Why adults with psychiatric conditions request euthanasia: A qualitative interview study of life experiences, motives and preventive factors

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

Patients said mental healthcare needed better accessibility and quality, and society needed a profound change in how it perceives and supports these patients.

“patients posited the need for improved accessibility and quality of mental healthcare, as well as a profound change in society's perception of, and support for, these patients.”

• AssumptionRests on an assumption: Patients' retrospective self-reports accurately reflect the life experiences and motives that led to their euthanasia requests.

May combine two claims.

Some patients strongly desired death, others were ambivalent about death ideation, and some requested euthanasia to hear they were ineligible, to restore hope and meaning.

“Whereas some patients longed for death strongly, others expressed ambivalence towards death ideation, and some even requested euthanasia to hear of their ineligibility for it, to restore hope and to (re)find meaning in life.”

• AssumptionRests on an assumption: Patients' retrospective self-reports accurately reflect the life experiences and motives that led to their euthanasia requests.

May combine two claims.

All patients expressed perceived failures to meet others' expectations and societal standards, and consequently felt they were a burden to society.

“In all cases, the patients expressed perceived failures to live up to the expectations of others and the societal standards/norms, and, as a consequence, they feel they are a burden to society.”

• AssumptionRests on an assumption: Patients' retrospective self-reports accurately reflect the life experiences and motives that led to their euthanasia requests.

May combine two claims.

Euthanasia was the only option for patients to be eligible for organ donation, which they saw as giving meaning to their life and helping others.

“In addition, euthanasia was the only option for the patients to be eligible for organ donation, an act that was perceived to give meaning to one's own life and to help people in need.”

• AssumptionRests on an assumption: Patients' retrospective self-reports accurately reflect the life experiences and motives that led to their euthanasia requests.

May combine two claims.

The medical burden often began in early adolescence and worsened over the long-term illness course, often leading to suicide proneness and disability status, with no further expectation of improvement.

“The medical burden often started in early adolescence and deteriorated precipitously in the long-term course of illness, often resulting in suicide proneness and disability status, with no further expectation of improvement.”

• AssumptionRests on an assumption: Patients' retrospective self-reports accurately reflect the life experiences and motives that led to their euthanasia requests.

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

Fourteen patients were professionally inactive because of long-term sick leave or disability status.

“14 patients were professionally inactive, due to long-term sick leave or disability status.”

May combine two claims.

Some patients did not fear death or the afterlife, wishing to die with a terminally ill beloved, to be reunited with deceased loved ones, or believing in a better life after death.

“Some of the patients, however, feared neither death nor afterlife, as they cherished the deepest wish of dying together with their terminally-ill beloved, longed for a reunion with deceased beloveds in the afterlife, or truly believed in a better life after death.”

• AssumptionRests on an assumption: Patients' retrospective self-reports accurately reflect the life experiences and motives that led to their euthanasia requests.

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

The sample included 13 women and 3 men, with ages ranging from 29 to 60 years.

“The sample consisted of 13 women and 3 men, ranging in age from 29 to 60 years.”

May combine two claims.

All patients faced societal challenges including being single, loss of suitable work, and financial or juridical difficulties, leading to a perception of not finding a meaningful place in society or living in the margins.

“including the challenges of being single, loss of suitable work, financial and/or juridical difficultiesthat led to the perception of not being able to find a meaningful place in society or a life lived in the margins of society.”

• AssumptionRests on an assumption: Patients' retrospective self-reports accurately reflect the life experiences and motives that led to their euthanasia requests.

May combine two claims.

Oppressive, disrespectful, and abusive practices were reported, especially in residential settings, and were described as traumatising.

“Oppressive, disrespectful and abusive practices were mentioned, especially in residential settings, and literally phrased as 'traumatising'.”

• AssumptionRests on an assumption: Patients' retrospective self-reports accurately reflect the life experiences and motives that led to their euthanasia requests.

May combine two claims.

