Ask the Expert: Exploring the Clinician's Concern About Physician-Assisted Suicide
A patient I have been treating in psychotherapy receives a diagnosis of ovarian cancer. She requests that I agree to aid her with physician-assisted suicide. Is this unusual? How should I respond to her?
We do not have reliable data about how often psychotherapy patients raise the issue of assisted suicide. Oncologists and those working in critical care settings report that many patients or their families bring up the subject (1). Oregon is not the only state where the topic is discussed, nor is it the only state where patients are aided in ending their lives by health care professionals. This “request” should be viewed as would be any communication in psychotherapy, i.e., it has manifest meaning(s) and unconscious meaning(s). The exploration of this communication is an important endeavor (2). A “Yes” or a “No” closes off the opportunity to understand the patient's concerns. Engaging the patient in understanding what she is requesting and why she is requesting it creates the forum for the patient to achieve a deeper self-understanding. There are several areas to consider as you and patient discuss her request.
1.
Is the patient actually suicidal? Is her request an enactment of self-destructive impulses and the wish that you kill her? Although this might be the first thought on many therapists' minds, it is not a likely possibility. Of course, the issue needs to be explored, but once it is clear that the patient is not asking to commit suicide right now, it should not close off the discussion of her request. This request may take the form of a psychiatric consultation to assess suicidal ideation when the patient is in the hospital (see Case Report).
2.
Before discussing ending her life, I would want to engage the patient in a discussion of her understanding of her diagnosis, the proposed treatment, and her prognosis. Ovarian cancer is a serious medical illness, associated with a high mortality rate. That does not mean she will die of her cancer. Many other issues should be explored. Even if she believes her prognosis to be poor, that does not mean her death is imminent. Cancer is frightening to most people who may react to the diagnosis with the feeling that all treatment is futile. Some physicians, in a misguided effort to tell all, may dump the truth on a patient instead of discussing the seriousness of the illness and the outcome. “The 5-year survival, even with aggressive treatment, is 5%,” means that most people with the illness die. The statistic might be accurate, but it takes away all hope. “This is a serious illness and it can be fatal, but I intend to do everything that can be done to give you the best chance of beating it,” is not a lie but does not take away all hope.
a.
More controversial is whether you should speak with her other physicians. Her perception of what she has been told may differ from what her oncologist thinks she was told. She may have heard nothing past the word “cancer” and concluded that death was an inevitable outcome. Knowing what the treatment plans are, the chemotherapeutic agents to be used, etc., aids in helping the woman cope with the illness. Exploring the patient's fantasies regarding your conversations with her other physicians is a part of this process. There are many positive and negative ways a patient could experience her psychiatrist talking with her other physicians. A few possibilities are the following: feeling infantilized as if she were the sick child whose parents are discussing her but not including her in the discussion; believing that you will obtain a magical cure that her other physicians would not have offered without your intervention; blaming you for not protecting her adequately if there are side effects from treatment or treatment failures.
3.
Is this an attempt to gain control over a situation in which the patient feels helpless? Knowing she could die when she chooses may return her sense of control without having to go through with the act. As noted by Friedrich Nietzsche, “It is always consoling to think of suicide: in that way one gets through many a bad night.” Early in the course of the illness having control can be a protection against demoralization, fragmentation of the self, and nonadherence with treatment. Exploring why she is asking for assistance in dying now is a crucial part of the therapy. Many patients who ask about assisted suicide need the commitment that you will not abandon them and allow them to suffer alone. The promise to make sure her suffering will be maximally treated is much more powerful than a prescription for a lethal dose of medication.
4.
For some people the idea of their death is traumatic. Although the thought of one's death might be unpleasant or saddening, it is not traumatic for most people. One way patients may attempt to control the experience of this trauma is to hasten death. “I cannot even think about this, it is too painful” might be a comment a patient would make who experiences the idea of her death as a trauma.
5.
Who in the patient's social matrix has had a diagnosis of and been treated for cancer? To what extent do these experiences color her view of the cancer? Does she expect to die because significant others in her life have died of cancer? Did she witness suffering from pain and debilitation that was inadequately addressed, and thus she expects this is what will to happen to her? If so, the request to die to escape an otherwise painful death may make perfect sense.
6.
Her experience with other medical illness may never have been discussed in the therapy beyond her report of having been ill or having been in the hospital. What illnesses has she experienced? What have interactions with physicians been like? Was she ill as a child, or ever hospitalized? Serious medical illness and hospitalization can be extremely frightening for a child. Although she recovered and might not see how her early experience is germane, the current illness experience may evoke early memories of helplessness that are intolerable to her as an adult. Older patients who had surgery as children may have been held down on the operating room table and given ether cone anesthesia, struggling as they lost consciousness. Would not it be worth knowing if this is the memory fueling the patient's anxieties about her current illness and treatment?
7.
When patients are no longer able to come to the office for therapy, home/hospital visits and telephone sessions are part of fulfilling the promise to not abandon the patient. A time may come in the course of the illness that her suffering can no longer be adequately addressed. This requires frank discussions with the patient, her family, and her other physicians. Death is not bad or a failure, it is part of life. When life contains unreasonable suffering, alleviating that suffering is of paramount importance. Is assisted suicide the only way to address her suffering?
a.
