Euthanasia and Assisted Suicide of Patients With Psychiatric Disorders in the Netherlands 2011 to 2014

Earlier studies reported that 71%-79% of psychiatric patients who died through MAiD in the Netherlands had more than 1 psychiatric disorder.

“This finding is in line with those of earlier studies reporting that 71%–79% of psychiatric patients who died through MAiD in the Netherlands had more than 1 psychiatric disorder. 4,17,19”

In these Netherlands and Belgium samples, less than 20% suffer from schizophrenia and less than 10% each from anxiety disorders, trauma sequelae, addictive disorders, bipolar disorders or others.

“Less than 20% suffer from schizophrenia and less than 10% each from anxiety disorders, trauma sequelae, addictive disorders, bipolar disorders or others.”

About half of Belgian patients had made suicide attempts before, including while waiting for approval.

“about half of patients had made suicide attempts before [62, 63], including while waiting for approval [61].”

In the Netherlands, MAiD-NT cases were for patients with mood or personality disorders, mainly women aged between 50 and 70 years.

“for patients with mood or personality disorders, mainly women and aged between 50 and 70 years [62, 65].”

Kim et al. (2016) and Van Veen et al. (2018) showed that depression or anxiety disorders are most common among patients suffering from a psychiatric disorder requesting EAS.

“Kim et al. (2016) and Van Veen et al. (2018) showed that these disorders are most common among patients suffering from a PD requesting EAS.”

Previous studies also found an overrepresentation of females (70% and 77%) among patients who received EAS based on suffering from a psychiatric disorder.

“Previous studies also found an overrepresentation of females (70% and 77%)”

Empirical studies from the Netherlands show that psychiatrists disagree about irremediability in 11% to 20% of PADs due to psychiatric suffering.

“Empirical studies from the Netherlands show that there is disagreement about irremediability between psychiatrists in 11% to 20% of the PADs due to psychiatric suffering.8,51”

In the 2016 study, reasons for treatment refusal were lacking motivation in 29% of all cases, concern about adverse effects or risks of harm in 18%, and doubts about efficacy in 15%.

“Reasons for refusal were lacking motivation in 29% of all cases, concern about adverse effects or risks of harm in 18%, and doubts about efficacy in 15%.”

In samples from the Netherlands and Belgium of patients with psychiatric disorders without dementia receiving assisted suicide or euthanasia, more than half are female.

“Samples from the Netherlands and Belgium show the following picture for patients with psychiatric disorders (without dementia), combined for assisted suicide and euthanasia: more than half of the patients are female”

In these Netherlands and Belgium samples, about half of the patients suffer from depression and the other half from personality disorders.

“about half of them suffer from depression and the other half from personality disorders.”

Comorbidities are common in these Netherlands and Belgium samples of psychiatric patients receiving assisted suicide or euthanasia.

“Comorbidities are common (25-27).”

In the few European countries that provide euthanasia for mental illness, the majority of those requesting it are women and marginalized individuals disproportionately seeking relief from suffering because of marginalization, including unresolved social and economic suffering and loneliness.

“in the few European countries that provide euthanasia for mental illness, the majority of those requesting it are women and marginalized individuals disproportionately seeking relief from suffering, not from their mental illnesses per se, but because of marginalization, including unresolved social and economic suffering and loneliness”

In a 2016 study of 66 case summaries of Dutch patients who received PAD due to psychiatric suffering between 2011 and 2014, 56% of the patients had refused at least 1 treatment, ranging from psychotherapy to medication or ECT.

“More recently, in a 2016 study of 66 case summaries of Dutch patients who received PAD due to psychiatric suffering between 2011 and 2014, it was found that 56% of the patients had refused at least 1 treatment, ranging from psychotherapy to medication or ECT.”

Personality disorders play a common role in treatment refusal.

“It was also reported that personality disorders play a common role in treatment refusal.8”

An earlier study showed that 56% of patients with a psychiatric disorder who received MAiD refused some form of treatment.

“The finding that treatment refusal is a relevant issue is in line with results from an earlier study showing that 56% of patients with a psychiatric disorder who received MAiD refused some form of treatment.19”

Cases of assisted dying in patients with eating disorders have been documented in the United States, the Netherlands, and Belgium.

“cases have been documented in the United States (2), the Netherlands (6–10), and Belgium (11–13).”

In an analysis of 66 patients who received MAiD for mental disorders in the Netherlands between 2011 and 2014, depression was the most common disorder (55%), but most patients also had been diagnosed with one or more additional psychiatric disorders, such as personality disorders, psychotic disorders, post-traumatic stress, anxiety, somatoform/eating disorders, prolonged grief and autism.

