Euthanasia and assisted suicide in psychiatric patients: A systematic review of the literature

May combine two claims.

Among 150 patients whose request was refused, 18% were depressed and 37% tired of living.

“Finally, among the 150 patients whose request was refused, 18% were depressed and 37% tired of living.”

• cites Jansen-van der Weide et al., 2005 sourcePartly supported

  Table 1 (Characteristics of Patients Who Explicitly Request EAS) lists 150 patients whose requests were refused and reports that 37% gave ‘tired of living’ and 18% gave ‘depressed’ as reasons for requesting EAS. The claim turns the latter into a statement that 18% were depressed; the table separately reports depression as a symptom in 32% of this group. (LLM, conf=0.92)

  Experimental — accuracy not yet measured

May combine two claims.

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).”

• cites Dierickx et al., 2017 sourcePartly supported

  The Results report that women made up the majority of officially reported euthanasia cases in every diagnostic group (58.1%–77.1%). The Discussion says the authors had no information on the number of actual requests, so this paper cannot establish whether women predominated among requests. (LLM, conf=0.91)

  Experimental — accuracy not yet measured
• cites Groenewoud et al., 1997 sourceSupported
• cites Kim et al., 2016 sourceSupported

May combine two claims.

Among 144 patients who withdrew their EAS application, 10% initially requested EAS because of depression and 22% because they were tired of living.

“Moreover, among the 144 patients who withdrew their EAS application, 10% initially requested EAS because of their depression and 22% because they were tired of living.”

• cites Jansen-van der Weide et al., 2005 sourceSupported

May combine two claims.

In a survey of Dutch psychiatrists (552 respondents out of 673), among patients who requested pEAS in the previous two years (n=201, 63% women), the most frequent diagnoses were mood disorder (51%) and personality disorder (64%), or both (48%).

“A first analysis of the data from a survey of Dutch psychiatrists (552 respondents out of 673) indicated that among patients who requested pEAS in the previous two years (n=201, 63% women), the most frequent diagnoses were mood disorder (51%) and personality disorder (64%), or both (48% of patients) (Groenewoud et al., 1997).”

• cites Groenewoud et al., 1997 sourcePartly supported

  Split into 2 atoms — 1 confirmed, 1 partially supported, 0 disputed, 0 misattributed, 0 unverifiable. Expand the claim to see per-atom verdicts.

  Experimental — accuracy not yet measured

May combine two claims.

Physical and psychological suffering increased during years (average annual change +1.8%), while physical suffering only and psychological suffering only decreased (average annual change -1.5% and -0.3% respectively).

“Physical and psychological suffering increased during years (average annual change: +1.8%), while physical suffering only and psychological suffering only decreased (average annual change: -1.5% and -0.3% respectively).”

• cites Dierickx et al., 2016 sourcePartly supported

  Table 2 (shown under Conclusion; page unavailable) reports average annual changes of +1.8% for cases reporting both physical and psychological suffering and −1.5% for physical suffering only. The available passage cuts off before the psychological-suffering-only row, so it does not verify the claimed −0.3% figure. These are changes in the proportions of reported euthanasia cases, not measures of suffering in the wider population. (LLM, conf=0.82)

  Experimental — accuracy not yet measured

May combine two claims.

Patients with only mood disorders were generally older than 60 years of age (65%), whereas the others were generally younger than 60.

“Patients with only mood disorders were generally older than 60 years of age (65%), whereas the others were generally younger than 60.”

• cites Dierickx et al., 2017 sourcePartly supported

  Table 2 (Results) shows that 65.1% of patients with a mood disorder alone were 60 or older. Most patients in the two other psychiatric-disorder groups were under 60 (83.3% and 86.4%), but this does not hold for patients with dementia, only 6.5% of whom were under 60. The claim is supported if “the others” means the other psychiatric-disorder groups, but not if it includes dementia. (LLM, conf=0.85)

  Experimental — accuracy not yet measured

May combine two claims.

Higher education was positively associated with assisted suicide and negatively with unassisted suicide; living alone, not having children and absence of religious affiliation were factors associated with both assisted and unassisted suicide.

