Euthanasia in adults with psychiatric conditions: A descriptive study of the experiences of Belgian psychiatrists

May combine two claims.

The open question yielded additional motives for the request: fears other than suicide, being finished with treatment, complex grief, self-hatred, and financial difficulties.

“In addition, the open question yielded additional motives for the request: namely, all types of fears other than suicide (e.g. potential repetitive traumatic events), being finished with treatment (due to, for example, treatment resistance on the level of the APC’s psychopathology, even if the APC is improving on the physical level), complex grief, self-hatred and financial difficulties.”

May combine two claims.

Most psychiatrists (87%) indicated more than 3 reasons for the request, with an average of 6-7 reasons.

“Most psychiatrists (87%) indicated more than 3 reasons for the request, with a minimum of 1, a maximum of 12, and an average of 6–7.”

May combine two claims.

In euthanasia cases, all but one adult with psychiatric conditions were in treatment at first consultation; mean and median treatment history were 8 and 5 years.

“At the time of their first consultation for euthanasia, all but one APC were in treatment. The mean and median length of treatment history were 8 and 5 years, respectively”

May combine two claims.

In euthanasia cases (n = 23), 70% had comorbid disorders and 48% suffered from severe physical co-morbidities.

“These cases mainly concerned APC with comorbid disorders (70%), and close to half (48%) suffered from severe physical co-morbidities”

May combine two claims.

When asked to report the two main reasons, existential suffering and no perspective for improvement were most frequent; loneliness ranked third in all cases, while pain-related problems ranked third in performed euthanasia cases.

“When asked to report the two main reasons for euthanasia requests, the most frequent were: existential suffering, and no perspective for improvement. Whereas loneliness was ranked third in all reported cases, pain-related problems closed the top three ranking with regard to the 23 performed euthanasia cases.”

• Also stated in: § Abstract · plain

  “Existential suffering was the main reason for the request.”

May combine two claims.

The most frequently reported reasons for requesting euthanasia were no perspective for improvement (87%), very low quality of life or survival mode (72%), and existential suffering (63%).

“No perspective for improvement (87%), a very low level of quality of life, just being in ‘survival mode’ (72%), and existential suffering (63%) were most often reported”

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

The mean and median length of treatment history for all adults with psychiatric conditions was 11 and 7 years, respectively.

“The mean and median length of treatment history were 11 and 7 years, respectively.”

May combine two claims.

At their first consultation for euthanasia, 91% of adults with psychiatric conditions were in treatment, most often including psychotropics (80%), other medical drugs (28%), and/or psychotherapy (67%).

“At their first consultation for euthanasia, 91% were in treatment, most often including psychotropics (80%) and/or other medical drugs (28%) and/or psychotherapy (67%).”

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

The sample of 46 psychiatrists was mostly men (65%), mainly working in private or group clinical practice (63%) and/or psychiatric hospital care (63%) for more than 10 years (91%).

“Most were men (65%), mainly working in a private or group clinical practice (63%) and/or psychiatric hospital care (63%) for more than 10 years (91%).”

May combine two claims.

In performed euthanasia cases, the most frequent reasons were no perspective for improvement (96%), low quality of life (83%), existential suffering (74%), and no purpose left in life (78%).

“and even to a greater extent if the APC died by means of euthanasia (96%, 83% and 74%, respectively). In the 23 performed euthanasia cases, ‘No purpose left in life’ (78%) was also more often indicated.”

May combine two claims.

In all cases, other professionals were consulted, most often the general practitioner (63%) and the psychiatrist's colleagues (46%), and to a greater extent when death by euthanasia was the outcome.

“In all cases, other professionals were consulted, most often the general practitioner (63%) and the psychiatrist’s colleagues (46%), and to a greater extent when death by euthanasia was the outcome.”

May combine two claims.

In four out of five cases, at least two legal advices were given or obtained, mostly positive ones (70%).

“In four out of five cases, at least two legal advices were given or obtained, mostly positive ones (70%).”

May combine two claims.

Pressure from colleagues to approve euthanasia was reported in 6.5% of all requests and 13.0% of euthanasia cases.

“Pressure from colleagues to approve euthanasia | 3 (6.5) c | 3 (13.0) b”

May combine two claims.

When euthanasia was the outcome, the adult patient's social inner circle was consulted in almost all cases (91%), and in 43.5% also after the final decision had been reached.

“When euthanasia was the outcome, the APC’s social inner circle was consulted in almost all cases (91%), and in 43.5% also after the final decision had been reached.”

May combine two claims.

Family and/or friends were consulted in 74% of cases, and in 54% of these also during a concluding session after a final decision.

“In addition, family and/or friends were also often consulted (74%), and a third of these family and/or friends also during a concluding session after a final decision (54%).”

May combine two claims.

The mean and median length of the euthanasia assessment procedure were 14 and 7 months for all requests, and 13.5 and 6 months for euthanasia cases, with a range of 2 weeks to 5 years.

“Based on the answers of the responding psychiatrists, the mean and median length of the euthanasia assessment procedure were 14 and 7 months, respectively, and if the patient died by euthanasia, 13.5 and 6 months, with a minimum of 2 weeks and a maximum of 5 years”

• Also stated in: § Abstract · plain

  “The entire procedure spanned an average of 14 months, and an average of 13.5 months in the 23 cases that culminated in the performance of euthanasia.”

May combine two claims.

One-quarter of the psychiatrists involved in the 23 cases that culminated in euthanasia reported difficulties assessing medical futility (26%), incurability of the disorder (22%), and lack of reasonable therapeutic perspectives (26%).