Most patients continued to consider suicide as one of many options to hasten death, as a plan B if euthanasia was denied or delayed, or as a plan A due to acquired capability.

“Most of the patients, however, keep considering suicide as one of many options to hasten their deathbe it as a plan B should their euthanasia request be denied or the procedure take too much time, or as plan A due to acquired capability”

• AssumptionRests on an assumption: Patients' retrospective self-reports accurately reflect the life experiences and motives that led to their euthanasia requests.

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

The study identified 16 eligible adults with psychiatric conditions and conducted 16 interviews between August 2019 and July 2020.

“We succeeded in identifying 16 eligible adults with psychiatric conditions.In total, 16 interviews were held from August 2019 to July 2020.”

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

Patients advocated equality of mental healthcare resources, perceiving an oversupply for easy-to-treat patients and an undersupply for difficult-to-treat and forgotten patients in outdated facilities.

“In addition, the patients advocated for equality of mental healthcare resources, as they detected an oversupply of therapeutic options for the so-called 'easy-to-treat patients' in contrast to an undersupply for the 'difficult-to-treat' and 'forgotten patients' in outdated facilities.”

• AssumptionRests on an assumption: Patients' retrospective self-reports accurately reflect the life experiences and motives that led to their euthanasia requests.
• AssumptionRests on an assumption: The factors patients identified as preventive are modifiable and would have prevented euthanasia if they had been addressed.

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

Patients were at different stages of the euthanasia request procedure, from exploration to having obtained multiple advices.

“Patients were going through different stages in their euthanasia request procedure, ranging from the exploration phase to having obtained multiple advices on euthanasia.”

May combine two claims.

In later life, all patients struggled with thwarted belongingness and perceived burdensomeness because of few meaningful social connections and engagements, especially without social safety nets.

“Fourth, on the social level, all of the patients struggled in later life with both thwarted belongingness and perceived burdensomeness, due to few meaningful social connections and engagements, especially in the absence of social safety nets.”

• AssumptionRests on an assumption: Patients' retrospective self-reports accurately reflect the life experiences and motives that led to their euthanasia requests.

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

Patients wanted end-of-life care improved by embedding talks about death and dying in all clinical and non-clinical settings and by increasing transparency, equality, and uniformity in euthanasia assessment and procedures.

“the quality of care in the context of end-of-life care should also be enhanced in terms of: 1) embedding talks about death and dying in all clinical care settings (be they residential or ambulatory), as well as in non-clinical care settings, and 2) enhancing the quality of the euthanasia practice in end-of-life consultation centers by increasing the levels of transparency, equality and uniformity”

• AssumptionRests on an assumption: Patients' retrospective self-reports accurately reflect the life experiences and motives that led to their euthanasia requests.
• AssumptionRests on an assumption: The factors patients identified as preventive are modifiable and would have prevented euthanasia if they had been addressed.

May combine two claims.

Some patients described lifelong adversity, while others struggled mainly later in life.

“Whereas some patients reported lifelong adversity, others struggled predominantly in later life.”

• AssumptionRests on an assumption: Patients' retrospective self-reports accurately reflect the life experiences and motives that led to their euthanasia requests.

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

Patients who experienced childhood adversity wanted youth services and policies improved through adequate prevention, care, and follow-up.

“Each victim of adversity in childhood expressed the need for enhancing youth services and policies in terms of adequate prevention (e.g.early detection of diagnoses and abuse), care and follow-up.”

• AssumptionRests on an assumption: Patients' retrospective self-reports accurately reflect the life experiences and motives that led to their euthanasia requests.
• AssumptionRests on an assumption: The factors patients identified as preventive are modifiable and would have prevented euthanasia if they had been addressed.

May combine two claims.

Ten patients had more than one psychiatric disorder, with neurodevelopmental and mood disorders being the most common.

“10 patients suffered from more than one psychiatric disorder, with neurodevelopmental and mood disorders as the most common ones.”

May combine two claims.