“Higher education was positively associated with assisted suicide and negatively with unassisted suicide; living alone, not having children and absence of religious affiliation were factors associated with both assisted and unassisted suicide (Steck et al., 2016).”

• cites Steck et al., 2016 sourceSupported

May combine two claims.

While the unassisted suicide rate was higher in men than women, no difference was found for assisted suicides.

“While the unassisted suicide rate was higher in men than women, no difference was found for assisted suicides.”

• cites Steck et al., 2016 sourceSupported

May combine two claims.

Among pEAS cases reported to the Belgium FCEC in 2002-2013, 117 cases (88 women, 75%) were identified: 71% had only a mood disorder, 10% a mood disorder with another psychiatric disorder, and 19% had other psychiatric disorders.

“Among the pEAS-C reported to the FCEC in the period 2002-2013, 117 cases (88 women, 75%) were identified (Dierickx et al., 2017): 71% had only a mood disorder, 10% a mood disorder with another psychiatric disorder, and 19% had other psychiatric disorders.”

• cites Dierickx et al., 2017 sourceSupported

May combine two claims.

Physicians do not use, and review committees do not require, a high threshold of decision-making capacity for requesting pEAS.

“Contrary to what might be expected, physicians do not use, and the review committees do not require, a high threshold of decision-making capacity for requesting (Doernberg et al., 2016;Tuffrey-Wijne et al., 2018).”

• cites Doernberg et al., 2016 sourceSupported
• cites Tuffrey-Wijne et al., 2018 sourceSupported

May combine two claims.

A patient may experience her/his unbearable suffering as irremediable, but in fact some correlates of suffering, for example economic or resource access issues, could change over time.

“Furthermore, a patient may experience her/his unbearable suffering as irremediable, but in fact some correlates of suffering, for example economic or resource access issues, could change over time (Verhofstadt et al., 2017).”

• cites Verhofstadt et al., 2017 sourcePartly supported

  In Method > Extent of suffering (page unavailable), patients describe their suffering as incurable or without hope of improvement. Method > Findings and Discussion > Main findings identify low income and access to alternative treatment as contributors to suffering. The paper does not say that those economic or access circumstances could change over time, so that part of the claim is unsupported. (LLM, conf=0.86)

  Experimental — accuracy not yet measured

May combine two claims.

The ratio of women to men among pEAS cases corresponds to the sex ratio among suicide attempters and is the opposite of the sex ratio in suicide deaths.

“This ratio corresponds to the sex ratio among suicide attempters and is the opposite of the sex ratio in suicide deaths (Bachmann, 2018;Canetto and Sakinofsky, 1998;Fox et al., 2017) often attributed to men's use of more fatal means.”

• cites Bachmann, 2018 sourceSupported
• cites Canetto and Sakinofsky, 1998 sourceNot checked — no full text of the source
• cites Fox et al., 2017Not matched

  Couldn’t be matched to a paper in Crossref, so it can’t be checked.

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

Four main study designs were represented: pEAS case series (n=13; 54%), surveys on physicians (n=6; 25%), qualitative studies (n=4; 17%), and longitudinal study (n=1; 4%).

“Four main study designs were represented: 1) pEAS case series (n=13; 54%); 2) surveys on physicians' practice of/attitudes towards pEAS (n=6; 25%); 3) qualitative studies (n=4; 17%); and 4) longitudinal study (n=1; 4%).”

May combine two claims.

Analysis of annual reports by the DRERC and the End-of-Life Clinic indicated that the number of pEAS cases is progressively increasing in the Netherlands, although still limited.

“Analysis of the annual reports by the DRERC (from 2002 to 2019) and the End-of-Life Clinic (from 2012 to 2017) indicated that the number of pEAS-C is progressively increasing in the Netherlands, although still limited”

May combine two claims.

Among the 24 selected studies, 13 (54%) were about pEAS in the Netherlands, four (17%) in Belgium, and seven (29%) in Switzerland.

“Among the 24 selected studies, thirteen (54%) were about pEAS in the Netherlands, four (17%) in Belgium, and seven (29%) in Switzerland.”

