One in four terminally ill patients in the State of Oregon who opt for physician assisted suicide have clinical depression and the Death with Dignity Act may not be adequately protecting them, concludes a study published on bmj.com today.
In 1997, the State of Oregon passed the Death with Dignity Act that allows physician assisted dying for terminally ill patients.
The extent to which potentially treatable psychiatric disorders may influence patients' choices to hasten death is hotly debated. There are several safeguards in the Act to ensure patients are competent to make the decision to end their life. This includes referral to a psychologist or psychiatrist if there is concern that a patient's judgment might be impaired because of mental illness.
However, it is well known that health care professionals often fail to recognise depression among the mentally ill. In 2007, none of the 46 Oregonians who died by lethal ingestion were evaluated by a psychiatrist or a psychologist.
Dr Linda Ganzini and colleagues from Oregon Health and Science University, assessed 58 Oregonians who were terminally ill and had requested physician assisted suicide or contacted an aid in dying organisation, to determine if they had depression or anxiety. The authors used standardised measures including questionnaires and interviews to assess depression and anxiety in the participants.
The researchers found that the current practice of legalised assistance with dying allowed some potentially ineligible (clinically depressed) patients to receive a lethal prescription.
Fifteen of the participants met the criteria for depression and 13 for anxiety. Forty-two patients had died by the end of the study, 18 received a prescription for a lethal medication under the Act and nine died by lethal ingestion. Fifteen who received a lethal prescription did not meet the criteria for depression, three did, and all three died by lethal ingestion within two months of the research interview.
Although the authors acknowledge that most patients who request aid in dying do not have a depressive disorder they point out that "the current practice of Death with Dignity Act may not adequately protect all mentally ill patients" and call for "increased vigilance and systematic examination for depression among patients who may access legalised aid in dying."
In an accompanying editorial, Dr Marije van der Lee from the Helen Dowling Institute in the Netherlands, says that while it is vital to protect vulnerable patients, examining terminally ill patients to determine if depression is impairing their judgement is complex.
She believes that depression does not necessarily impair judgement and says that in the Netherlands what is most important is that the patient makes an informed decision. She concludes: "we should focus on trying to 'protect' patients from becoming depressed in the first place, rather than focus on protecting patients from assisted suicide."
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