“In an analysis of 66 patients who received MAiD for mental disorders in the Netherlands between 2011 and 2014, depression was the most common disorder (55%), but most patients also had also been diagnosed with one or more additional psychiatric disorders, such as personality disorders, psychotic disorders, post-traumatic stress, anxiety, somatoform/eating disorders, prolonged grief and autism.”

The finding that treatment refusal is a relevant issue is in line with results from an earlier study.

“The finding that treatment refusal is a relevant issue is in line with results from an earlier study showing that 56% of patients with a psychiatric disorder who received MAiD refused some form of treatment.19”

A study by Kim et al. reported a somewhat higher prevalence of somatic comorbidity amongst psychiatric patients who received EAS (60%) compared to our findings.

“A study by Kim et al. reported a somewhat higher prevalence of somatic comorbidity amongst psychiatric patients who received EAS (60%) compared to our findings [12].”

The numbers of EAS in psychiatric practice are low and our findings are largely consistent with existing evidence.

“However, the numbers of EAS in psychiatric practice are low and our findings are largely consistent with existing evidence [10–14].”

In most qualitative studies, data collection could not be evaluated because studies were performed using already available data.

“In most of the qualitative studies (Doernberg et al., 2016;Kim et al., 2016;Miller and Kim, 2017) data collection could not be evaluated because studies were performed using already available data (Table 4).”

Women were preponderant in both pEAS cases and pEAS requests.

“Women were preponderant in both pEAS-C and pEAS-R (Dierickx et al., 2017;Groenewoud et al., 1997;Kim et al., 2016;Nicolini et al., 2019;Thienpont et al., 2015a;van Veen et al., 2018).”

It is less likely that the low response rate has compromised the validity of our findings.

“Therefore, it is less likely that the low response rate has compromised the validity of our findings.”

All persons who receive psychiatric PAD have some form of mental illness, and most also have personality disorders, have attempted suicide, and are socially isolated or lonely.

“they all have some form of mental illness; most also have personality disorders, have attempted suicide, and are socially isolated or lonely.5”

Although in theory patient and physician must agree that there is no prospect of improvement, the criterion is now overstretched toward its subjective component, according to psychiatrists interviewed in a Dutch government study.

“While in theory a patient and the physician together must agree that there is “no prospect of improvement,”5 the criterion is now overstretched to emphasize the subjective component, according to psychiatrists interviewed in a Dutch government study.6”

Most patients receiving psychiatric PAD refuse available treatments, such as electroconvulsive therapy or monoamine oxidase inhibitors for depression, yet are still judged to meet the futility criterion.

“This view is consistent with evidence showing that most patients receiving psychiatric PAD refuse available treatments (such as electroconvulsive therapy or monoamine oxidase inhibitors for depression) but are still deemed to meet the futility criterion.5”

Some persons receive psychiatric PAD shortly after a suicide attempt, as in the case of a man who survived a jump from a building with broken thighs and then received PAD during the resulting hospitalization.

“Indeed, some receive PAD shortly after a suicide attempt, like a man who jumped off a building, survived the fall with broken thighs, and then received PAD during the ensuing hospitalization.5”

The time frame 2011 to early 2014 represents the period during which summaries of most psychiatric EAS cases were published.

“Therefore, the time frame covered by the present study represents the period during which the summaries of most psychiatric EAS cases were published.5”

Studies of Dutch casefile summaries (Kim et al. 2011-2014; van Veen et al. 2015-2017) found that most patients who received PAD for psychiatric suffering were diagnosed with multiple psychiatric disorders (71-79%), with common diagnoses including depression (46-74%), personality disorders and personality problems (52-54%), anxiety disorders (11-23%), and PTSD (20-23%).

“Both studies found that most patients were diagnosed with multiple psychiatric disorders (71–79%). Common diagnoses were depression (46–74%), personality disorders and personality problems (52–54%), anxiety disorders (11–23%), and PTSD (20–23%).”

There is disagreement about whether patients who refuse certain treatments can be said to suffer irremediably; a casefile study shows that 56% of Dutch patients who received PAD due to psychiatric suffering did refuse some sort of treatment.

“Thirdly, there is disagreement about whether patients who refuse certain treatments can be said to suffer irremediably. This is not a mere theoretical discussion: a casefile study shows that 56% of Dutch patients who received PAD due to psychiatric suffering did refuse some sort of treatment (11).”

Research shows that many patients requesting PAD suffer from long lasting and complex psychiatric disorders; this chronicity may make it more challenging to assess if the death wish is unduly influenced by the psychiatric disorder.