• Also stated in: § Description of main studies · plain

  “At the end of the selection process (Figure 1), 24 articles were retained (Table 1): thirteen (54%) were about pEAS in the Netherlands, four (17%) in Belgium, and seven (29%) in Switzerland.”

Probably not a substantial claim: may not pass S3 (load-bearing), S4 (based).

The number of psychiatric patients requesting euthanasia or assisted suicide continues to increase.

“The number of psychiatric patients requesting Euthanasia or Assisted Suicide (EAS) continues to increase.”

May combine two claims.

At the end of the evaluation, 48 of the pEAS requests were accepted and 35 patients underwent pEAS.

“At the end of the evaluation, 48 of the pEAS-R were accepted and 35 patients underwent pEAS.”

• cites Thienpont et al., 2015aNot matched

  Couldn’t be matched to a paper in Crossref, so it can’t be checked.

May combine two claims.

In Switzerland, among 3,666 EAS cases, patients with mental illness only were 61 (2.1%) while patients with mental and somatic disorders were 46 (1.6%).

“In a recent analysis of death records , among 3,666 EAS-C, patients with mental illness only were 61 (2.1%) while patients with mental and somatic disorders were 46 (1.6%) (Bartsch et al., 2019).”

• cites Bartsch et al., 2019 sourceNot checked — no full text of the source

May combine two claims.

Considering all 3,666 Swiss EAS cases, psychiatric diagnoses were present in 13.1% of cases; specific diagnoses mentioned were depression (8.8%), other/not further specified (5.8%), psychosis (0.4%) and bipolar disorder (0.3%).

“However, considering all the 3,666 cases, psychiatric diagnoseshence with possible psychiatric comorbidities -were present in 13.1% of cases, and in this case specific diagnoses were mentioned, in particular, depression (8.8%), other/not further specified (5.8%), psychosis (0.4%) and bipolar disorder (0.3%).”

• cites Bartsch et al., 2019 sourceNot checked — no full text of the source

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

All 100 pEAS requesters were considered competent to request pEAS, and were deemed by the authors to be suffering unbearably and irremediably.

“All 100 were considered competent to request pEAS, and were deemed by the authors to be suffering unbearably and irremediably.”

• cites Thienpont et al., 2015aNot matched

  Couldn’t be matched to a paper in Crossref, so it can’t be checked.

May combine two claims.

Ninety of these 100 pEAS requesters had more than one psychiatric diagnosis; the most frequent diagnoses were depression (n=58) and personality disorder (n=50); there was an unusually high number of autism spectrum disorder cases.

“Ninety patients had more than one psychiatric diagnosis, and the most frequent psychiatric diagnoses were depression (n=58) and personality disorder (n=50); however, there was an unusually high number of autism spectrum disorder cases.”

• cites Thienpont et al., 2015aNot matched

  Couldn’t be matched to a paper in Crossref, so it can’t be checked.

May combine two claims.

Concerning pEAS requests, results were similar across different countries, with a majority of women (63-77%), mood disorders (51-58%), personality disorders (50-64%) and medical comorbidity (22-23%).

“Concerning pEAS-R, results were similar across different countries, with a majority of women (63-77%), mood disorders (51-58%), personality disorders (50-64%) and medical comorbidity (22-23%).”

May combine two claims.

In an analysis of 100 consecutively referred pEAS requests in Belgium, 77 were women, with an average age at intake of 46±16 years for men and 47±12 years for women.

“An analysis of 100 consecutively referred pEAS-R (Thienpont et al., 2015a) showed that 77 of these patients were women, with an average age at intake of 46±16 years for men and 47±12 years for women.”

• cites Thienpont et al., 2015aNot matched

  Couldn’t be matched to a paper in Crossref, so it can’t be checked.

May combine two claims.

In a national mortality follow-back study, out of 5,361 deceased patients, 183 (3.4%) had a psychiatric disorder; of them, 11.4% requested pEAS and 4.8% received pEAS.

“Out of the 5,361 deceased patients, 183 (3.4%) had a psychiatric disorder; of them, 11.4% requested pEAS and 4.8% received pEAS.”