Euthanasia was chosen to protect loved ones from complex mourning, from witnessing a suicide death, or from vulnerability to prosecution.

“Euthanasia was also chosen to protect loved ones from complex mourning, from witnessing a suicide death, or/and from making them vulnerable to prosecution.”

• AssumptionRests on an assumption: Patients' retrospective self-reports accurately reflect the life experiences and motives that led to their euthanasia requests.

May combine two claims.

Adverse clinical experiences contributed to the medical burden, including perceived diagnostic and treatment errors, troubled patient-caregiver relationships, and disrespect.

“Adverse clinical experiences contributed to the burden of the medical disease.Among these, perceived diagnostic and treatment errors, troubled patient-caregiver relationship, and disrespect were reported.”

• AssumptionRests on an assumption: Patients' retrospective self-reports accurately reflect the life experiences and motives that led to their euthanasia requests.

May combine two claims.

Most patients were suicide-attempt survivors and feared new failed attempts and their consequences.

“Most of the patients were suicide-attempt survivors and feared (the consequences of) new failed suicide attempts.”

• AssumptionRests on an assumption: Patients' retrospective self-reports accurately reflect the life experiences and motives that led to their euthanasia requests.

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

Eleven patients lived alone, one lived with her parents, two lived in a residential healthcare centre, and two lived with a partner and/or children.

“11 patients lived alone, 1 lived with her parents, and 2 others lived in a residential healthcare centre.The other two patients lived with their partner and/or children.”

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

Patients criticized fragmentation of care, saying it caused too many patients to slip through the safety net.

“The fragmentation of care was also criticized, as this caused too many patients to slip through the safety net.”

• AssumptionRests on an assumption: Patients' retrospective self-reports accurately reflect the life experiences and motives that led to their euthanasia requests.
• AssumptionRests on an assumption: The factors patients identified as preventive are modifiable and would have prevented euthanasia if they had been addressed.

May combine two claims.

Euthanasia was perceived as a more effective, softer, and dignified way of dying than suicide.

“In that respect, euthanasia was perceived as a more effective, softer and dignified way of dying than suicide.”

• AssumptionRests on an assumption: Patients' retrospective self-reports accurately reflect the life experiences and motives that led to their euthanasia requests.

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

Patients said personal feuds and quarrels among physicians at patients' expense should stop and waiting lists should be shortened.

“In addition, personal feuds and quarrels among physicians at the patient's expense should cease and waiting lists shortened.”

• AssumptionRests on an assumption: Patients' retrospective self-reports accurately reflect the life experiences and motives that led to their euthanasia requests.
• AssumptionRests on an assumption: The factors patients identified as preventive are modifiable and would have prevented euthanasia if they had been addressed.

May combine two claims.

Patients wanted a more human-centred, holistic clinical environment with continuity of care, shared decision-making, and a multidisciplinary recovery approach.

“the patients expressed the need for a more human-centred, holistic clinical environment, characterised by: 1) continuity of care (non-abandonment) and more tailor-made care; 2) a shift from medical paternalism to shared decision-making, based on values such as respect, connectedness and openness; and 3) congruence with a multidisciplinary recovery approach”

• AssumptionRests on an assumption: Patients' retrospective self-reports accurately reflect the life experiences and motives that led to their euthanasia requests.
• AssumptionRests on an assumption: The factors patients identified as preventive are modifiable and would have prevented euthanasia if they had been addressed.

May combine two claims.

Patients criticized waiting lists, staff shortages, insufficient or non-reimbursement, information gaps, and lack of 24/7 crisis care at home.

“Hence, they criticized the burden of waiting lists, staff shortages, insufficient or non-reimbursement, information gaps, and the lack of 24/7 access to crisis care in home-based environments.”

• AssumptionRests on an assumption: Patients' retrospective self-reports accurately reflect the life experiences and motives that led to their euthanasia requests.
• AssumptionRests on an assumption: The factors patients identified as preventive are modifiable and would have prevented euthanasia if they had been addressed.

