End of Life Decisions: A Guide for Psychiatrists

Physician-assisted death entered the Colorado legislative agenda in 2015 but failed to pass. Eighteen other states are considering similar bills, reflecting considerable national momentum. The Colorado Psychiatric Society (CPS) Ethics Committee explored the question, “How should an ethical psychiatrist interact with this law?” What follows is a brief history of physician-assisted death in the United States, a summary of the legislation, and guidance about how to interact with this highly charged topic.

Physician-assisted death entered public awareness in 1987, when Jack Kevorkian, M.D., a pathologist, advertised his physician-assisted suicide services in Detroit newspapers. His Michigan medical license was revoked in 1991. The subject gained some legitimacy in the medical community when Timothy Quill, M.D., a palliative care physician at the University of Rochester, published “Death and Dignity: A Case of Individualized Decision-Making” in which he described giving a prescription for barbiturates to a patient with leukemia who desired to die.

In 1997, Oregon voters passed the Death With Dignity Act (DWDA). As of January 2014, 1,173 people have received DWDA prescriptions in Oregon, and 752 people (64 percent) have died from ingesting those medications. In 2008, voters in the state of Washington passed a similar law. Physician-assisted death was legalized through court rulings in Montana (2009) and New Mexico (2014) and through legislative action in Vermont (2013).

The topic came to Colorado in February 2014, when Charles Selsberg advocated in the Denver Post for the ability to end his life and thus avoid suffering months of helpless indignity from ALS. He ultimately died after 13 agonizing days by refusing food and water. The subject gained further national attention in fall 2014, when Brittany Maynard, a 29-year-old woman with a terminal glioblastoma, intentionally publicized her decision to move from California to Oregon so she could end her life.

Modeled on the Oregon law, the Colorado bill would have allowed patients with terminal illness to request a prescription for life-ending medication from their attending physician. The bill included safeguards: the patient must be an adult residing in Colorado and must make two verbal requests at least 15 days apart; the request must also be made in writing and witnessed by two people; a second consulting physician must confirm the diagnosis and prognosis; and if the attending physician is concerned that mental illness may impair decision making, an assessment must be performed by a psychiatrist or psychologist.

There are several ways in which a psychiatrist may be involved with a patient who wants to access life-ending medication under DWDA. The first of these is contained within the legislation. The bill required that a psychiatrist or psychologist evaluate “whether the individual is capable and not suffering from a psychiatric or psychological disorder that impairs his or her ability to make an informed decision,” if the attending physician requests it. Richard Martinez, M.D., a forensic psychiatrist and ethicist, asserts that we must assess emotional as well as cognitive capacity when evaluating a patient’s decision to end his or her life.

Such a determination is subjective. One psychiatrist may believe that moderately severe depression interferes with capacity for this particular decision, although not for other forms of medical decision making; another might disagree. The evaluation of a patient is not the place to take a political stance. The psychiatrist must be grounded in fundamental psychiatric principles; differentiate between depression and grief; and explore other motivations for seeking a hastened death, such as inadequate treatment of pain.

A patient might ask his or her treating psychiatrist to conduct the end-of-life, decision-making-capacity evaluation. Each case must be considered individually. For patients with chronic psychosis or severe personality disorders, the treating psychiatrist is likely the person in the best position to understand and assess the patient’s capacity to request end-of-life medication. There may be other situations—for example, those with complicated transference and countertransference dynamics—in which performing the evaluation could be harmful to the treatment relationship, and a consulting psychiatrist should do the capacity assessment.

If a psychiatrist, because of personal experience, religious belief, or moral conviction, cannot refrain from injecting his or her own opinion about self-directed death into the therapeutic process, then the psychiatrist should refer the patient to another clinician. In these instances it is important to help patients find the counseling they seek without imposing our own judgments. Responding with “I don’t condone ending one’s life prematurely, so I can’t help you” conveys moral disapproval. Instead, “Let me help you find someone with more expertise on this topic” is neutral and assists the patient without compromising the physician’s personal morality.

Another way a psychiatrist may be professionally involved with end-of-life decisions is in counseling patients who become terminally ill during the course of their treatment or who initiate treatment as a result of the terminal diagnosis. Some of these patients may want to consider ending their life through self-administered medication and may seek the impartial counsel of a psychiatrist to explore their feelings about this emotionally intense decision.

We also may become involved with this issue by counseling a family member whose terminally ill loved one has decided to end his or her life with self-administered medication. Whether counseling a terminally ill individual or a family member, the psychiatrist must maintain a therapeutic stance and remain open to helping the patient explore and understand his or her own feelings and reactions.

Ending one’s life through a lethal dose of medication may be the right thing for a particular patient but is not always the right thing. For a nuanced and very readable discussion of this topic, see Atul Gawande’s Being Mortal (pages 243-249). A more scholarly ethical analysis of the topic is provided by Tom Beauchamp and James Childress in Principles of Biomedical Ethics, Sixth Edition, (pages 177-185). ■