• cites Evenblij et al., 2019bNot matched

  Couldn’t be matched to a paper in Crossref, so it can’t be checked.

May combine two claims.

After a pEAS request was denied, the majority of patients were still alive (69%); 16% died by suicide; 3% died of natural causes; 3% died as a result of EAS performed by the End-of-Life Clinic; 1.6% stopped eating and drinking.

“after the request was not granted, the majority of the patients were still alive (69%); they died by suicide (16%); they died of natural causes (3%); they died as a result of EAS performed by the End-of-Life Clinic (3%); they stopped eating and drinking (1.6%).”

• cites Evenblij et al., 2019aNot matched

  Couldn’t be matched to a paper in Crossref, so it can’t be checked.

May combine two claims.

Among End-of-Life Clinic applicants with psychiatric/psychological conditions, EAS requests were not granted in 43.6% and 15.4% died before decision.

“Among them, EAS requests were not granted in 43.6% and 15.4% died before decision.”

• cites Snijdewind et al., 2015 sourceNot checked — no full text of the source

Classified as probably not a substantial claim.

The number of studies on pEAS is still scant.

“the number of studies on this topic is still scant”

May combine two claims.

After requesting pEAS, some psychiatric patients withdrew their requests or were on hold.

“In fact, after requesting pEAS, some psychiatric patients withdrew their requests or were on hold.”

Probably not a substantial claim: may not pass S3 (load-bearing), S4 (based).

Psychiatrists/clinical psychologists may not always be involved in the pEAS evaluation process.

“However, psychiatrists/clinical psychologists may not always be involved in the pEAS evaluation process.”

Probably not a substantial claim: may not pass S3 (load-bearing), S4 (based).

The amount of information in English in international websites of relevance is limited.

“the amount of information in English in international websites of relevance is limited”

Probably not a substantial claim: may not pass S3 (load-bearing), S4 (based).

The rate of cases in which the decision is precipitated by the comorbidity of a psychiatric disorder and a primary somatic problem is much higher.

“the rate of cases in which the decision is precipitated by the comorbidity of a psychiatric disorder and a primary somatic problem is much higher”

May combine two claims.

All case series studies had good/fair ratings, with the exception of one with poor reporting because of the partial description of the sample.

“Assessment of the strength of reporting for the selected studies, according to the study design, indicated that all case series studies had good/fair ratings, with the exception of one with poor reporting because of the partial description of the sample (Bartsch et al., 2019) (Table 2).”

• cites Bartsch et al., 2019 sourceNot checked — no full text of the source

May combine two claims.

The issue of irremediable/irreversible suffering should be considered also in relation to the high percentage of patients who no longer wish to die and/or withdraw their pEAS request, indicating the possible transient nature of unbearable mental suffering and its complexity.

“The issue of irremediable/irreversible suffering should be considered also in relation to the high percentage of patients who no longer wish to die and/or withdraw their pEAS request, indicating the possible transient nature of”

• cites Caceda et al., 2017 sourceNot checked — no full text of the source

May combine two claims.

Unbearable mental suffering may limit the individual capacity of self-determination and control, making it impossible for patients to be eligible for EAS.

“in fact unbearable mental suffering may limit the individual capacity of self-determination and control, making it impossible for patients to be eligible for EAS”

Classified as probably not a substantial claim. May combine two claims.

The sole act of requesting (p)EAS, as well as approval of the request, could trigger a process of change.

“Another interpretation of these data is that the sole act of requesting (p)EAS (as well as the approval of the request) could trigger a process of change.”

Probably not a substantial claim: may not pass S4 (based).

If there is insufficient evidence base to make highly reliable judgments of irremediability, then adding more opinions into the mix is unlikely to improve the accuracy.

“However, it should be noted that if there is insufficient evidence base to make highly reliable judgments of irremediability, then adding more opinions into the mix is unlikely to improve the accuracy.”

May combine two claims.

pEAS may also be a solution to cope with suffering for some patients, while for others pEAS might represent loss of hope, and demoralization.

“Hence, pEAS may also be a solution to cope with suffering for some patients, while for others pEAS might represent loss of hope, and demoralization.”