May combine two claims.

Patients said their current euthanasia request was a well-considered request for hastened death, whereas suicide acts and attempts could be performed out of despair or as a cry for attention.

“Patients explicitly stated that their current euthanasia request was based on a well-considered request for hastened death (be it tentatively, prospectively, or actually), whereas suicide acts and attempts can be performed out of despair or as a cry for attention.”

• AssumptionRests on an assumption: Patients' retrospective self-reports accurately reflect the life experiences and motives that led to their euthanasia requests.

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

In the euthanasia context, patients wanted the skewed image of mentally ill patients corrected, misrepresentation of euthanasia practice stopped, and a more nuanced debate.

“In the context of euthanasia, patients expressed the need to correct the skewed image of mentally-ill patients in general, to stop the current misrepresentation of the euthanasia practice”

• AssumptionRests on an assumption: Patients' retrospective self-reports accurately reflect the life experiences and motives that led to their euthanasia requests.
• AssumptionRests on an assumption: The factors patients identified as preventive are modifiable and would have prevented euthanasia if they had been addressed.

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

Some patients said paternalism and coercion can be accepted as necessary and unavoidable in certain circumstances, but critical analysis and reflection are essential about when, why, and how authoritarian approaches are used.

“Although some of the patients reported that one can accept recourse to paternalism and coercion as necessary and unavoidable in certain circumstances, critical analysis and reflection are deemed essential with regard to when, why and how more authoritarian approaches can be used under which circumstances and to what extent.”

• AssumptionRests on an assumption: Patients' retrospective self-reports accurately reflect the life experiences and motives that led to their euthanasia requests.

May combine two claims.

Patients pointed to societal issues such as underrecognition of mental suffering and lack of attention to the needs of those not following societal norms.

“Patients pointed to numerous societal issuese.g. the underrecognition of mental suffering and the lack of attention paid to the specific needs of those not following societal norms”

• AssumptionRests on an assumption: Patients' retrospective self-reports accurately reflect the life experiences and motives that led to their euthanasia requests.
• AssumptionRests on an assumption: The factors patients identified as preventive are modifiable and would have prevented euthanasia if they had been addressed.

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

Patients called for more and better-equipped youth mental health services to prevent minors from being admitted to adult psychiatric wards or placed in unsuitable foster care without follow-up.

“Emotional pleas were made to increase the number of (better equipped) youth mental health services to avoid minors being admitted to adult psychiatric wards or being placed in unmatching foster care without follow-up.”

• AssumptionRests on an assumption: Patients' retrospective self-reports accurately reflect the life experiences and motives that led to their euthanasia requests.
• AssumptionRests on an assumption: The factors patients identified as preventive are modifiable and would have prevented euthanasia if they had been addressed.

May combine two claims.

Patients reported fatigue and linked it to the long and uneven course of their clinical and life trajectory, in which adversity was central and contributed to greater hopelessness.

“'fatigue' was reported by patients and attributed/ascribed to the consequences of the long duration and the 'bumpy' course of the clinical and life trajectory in which adversity was key and which contributed to feelings of increased hopelessness.”

May combine two claims.

A new finding was that ambivalence towards death ideation did not appear in all cases, as some longed intently for death due to a desire to die with a loved one, reunion with deceased loved ones, or belief in a better afterlife.

“A new finding emerged: namely, that ambivalence towards death ideation did not appear in all cases, as some of the patients longed intently for death, due to, for example, the deep desire to die with a loved one (double euthanasia), to be reunited with deceased loved ones, or the strong belief in a better afterlife.”

• AssumptionRests on an assumption: Patients' retrospective self-reports accurately reflect the life experiences and motives that led to their euthanasia requests.

May combine two claims.

Patients experienced a variety of intrapersonal, interpersonal, social, and societal elements in life, often starting early and progressing over the life course.

