requires that any terminally ill patient requesting medical help to commit suicide must first be declared mentally competent by a physician. However, the results of a recent study suggest that, despite that legal protection, some clinically depressed patients are seeking and receiving lethal prescriptions.

In a recent issue of the BMJ, a team of researchers from the Portland Veterans Affairs Medical Center and the Oregon Health and Science University evaluated the mental state of 58 adults who had either requested aid in dying from a physician or contacted Compassion and Choices of Oregon for information about assisted suicide.

Forty-four of those patients had been diagnosed with terminal cancer and another seven had amyotrophic lateral sclerosis.

Eight participants were depressed according to the hospital anxiety and depression scale and 13 scored positive for anxiety. Eleven patients scored 10 or higher on the 20-point Beck hopelessness scale. A score of 20 on that measurement translates to “very hopeless.” Fifteen patients met study criteria for depression as measured by the American Psychiatric Association Diagnostic and Statistical Manual-IV axis I disorders or by the hospital anxiety and depression scale.

As measured on an 11-point scale, the mean desire to die among depressed patients was 5.7. Seven patients felt that depression had no influence on their desire to die, but six felt that depression did play a role. Only one patient agreed to counseling, though it was offered to all patients diagnosed with depression.

Three of the 18 patients who met study criteria for depression received a prescription for lethal drugs. All died within two months of participating in the study and none had been evaluated by a mental health professional before participating in the study.

A difficult issue

The researchers wrote, “Physicians, hospice professionals, and family members of patients in Oregon who pursue aid in dying generally do not believe that depression influences choices for hastened death.” The researchers wrote that none of those who died of lethal ingestion in Oregon in 2007 were evaluated by a psychiatrist or psychologist, and added that health care professionals frequently miss the signs of depression.

Even when signs of a mental disorder are recognized, Linda K. Ganzini, MD, professor of psychiatry and medicine senior scholar at the Center for Ethics in Health Care, Oregon Health and Science University, said that insisting on psychiatric treatment for these patients may be countertherapeutic. “These people have a strong need to be in control and power struggles with their physician are likely to backfire,” she told HemOnc Today.

In addition, Ganzini said that the issue of physician-assisted suicide is an important one that should be part of the larger health care conversation. “Issues of access and justice in medicine are overwhelming; 58% of voters in the State of Washington just voted for an assisted suicide law. That amount of support indicates some dissatisfaction with how patients understand their options at the end of life and there is something to learn from it,” she said.

“A conversation about physician assisted suicide can be leveraged into conversations about bigger issues. It is true that requests to actually obtain physician assisted suicide are rare, but acknowledging that not everyone has the same needs at the end of life is important.” – by Jason Harris

BMJ. 2008;doi:10.1136/bmj.a1682.

HemOnc Today spoke about physician-assisted suicide with Diane E. Meier, MD, director of the Center to Advance Palliative Care in New York, a professor of geriatrics and internal medicine at the Mount Sinai School of Medicine and the school’s Catherine Gaisman Professor of Medical Ethics. Click here for the full Q&A.

Click here to read perspective about physician-assisted suicide from a HemOncToday.com blogger.