Probably not a substantial claim: may not pass S3 (load-bearing), S4 (based). The quote only partly states this claim.

The high percentage of patients still alive after a not granted pEAS request and the high rate of pEAS request withdrawals can be seen as a consequence of the fact that death desire is transient in nature.

“The high percentage of patients still alive after a not granted pEAS request (69%) and the high rate of pEAS requests withdrawals (37%) can be seen not only as a consequence of the fact that death desire is transient in nature.”

• AssumptionRests on an assumption: Death desire is transient in nature.

Probably not a substantial claim: may not pass S3 (load-bearing), S4 (based).

Most pEAS patients plausibly suffered from a treatment-resistant mood disorder.

“Most of pEAS patients plausibly suffered from a treatment-resistant mood disorder.”

Probably not a substantial claim: may not pass S3 (load-bearing).

A specific instrument has been proposed to assess the nature and extent of suffering in psychiatric patients.

“Moreover, a specific instrument has been proposed to assess the nature and extent of suffering in psychiatric patients (Verhofstadt et al., 2019a).”

• cites Verhofstadt et al., 2019aNot matched

  Couldn’t be matched to a paper in Crossref, so it can’t be checked.

Classified as probably not a substantial claim.

Four criteria for medical decision-making capacity are widely accepted: the ability to understand the relevant information, the ability to appreciate the disorder and the medical consequences of the situation, the ability to reason about treatment choices, and the ability to communicate a choice.

“Four criteria for medical decision-making capacity are widely accepted: the ability to understand the relevant information, the ability to appreciate the disorder and the medical consequences of the situation, the ability to reason about treatment choices and the ability to communicate a choice (Appelbaum and Grisso, 1988).”

• cites Appelbaum and Grisso, 1988 sourceNot checked — no full text of the source

May combine two claims.

The analysis of the included studies indicates that psychiatric patients who obtained or requested pEAS had frequently a particularly severe symptomatology, with a high rate of psychiatric and physical comorbidities.

“More in general, the analysis of the included studies indicates that -not surprisingly -psychiatric patients who obtained or requested pEAS had frequently a particularly severe symptomatology, with a high rate of psychiatric and physical comorbidities.”

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

There is still no consensus on the definition of resistance, and it is generally considered only as the absence of a pharmacological response.

“However, there is still no consensus on the definition of resistance, and it is generally considered only as the absence of a pharmacological response (i.e., a depressive disorder not responding to one antidepressant or two or more antidepressants from different pharmacological classes at adequate dose and duration (Berlim and Turecki, 2007)).”

• cites Berlim and Turecki, 2007 sourceNot checked — no full text of the source

Probably not a substantial claim: may not pass S3 (load-bearing).

If an evaluation for pEAS has a therapeutic effect in alleviating suffering, then the patient's suffering is not irremediable.

“Furthermore, it should be noted that if an evaluation for pEAS has a therapeutic effect in alleviating suffering, this means that the patient's suffering is not irremediable.”

May combine two claims.

The presence of intense mental suffering in patients with a psychiatric/psychological condition could limit their capacity to foresee feasible alternatives and could induce the wish to die.

“The presence of intense mental suffering in patients with a psychiatric/psychological condition could limit their capacity to foresee feasible alternatives and could induce the wish to die.”

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

Clinicians' counter-transference reactions could represent an over-identification with the patient and/or indicate a low tolerance for situations that are impossible to control.

“Clinicians' counter-transference reactions could represent an over-identification with the patient and/or, similarly to patients, indicate a low tolerance for situations that are impossible to control (Nicolini et al., 2019).”

• cites Nicolini et al., 2019Not matched

  Couldn’t be matched to a paper in Crossref, so it can’t be checked.

Probably not a substantial claim: may not pass S3 (load-bearing), S4 (based). May combine two claims.

In some suicidal patients, the request to die can represent a request for a reason to live, for reassurance of their value, or a paradoxical attempt to regain control over their lives.

“In some suicidal patients, the request to die can represent a request for a reason to live, for reassurance of their value, or a paradoxical attempt to regain control over their lives.”