“the patients experienced a variety of intrapersonal, interpersonal, social and societal elements in their life, which often started at early age and progressed during the course of life”

• AssumptionRests on an assumption: Patients' retrospective self-reports accurately reflect the life experiences and motives that led to their euthanasia requests.

May combine two claims.

Patients had societal difficulties, including challenges of being single, work loss or burden, juridical problems, financial problems, finding no meaningful place in society, and living on society's margins.

“Societal difficulties”

• Also stated in: § 4. Conclusion · plain

  “Financial difficulties”

May combine two claims. The quote only partly states this claim.

Patients had negative self-perceptions, including feeling not valuable, not worthy of living, less resilient to daily stressors, extremely vulnerable, and burdened by sexual orientation, perceived failure to meet standards, and perceived burden to society.

“Not being of value”

• Also stated in: § 4. Conclusion · plain

  “Not worthy of living”

May combine two claims.

Somatic comorbidities included chronic or total pain (5), permanent injuries after failed suicide attempts (3), and endocrine diseases (2).

“Chronic/total pain | 5”

• Also stated in: § 4. Conclusion · plain

  “Permanent injuries after failed suicide attempts | 3”

• Also stated in: § 4. Conclusion · plain

  “Endocrine Diseases | 2”

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

The sample contained 16 patients: 13 women and 3 men.

“| Biological Sex | | | Male | 3 | | Female | 13 |”

May combine two claims. The quote only partly states this claim.

Patients saw euthanasia as legal, avoiding legal consequences of suicide and allowing organ donation.

“Euthanasia = legal”

• Also stated in: § 4. Conclusion · plain

  “opens option of organ donation”

May combine two claims. The quote only partly states this claim.

Patients had social difficulties, including thwarted belongingness, solitude, isolation, and no social safety nets.

“No social safety nets available”

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

The sample's age distribution was two patients under 30, two aged 30-40, five aged 41-50, and seven aged 51-60.

“| Age Category | | | <30 | 2 | | 30-40 year | 2 | | 41-50 year | 5 | | 51-60 year | 7 |”

May combine two claims. The quote only partly states this claim.

The qualitative analysis identified key issues across patients' lives: time course and burden of the clinical trajectory, burden of the medical condition, symptom severity, developmental and life-cycle events, consequences of mental illness, interpersonal difficulties, social difficulties, and societal difficulties.

“Key issues permeating the lives of adults with psychiatric conditions and a euthanasia request.”

May combine two claims. The quote only partly states this claim.

Motives for requesting euthanasia included exceeded coping capacity from accumulated misfortunes, beliefs about the afterlife, symbolic reunion with deceased loved ones, euthanasia as a therapeutic tool providing hope, and temporary prevention of suicide attempts by hearing one is ineligible for euthanasia.

“Belief system regarding the afterlife”

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

At the time of the study, nine patients had no formal euthanasia advice, four had one formal advice, and three had been formally accepted for euthanasia.

“| No formal advice on euthanasia obtained | 9 | | One formal advice on euthanasia obtained | 4 | | Formally accepted for euthanasia Psychiatric Conditions (dsm5) a Neurodevelopmental disorders b | 3 7 |”

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

The risk of attempted or completed suicide in these patients is estimated to be ten times that of the general population.

“The risk of attempted and/or completed suicide has been estimated to be 10 times as high in these patients than in the general population (Bachmann, 2018).”

• cites Bachmann, 2018 sourceNot checked yet

  Not checked in the free run.

May combine two claims.

Inductive thematic saturation was reached, with no new main themes emerging after the seventh interview.

“We used a model of sampling-based saturation, namely inductive thematic saturation, that relates to the emergence of new themes (no new main themes emerged after the 7th interview) (Saunders et al., 2018).”

• cites Saunders et al., 2018 sourceNot checked yet

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

The recruitment procedure led the team to believe that the vast majority of patients with psychiatric conditions requesting euthanasia were on the research radar.