“First, research shows, that many patients requesting PAD suffer from long lasting and complex psychiatric disorders (10–12). This chronicity, may make it more challenging to assess if the death wish is unduly influenced by the psychiatric disorder (25).”

Studies of Dutch casefile summaries show that all patients who received PAD on the basis of psychiatric suffering were ultimately considered capable of making an informed decision; one study showed that in 8% of cases the doctors involved had differences of opinion about patient decision-making capacity, but in another study no cases of divergent views were found.

“Studies of Dutch casefile summaries show that all patients who received PAD on the basis of psychiatric suffering were ultimately considered capable of making an informed decision (11, 12). One study showed that in 8% of the cases the doctors involved had differences of opinion about patient decision-making capacity, but in another study no cases of divergent views were found.”

In the study by Kim et al., depressive disorders (55%), posttraumatic stress disorder and other anxiety disorders (42%) were prominent, 52% of patients had personality-related problems, and social isolation or loneliness were mentioned in 56% of cases.

“In the study by Kim et al. [10] depressive disorders (55%), posttraumatic stress disorder and other anxiety disorders (42%) were prominent whereas 52% of the patients had personality-related problems, sometimes without a formal PD diagnosis, more so in younger patients. Social isolation or loneliness were mentioned in 56% of the cases.”

The prevalence of PD was higher in patients who were younger.

“The prevalence of PD was higher in patients who were younger.”

Kim and co-workers reviewed the first 66 psychiatric cases of EAS published and found that 52% of these were patients with personality disorders or difficulties.

“Kim and co-workers reviewed the first 66 psychiatric cases of EAS published and found that 52% of these were patients with personality disorders or difficulties [10].”

Case reviews in the Netherlands suggest that in some reported cases of euthanasia on patients suffering from a psychiatric disorder some due care criteria may have been evaluated suboptimally.

“case reviews in the Netherlands suggest that in some of the reported cases of euthanasia on patients suffering from a psychiatric disorder some of the due care criteria may have been evaluated suboptimally (Doernberg, Peteet, & Kim, 2016;Kim, De Vries, & Peteet, 2016).”

Retrospective casefile studies of Dutch PPD who died through MAID show that when experts disagree on a criterion, it often concerns irremediability.

“Retrospective casefile studies of Dutch PPD who died through MAID show if experts disagree on a criterion, it often concerns irremediability.1,4”

Most jurisdictions that permit MAID for PPD demand that the patient is competent and has a medical condition causing irremediable and unbearable suffering.

“For this request to be granted, most of these jurisdictions demand that the patient is competent in her request and has a medical condition that causes irremediable and unbearable suffering.1,2”

Psychiatric MAiD is relatively uncommon, but its use appears to be rising in Belgium and the Netherlands and for a diverse range of disorders and emotional states, including personality disorders and loneliness.

“Although psychiatric MAID is relatively uncommon, its use appears to be rising in Belgium and the Netherlands and for a diverse range of disorders and emotional states, including personality disorders and loneliness (2, 3).”

Reinforcing feelings of hopelessness may not affect the progression of an advanced somatic condition but may profoundly affect the severity of a person's suffering.

“Consequently, although the reinforcement of feelings of hopelessness may not have a direct effect upon the progression of an advanced, somatic condition, it may nevertheless have a profound effect upon the severity of a person's suffering [16].”

Other studies relied on second-hand accounts or case analyses, which probably do not fully capture patients' life histories.

“Other research has been based on second-hand accounts (e.g., psychiatrists) (Verhofstadt et al., 2020a(Verhofstadt et al., , 2020b;;Evenblij et al., 2019;Bolt et al., 2015) or case analyses (Kim et al., 2016), which likely do not fully capture the patients' life history.”

Almost three out of four Belgian psychiatrists question the adequacy of euthanasia assessment in current practice.

“In addition, almost three out of four Belgian psychiatrists question the adequacy of euthanasia assessment in current practice, which is in line with previous Dutch studies that indicate dissension among physicians regarding whether the legal criteria were/can be met.16–18”

In the Netherlands from 2011 to 2014, 110 psychiatric patients received medical aid in dying, of whom only 4 women (3% of the series) had eating disorders with borderline personality disorder.

“For example, in the Netherlands from 2011 to 2014, a total of 110 psychiatric patients were reported to have received MAID, of whom only 4 women (3% of series) had eating disorders with borderline personality disorder [17].”

In facilitating access to EAS for individuals with SE-AN, there is a significant gender skew and psychiatric diagnoses within the use of EAS in some countries (i.e., eating disorders, personality disorders, trauma, autism).

“we must also consider the significant gender skew and psychiatric diagnoses within the use of EAS in some countries (i.e., eating disorders, personality disorders, trauma, autism) [71–73].”