Case Presentation: An ethical dilemma

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Case Presentation An ethical dilemma

• Dr Rosalind Powell
• GPST1 Psychiatry

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Overview of Presentation

• Case presentation
• Suicide and assisted suicide
• Discussion should assisted suicide be legalised
  in the UK?

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Case presentationPresenting complaint

• I was asked to see 61 year old man as part of
  liason duty at KCH
• Expressed suicidal ideation to medical team
• To assess patient for underlying psychiatric
  illness

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History of presenting complaint

• Diagnosed 3 years ago as having metastatic
  prostate cancer on drug trial
• 1 week progressive weakness in legs and unable to
  walk
• Admitted to KCH diagnosed with spinal cord
  compression
• Confided in junior doctor would take own life
  when discharged.

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History of presenting complaint

• Long term supporter of voluntary euthanasia
• 3 years ago decided when time came he may choose
  to end his life
• Considered Zurich
• 6/12 found exit international website promoting
  euthanasia.
• Bought recommended book
• Purchased tablets
• Daughter aware and supportive

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Exit International

• The Peaceful Pill eHandbook (by Dr Philip
  Nitschke Dr Fiona Stewart)  a "video book" that
  sets a new international standard in the
  provision of information detailing how a
  (seriously ill or elderly) person might obtain a
  peaceful and dignified death, at a time and place
  of their choosing.
  www.exitinternational.net

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Past Medical History

• Diagnosed with metastatic prostate cancer 2006
• Had debulking operation and chemotherapy with no
  effect
• Having radiotherapy
• Steroid induced diabetes mellitus
• Restless legs

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Past psychiatric history

• nil

Family History

• nil

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Drug history

• Lansoprazole
• Prednisolone 10mg od
• Tamsulosin
• Diclofenac
• Gliclazide
• Pramipexole (dopamine agonist)
• Abiraterone/placebo drug trial

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Personal History

• Happy childhood, made friends easily
• Attended primary and secondary school gained
  O-levels and A-levels
• Degree and Masters in History
• Immigration officer
• 2 marriages 1st ended amicably, 2 daughters,
  good relationship
• Married Latvian woman recently, applying for
  residency. Unaware of his plans

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Forensic History

• Nil

Social History

• Lives with wife, daughters nearby
• Denied alcohol / illicit drug use

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Mental state exam

• Appearance lying in hospital bed, kempt
• Appropriate eye contact and behaviour
• Restless legs
• Speech normal in tone/volume/rate/quality/fluency
  
• Mood subjectively ok
• objectively euthymic

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Mental state exam

• Risk
• Thoughts of suicide
• Plan in place, chosen method (pills)
• Family members aware (except wife)
• An option
• Sense of control over destiny
• No thoughts for other acts DSH/harm to others

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Mental state exam

• Denied any obsessions/compulsions
• Denied any altered perception
• Denied any thought disorder
• Cognition and orientation good
• Insight - good

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Biological markers depression

• Sleep normal until restless legs
• Appetite good
• Weight loss none recently
• No loss emotional reactivity (able to laugh)
• No early morning wakening
• No anhedonia able to read books
• Good concentration

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Dilemma

• Patient revealed if at home and unable to take
  his tablets, would get daughter to assist him.
• Aware she may face prosecution but thought this
  would be unlikely

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Impression

• Adverse life events
• Diagnosis prostate cancer
• Not improving on drug trial, now unable to walk
• Long-held belief in euthanasia
• At high risk of suicide/ assisted suicide
• No psychiatric diagnosis not depressed
• had capacity to choose method of ending his life

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Plan

• Unable to offer any psychiatric treatment as no
  psychiatric condition
• Advise that daughter could face prosecution if
  assisted him
• Advise should tell wife / have open family
  discussion
• Advise team to contact legal department
• Contact MPS

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MPS advice

• Contacted that day
• Discussed case and admission that patients
  daughter may assist him
• As no crime had yet been committed , nothing more
  I could do.
• Conversation logged for future

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Suicide

• Self destruction as a deliberate act oxford
  concise medical dictionary 1998
• Incidence 1 of all deaths (may be under
  reported)
• Three times higher rate in men than women
• Suicide rates in young men rising
• Highest rates suicide found in the elderly

Psychiatry at a glance second edition C.Katona M.
Robertson 2000
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Suicide Aetiology

• 1. Associated psychiatric disorders
• Major depressive disorder (50)
• Schizophrenia personality disorder
• Alcoholism substance misuse
• 2. Biochemical abnormalities 5HT underactivity
• 3. Sociological factors
• Social disintegration (higher rates in
  unemployment, lower in wartime)
• Isolation from society (living alone,
  divorced/single, moving house)
• For good of society/ altruistic