“By following this procedure, the team believes the vast majority of patients with psychiatric conditions requesting euthanasia were on the research radar.”

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

The interviewers had clinical psychology backgrounds, experience interviewing about end-of-life topics, and affinity with this patient population.

“All interviews were conducted by MV and KP, who both have a background in Clinical Psychology, experience in conducting interviews on end-of-life topics, and affinity with this specific patient population.”

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

Purposive sampling was used to ensure diversity and heterogeneity in diagnosis and procedural outcomes and thereby to reduce bias.

“Purposive sampling was used to ensure diversity and heterogeneity in diagnosis and procedural outcomes (i.e.euthanasia request not granted, under review, granted or withdrawn) and, hence, to minimise the risk of bias.”

May combine two claims.

The study showed that euthanasia in psychiatry is highly complex because patients differ in background, motives, and multi-layered mental suffering that extends beyond psychiatry.

“This study revealed the many complexities of euthanasia in the context of psychiatry, due to the many differences in patients' background characteristics, in their motives for requesting euthanasia, and the multi-layered aspects of mental suffering that go beyond the field of psychiatry.”

May combine two claims.

Earlier research concentrated on unbearable suffering in patients requesting euthanasia and paid less attention to the life experiences that led them to request it.

“Previous research focused on studying the key aspect of unbearable suffering in these patients who request euthanasia (Verhofstadt et al., 2017(Verhofstadt et al., , 2019a;;Dees et al., 2011), and less on the underlying life experiences that lead them to request euthanasia.”

• cites Verhofstadt et al., 2017 sourceNot checked yet

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• cites Verhofstadt et al., 2019aNot checked yet

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• cites Dees et al., 2011 sourceNot checked yet

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

Recruitment continued so that the sample would be heterogeneous in socio-demographics, clinical profile, and clinical setting.

“We continued to recruit and conduct interviews so that the sample would be heterogenous in terms of socio-demographics, clinical profile, and clinical setting.”

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

Two researchers independently coded at least three transcripts, and all coding results were compared and commonalities discussed.

“Third, KC and KP independently identified and coded emergent themes of at least 3 transcripts.Fourth, all coding results were compared and commonalities were discussed.”

May combine two claims.

This longing can be partly attributed to a strong belief system and partly viewed as a coping strategy for cognitive dissonance about death and dying.

“This can be partially attributed to the patient's strong belief system and partially viewed as a coping strategy to deal with cognitive dissonance regarding death and dying.”

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

Confirmation bias was consciously monitored and avoided as much as possible by continually re-evaluating patient responses and keeping existing clinical assumptions at bay.

“Confirmation bias was consciously monitored and avoided as much as possible, as the patient's responses were continually re-evaluated and existing clinical assumptions kept at bay.”

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

Women are more likely to have mood and trauma-related disorders, while men are more likely to have substance abuse.

“whereas more women suffer from mood and trauma-related disorder, more men suffer from substance abuse”

• cites Nicolini et al., 2021Not checked yet

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

Ample literature indicates associations between low socioeconomic status, limited social network and social isolation, and psychopathology and suicide risks.

“ample literature has indicated the association between low socioeconomic status (in terms of unemployment, financial strain, individual-level inequalities), limited social network and social isolation on the one hand, and psychopathology and suicide risks on the other”

• cites Lorant et al., 2018 sourceNot checked yet

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• cites Milner et al., 2014 sourceNot checked yet

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• cites Huang et al., 2017Not checked yet

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

Demoralization mediates suicidal thinking and leads to a desire to die.

“Its clinical importance relates to its mediation of suicidal thinking, leading to a desire to die (Robinson et al., 2016).”

• cites Robinson et al., 2016 sourceNot checked yet

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

Interviewers found it difficult to conduct three interviews with patients who had neurodevelopmental disorders, because these patients frequently shifted attention and disengaged from details.

“both interviewers expressed difficulties in conducting 3 interviews with patients with neurodevelopmental disorders, where frequent shifts in attention and disengagement from details were noticed.”