The Supreme Court did not affirm a constitutional right to assisted suicide. Comments on that decision indicate that palliative care was a strong suggestion by the Court (3). George Annas notes, “Doctors who provide palliative care with the primary intention of relieving pain and suffering, and with the patient's consent, are strongly encouraged to continue to do so by the Court. Indeed, at least five members of the Court seem to think there is something akin to a ‘right not to suffer,’ at least when death is imminent. Their concurring opinions can be read as a warning to the states not to adopt restrictive statutes that prohibit or inhibit physicians from doing everything in their medical power to prevent suffering” (3)
b.
A discussion of palliative care including what will and what will not be done is a crucial part of compassionate treatment. Aggressive treatment of pain, including terminal sedation, has a risk of resulting in the patient's demise, but it is not killing the patient (4). Knowing she will be cared for, she will not be forced to suffer, she can ask for increased sedation without fear of being denied, and she will not die alone are potent therapeutic components for patients with terminal illnesses. Freud considered the possibility that the pain from his cancer would reach a point of being intolerable. On September 21, 1939, he told his physician Max Schur, “Lieber Schur, Sie erinnern sich wohl an unser erstes Gespräch. Sie haben mir damals versprochen mich nicht im Stiche zu lassen wenn es so weit ist. Das ist jetzt nur noch Quälerei und hat keinen Sinn mehr” (My dear Schur, you certainly remember our first talk. You promised me then not to forsake me when my time comes. Now it is nothing but torture and makes no sense anymore) (5).
8.
Requesting her physician's aid in suicide may be an expression of rage. The rage is often conscious but will not be expressed until the therapist inquires about the patient's anger. The rage can be self-directed and the cancer seen as punishment for forbidden acts, thoughts, and desires. The wish to die may be a wish to punish others by refusing to undertake treatment. The request that her psychiatrist help her die may be a test to see if you care if she is alive. “Do you love me?” is really the question. Agreeing to aid the patient in dying is telling her she is not lovable enough to want to keep her alive.
9.
The request from a patient that you aid in physician-assisted suicide is a complex metacommunication. Research on requests for physician-assisted suicide indicates three main themes identified by patients and families: 1) an openness to discuss physician-assisted suicide; 2) clinician expertise in dealing with the dying process; and 3) the physician's maintenance of clinician-patient relationship even when there is disagreement about assisted suicide (6). Such a request must always be treated with integrity, compassion, and respect. The patient who has made this request has opened up an important segment of her therapy. It is hoped that we are able to honor the request in the appropriate manner.
CASE REPORT
An emergency consultation was requested for an 85-year-old woman who told a nurse she did not think she wanted to “go on this way.” The consultation request was to “assess suicide risk.” The patient had metastatic cancer from an unknown primary tumor. The psychiatrist met with her and reported that she was not suicidal. The patient was a retired social worker and used connections to colleagues to request a consultation from a psychoanalyst. Numerous telephone calls from her colleagues resulted in a psychoanalytically trained consultation-liaison psychiatrist going to see the patient. Over the next several days, the patient spoke about her life in detail, much of which involved abandonment by important people. At the end of approximately 45 minutes she would suggest that they end for the day. She was in considerable pain much of the time and short of breath from metastases to her lungs. At the end of the week the consultant asked the patient why it was important for her to see a psychoanalyst at this time. She responded that she was terrified that she would suffer untreated pain, quoting statistics on the percentage of patients with cancer who do not receive adequate analgesia in the final weeks of life. Looking directly into the psychiatrist's eyes she said, “I knew an analyst would understand my fears and not allow me to suffer.” The psychiatrist responded that her fears were realistic in a general way but that her physician, someone she had only met during this hospitalization, was someone who would not allow her to suffer. He paged the physician who agreed to come to talk with them. The patient voiced her concerns, resulting in an angry response from the physician, who felt he was being accused without her knowing him. He made it clear that he would guide his treatment of her pain by her level of comfort and that they would together decide how much pain, or sedation, she would tolerate. Without prompting he told her he would take care of her until she died. After he left the patient said to the psychiatrist, “See I told you, an analyst would understand this.” Over the next 2 weeks the patient required increasing doses of narcotic analgesics to manage her pain, resulting in sedation for most of each day, until she passed away.
References
1.
Meier DE, Emmons C, Wallenstein S, Quill T, Morrison RS, Cassel CK: A national survey of physician-assisted suicide and euthanasia in the United States. N Engl J Med 1998; 338: 1193– 1201
2.
Muskin PR: The request to die: role for a psychodynamic perspective on physician-assisted suicide. JAMA 1998; 279: 323– 328
3.
Annas GJ: The bell tolls for a constitutional right to physician-assisted suicide. N Engl J Med 1997; 337: 1098– 1103
4.
Quill TE, Dresser R, Brock DW: The rule of double effect: a critique of its role in end-of-life decision making. N Engl J Med 1997; 337: 1768– 1771
5.
Schur M: Freud: Living and Dying. New York, International Universities Press, 1972
6.
Back AL, Starks H, Hsu CP, Gordon JR, Bharucha A, Pearlman RA: Clinician-patient interactions about requests for physician-assisted suicide: a patient and family view. Arch Intern Med 2002; 162: 1257– 1265
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Published online: 1 October 2007
Published in print: Fall 2007
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Philip R. Muskin, M.D., Professor of Clinical Psychiatry, Columbia University Chief of Service: Consultation-Liaison Psychiatry, New York-Presbyterian Hospital/Columbia University Medical Center. Faculty Psychoanalyst, Columbia University Psychoanalytic Center for Research and Training.
Speakers Bureau: AstraZeneca, Bristol-Myers, Forest, Lilly, Wyeth.
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