Psychiatry at a glance second edition C.Katona M.
Robertson 2000
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Risk Factors

• S ex
• A ge
• D epression
• P revious attempts
• E thanol abuse
• R ational thinking loss
• S ocial support lacking
• O rganised plan
• N o pastimes
• S ickness

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Legality of suicide

• Suicide was illegal under English law until the
  passing of the Suicide Act 1961.
• The same act makes it an offence to assist
  suicide.
• Assisted Dying for the Terminally Ill Bill
  blocked in the House of Lords May 2006 Bill
  presented by Lord Joffe with focus on Physician
  Assisted Suicide

http//news.bbc.co.uk/1/hi/health/4763067.stm
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Assisted Dying for the Terminally Ill Bill

• The Joffe Bill would enable an adult who has
  capacity and who is suffering unbearably as a
  result of a terminal illness to receive medical
  assistance to die at his own considered and
  persistent request (House of Lords, 2005). 
• The doctor who agrees to participate in PAS is
  responsible for determining the following  the
  patient has a terminal illness that will cause
  death within six months, the request is voluntary
  (uncoerced), the patient has mental capacity, and
  his or her unbearable suffering (subjectively
  defined by the patient and either mental or
  physical) arises from the terminal illness,
  regardless of whether suffering can be relieved
  or treated.

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Reaction of RCPsych

•  
• We recognise that the proposed Bill has been
  conceived with compassionate intent to help
  individuals who experience intolerable suffering
  under very specific circumstances.
• However, the Royal College of Psychiatrists is
  deeply worried about the possible unintended
  effects of the Assisted Dying for the Terminally
  Ill Bill if it were to be enacted.
• Concerns re. role of doctor, assessment capacity,
  depression and suicide, coercion. Usually work to
  prevent suicide.

• http//www.rcpsych.ac.uk/pressparliament/collegere
  sponses

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Should assisted suicide be legalised?

• Arguments for
• Autonomy just as a person has the right to
  determine the course of their life, a person has
  the right to decide the course of their own dying

Gordijin and Janssens the prevention of
euthanasia through palliative care New
developments in the Netherlands Elsevier Science
2000
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Should assisted suicide be legalised?

• Arguments for
• 2. Relieve suffering
• 3. Dying with dignity article 8 European
  Convention on Human rights right to respect for
  private life
• e.g. Dianne Pretty, Debbie Purdy

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Should assisted suicide be legalised?

• Arguments against
• Slippery slope may end in non-voluntary
  euthanasia
• Difficult to legislate
• Focus will shift away from palliative care
• PAS against Hippocratic oath
• Sanctity of life

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Who has the answers?

• Netherlands
• 1995 2.4 deaths result voluntary euthanasia
• 0.8 deaths result non-voluntary euthanasia
• Termination of life on request and Assisted
  Suicide Act 2002.
• Euthanasia and PAS legalised in specific cases

Voluntary euthanasia under control?J. Med.
Ethics 19992516-21H Jochemsen and J Keown
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Non- Voluntary euthanasia in Netherlands
Slippery slope?

• Neonates
• In 1995 90 neonates were administered a drug for
  intentional termination of life. 1000 neonates
  die before 1st birthday (all causes) 9 of all
  neonatal deaths.1
• Psychiatric patients
• Psychiatrist Dr Chabot helped a depressed
  (physically healthy) 50 year old woman to commit
  suicide. Found in favor by Supreme Court. Later
  reprimanded by medical disciplinary board.
• 4 cases of psychiatric patients assisted suicide
  each year2

1. Voluntary euthanasia under control?J. Med.
Ethics 19992516-21H Jochemsen and J Keown 2.
BMJ 1995310894-895 (8 April) Reprimand for
Dutch doctor who assisted suicide
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U.S.A.

• Death with dignity act 1997 Oregon
• Washington Death with Dignity Act 2008
• Allows terminally ill residents to end their
  lives with prescribed medication
• Patient administers own medication

http//www.oregon.gov/DHS/ph/pas/docs/year11.pdf
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Oregon Death with dignity
http//www.oregon.gov/DHS/ph/pas/docs/year11.pdf
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Oregon Death with dignity

• During 2008, 88 prescriptions for lethal
  medications
• total of 60 DWDA deaths
• corresponds to estimated 19.4 DWDA deaths per
  10,000 total deaths. (0.19)

http//www.oregon.gov/DHS/ph/pas/docs/year11.pdf
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Conclusion

• A difficult case
• PAS and assisted suicide illegal in UK
• Current case in House of Lords
• Multiple arguments for and against assisted
  suicide
• Model in Netherlands may confirm slippery slope
• Emotive area of medicine

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Discussion

• Who is for and who is against assisted suicide?

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Any Questions?