Probably not a substantial claim: may not pass S2 (checkable).

The findings point to the need for more open dialogic and patient-centred approaches in psychiatry.

“these findings point to the need for more open dialogic and patient-centred approaches in psychiatry.”

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

The report points to underfinancing of the mental health sector and poor allocation of its financial means.

“The report points not only to the sector being underfinanced, but also on the poor allocation of these financial means (Hermans et al., 2012).”

• cites Hermans et al., 2012 sourceNot checked yet

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

Men are more likely to die by suicide, while women are more likely to attempt suicide.

“whereas more men commit suicide, more women undertake suicide attempts”

• cites Nicolini et al., 2021Not checked yet

  Not checked in the free run.

May combine two claims.

Some patients requested euthanasia to be told they were ineligible and thereby restore hope, so these requests can be considered a potential therapeutic tool to prevent giving up hope and attempting suicide.

“some of the patients requested euthanasia to be told of their ineligibility for it and thus to restore hope.In this respect, these requests can be considered as a potential therapeutic tool to prevent patients from giving up hope and attempting suicide.”

Classified as probably not a substantial claim.

The third research question produced a long list of preventive factors, most pointing to global recommendations to enhance accessibility, quality, and efficiency of mental healthcare for adults in Belgium.

“This question resulted in a long list of factors, the majority of which point to the recommendations that have been made in global reports: i.e., to enhance the accessibility, quality and efficiency of mental healthcare resources for adult patients in Belgium (Mistiaen et al., 2019).”

• cites Mistiaen et al., 2019Not checked yet

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• AssumptionRests on an assumption: The factors patients identified as preventive are modifiable and would have prevented euthanasia if they had been addressed.

May combine two claims.

Researchers could not access medical records or contact treating physicians to confirm patients' mental competence, diagnosis, reported perceptions, or frequency of prior suicide attempts.

“the researchers had 1) neither access to medical records nor contact with the patient's treating physician to confirm e.g., the patient's mental competence and diagnosis, the perceptions conveyed by the patient, the frequency of prior suicide attempt”

May combine two claims.

These results may be interpreted as factors that could prevent patients from requesting euthanasia and also as factors that could prevent vulnerable people from developing mental illness and long psychiatric trajectories.

“These results may be interpreted not only as factors that could prevent patients from requesting euthanasia, but also as factors that could prevent vulnerable people from developing a mental illness and a long trajectory in psychiatry in the first place.”

• AssumptionRests on an assumption: The factors patients identified as preventive are modifiable and would have prevented euthanasia if they had been addressed.

May combine two claims.

The sample may seem to lack gender heterogeneity with many women, but more women than men die by euthanasia for psychiatric reasons.

“Our sample may seem to lack heterogeneity in terms of gender, with many women included in this study, however more women than men die by means of euthanasia for psychiatric reasons (Evenblij et al., 2019;Thienpont et al., 2015;Dierickx et al., 2017).”

• cites Evenblij et al., 2019Not checked yet

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• cites Thienpont et al., 2015 sourceNot checked yet

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• cites Dierickx et al., 2017 sourceNot checked yet

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May combine two claims.

The study lacked social desirability or acceptability bias because interviewers were not involved in patients' euthanasia procedures and did not pressure patients, resulting in rich data.

“Another strength of this study is the lack of social desirability or acceptability bias, as the interviewers were not involved in the patient's euthanasia procedure and the patients were not pressured to phrase their views and experiences in any direction, which resulted in very rich data.”

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

Those difficulties reduced the success of obtaining clear information, required more assertive prompting, and complicated interpretation during coding and analysis.

“This led to lower success in gaining clear information, called for more assertive prompting, and also created difficulties in interpreting meanings during coding and analysis.”

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

Belgium invests about 6% of its total healthcare budget in mental health, below the 10% recommended by the OECD, despite high overall mental health costs and the second highest ratio of inpatient psychiatric beds.

“roughly only 6% of Belgium's total healthcare budget is invested in mental health, which is below the 10% that is recommended by the Organisation for Economic Cooperation and Development (OECD), despite being one of the European countries with the highest overall costs related to mental health problems, and with the second highest ratio of in-patient psychiatric beds (Hermans et al., 2012).”

• cites Hermans et al., 2012 sourceNot checked yet

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

Critical psychiatry movements challenge the legitimacy of exclusive authority.

“At the core of critical psychiatry, the legitimacy of exclusive authority has been challenged (Bracken and Thomas, 2010;Roberts, 2005;Schramme, 2012).”

• cites Bracken and Thomas, 2010Not checked yet

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• cites Roberts, 2005 sourceNot checked yet

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• cites Schramme, 2012 sourceNot checked yet

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

It is not known from official records whether more women than men apply for euthanasia for psychiatric reasons, nor the total number of such requests in private or group practices or inpatient settings.

“As of today, we have no insights in the total number of patients requesting euthanasia for psychiatric reasons in e.g., private or group practices, in inpatient settings,”

May combine two claims.

Both spontaneous recovery and suicide deaths have been reported among patients judged eligible for euthanasia and among those approved for it.

“Both outcomes have been reported in patients considered eligible as well as in patients approved for euthanasia (Thienpont et al., 2015;van Veen et al., 2020b;Rousseau et al., 2017;Verhofstadt et al., 2021).”

• cites Thienpont et al., 2015 sourceNot checked yet

  Not checked in the free run.

• cites van Veen et al., 2020bNot checked yet

  Not checked in the free run.

• cites Rousseau et al., 2017 sourceNot checked yet

  Not checked in the free run.

May combine two claims.

Researchers did not use instruments to assess mental capacity or to separate primary from secondary psychiatric diagnoses.

“2) not made use of instruments to assess e.g., the mental capacity themselves or to distinguish between primary and secondary psychiatric diagnoses.”

Classified as probably not a substantial claim.

The study provided unique and detailed insight into patients' views and experiences of end-of-life decisions, including the tension between euthanasia and suicide.

“Our study did provide unique and detailed insight into the patient's views towards, and experiences of, the many aspects of end-of-life decisions, including the tension between euthanasia and suicide.”

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

The interview study offers a deeper understanding of why the respondent patients requested euthanasia and what could have prevented them.

“This interview study is based on the patients' self-reports and offers a deeper understanding of why our respondent patients have requested euthanasia and what could have prevented them from doing so.”

• AssumptionRests on an assumption: Patients' retrospective self-reports accurately reflect the life experiences and motives that led to their euthanasia requests.

The quote only partly states this claim.

Belgian euthanasia law and practice show that requesting euthanasia should be understood as a cry for more attention, help, recognition, and support.

“3) the evidence that applying for euthanasia must be seen as a cry for additional attention and help, for being seen, recognised and supported.”

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

Although Belgian deontological and other guidelines have value for applying legal criteria in psychiatry, they say little about handling the multi-layered aspects of mental suffering that can complicate medical decisions.

“Notwithstanding the added values of the Belgian deontological and other guidelines (Verhofstadt et al., 2019b;Belgian National Board of Physicians, 2019) on how to implement the legal criteria in psychiatry, there is little mention of how to deal with the multi-layered aspects of mental suffering that may complicate medical decision-making.”

• cites Verhofstadt et al., 2019bNot checked yet

  Not checked in the free run.

• cites Belgian National Board of Physicians, 2019Not checked yet

  Not checked in the free run.

Probably not a substantial claim: may not pass S2 (checkable).

These three shortcomings should be treated as a wake-up call for underfunded psychiatry in Belgium and in other countries with similar legislation.

“All three should be interpreted as a wake-up call for the underfunded psychiatry in Belgium and the countries around the globe considering or having implemented similar legislation.”

• AssumptionRests on an assumption: Psychiatry in Belgium and other countries is underfunded.