“One-quarter of the psychiatrists that were involved in the 23 cases that culminated in euthanasia reported having difficulties in the assessment of the legal criteria ‘medical futility’ (26%) and ‘incurability of the disorder’ (22%), and with its operationalised criterion ‘lack of reasonable therapeutic perspectives’ (26%).”

The quote only partly states this claim.

Most adults with psychiatric conditions suffered from comorbid psychiatric and/or somatic disorders.

“Information on 46 unique cases revealed that most APC suffered from comorbid psychiatric and/or somatic disorders”

May combine two claims.

In cases where the adult with psychiatric conditions died otherwise, for example by suicide, negative advices were obtained more often, or absence of hopelessness or remaining reasonable treatment options were reported; in three cases psychiatrists reported improvement in the medical condition due to a new treatment programme.

“In cases in which the APC died otherwise – for example, suicide (data not shown for reasons of privacy, as n = 5, and the cause of death is not reported in all cases), negative advices were obtained more often, or the absence of hopelessness or remaining reasonable treatment options were reported. In three of the latter cases, psychiatrists reported an improvement in the medical condition due to a”

May combine two claims.

Among psychiatrists who felt pressured by the APC's family or friends, 15% concerned pressure to decide in favour and 9% against approving the request.

“When they felt pressured by the APC’s family or friends, this concerned pressure to decide in favour (15%) or against (9%) approving the APC’s request.”

May combine two claims.

Pressure from the patient's family or friends to approve euthanasia was reported in 15.2% of all requests and 17.4% of euthanasia cases.

“Pressure from patient’s family or friends to approve euthanasia | 7 (15.2) | 4 (17.4)”

May combine two claims.

Both positive and negative experiences of the assessment procedure were reported, including reduced suicide risk for the adult with psychiatric conditions and emotional burden or feeling pressured for the psychiatrist.

“Both positive and negative experiences of the assessment procedure were reported: for example, reduced suicide risk for the APC; an emotional burden and a feeling of being pressured for the psychiatrist.”

May combine two claims.

The legal criterion incurability of the disorder was considered sufficiently met in 70% of performed euthanasia cases (76% corrected for missings), while its operationalised criterion was considered sufficiently met in 83%.

“Note that, whereas the legal criterion ‘incurability of the disorder’ was considered sufficiently met in 70% of all performed euthanasia cases (76% if corrected for missings), its operationalised criterion (as suggested in the guidelines on how to adequately assess euthanasia requests from APC) was considered sufficiently met in 83%.”

May combine two claims.

In five cases, responding psychiatrists thought not all substantive due care criteria were sufficiently met; reported contra-indications included young age, remaining treatment options, and certain clinical conditions such as personality or bipolar disorder.

“In five cases, in the responding psychiatrists’ opinion, not all of the substantive due care criteria were sufficiently met. The APC’s young age, remaining treatment options according to the state-of-the-art protocol, as well as certain clinical conditions (i.e. personality or bipolar disorder) were reported as contra-indications.”

• Also stated in: § Abstract · plain

  “In a few cases in which euthanasia was the outcome, not all legal criteria were fulfilled in the reporting physicians’ opinions.”

May combine two claims.

As for outcomes, 61% of the adults with psychiatric conditions died by means of euthanasia (50%) or otherwise (e.g. suicide); 26% were still alive; and in 13% the reporting psychiatrist was out of the loop regarding the final decision.

“As for outcomes, 61% of the APC died by means of euthanasia (50%) or otherwise (e.g. suicide). In 26% of the cases, the APC were still alive. In 13%, the reporting psychiatrist was out of the loop regarding the final decision.”

May combine two claims.

In all performed euthanasia cases, at least two positive advices from other physicians were obtained, except in one case in which both positive and negative advices were obtained.

“In all performed euthanasia cases, at least two positive advices from other physicians were obtained, except in one case in which both positive and negative advices were obtained.”

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

Pressure from the patient to approve euthanasia was reported in 52.2% of all requests and 52.2% of euthanasia cases.

“Pressure from the patient to approve euthanasia | 24 (52.2) | 12 (52.2)”

May combine two claims.

According to respondents, the substantive due care criteria prescribed by the law on euthanasia were fulfilled in 61%-89% of all cases and in 70%-96% of performed euthanasia cases.

“According to the respondents, the substantive due care criteria, as prescribed by the law on euthanasia were fulfilled in 61%–89% of all cases and in 70%–96% of performed euthanasia cases.”

May combine two claims.

The reasons for the APC's euthanasia request are not entirely dependent on clinical symptoms alone (e.g. loneliness), and the APC's problems are deeply rooted and branched into various aspects of the patient's past and current life.

“this study confirms former research,22,23 which maintains that the reasons for the APC’s euthanasia request are not entirely dependent on clinical symptoms alone (e.g. loneliness) and that the APC’s problems are deeply rooted and branched into various aspects of the patient’s past and current life.”

• cites [22] Verhofstadt M Thienpont L Peters G-JY. When unbearable suffering incites psychiatric patients to request euthanasia: qualitative study. Br J Psychiatry 2017; 211(4): 238– 245. 28970302 PMC5623879 sourceNot checked yet

  Not checked in the free run.

• cites [23] Dees M Vernooij-Dassen M Dekkers W, et al. Unbearable suffering of patients with a request for euthanasia or physician-assisted suicide: an integrative review. Psychooncology 2010; 19(4): 339– 352. 19771571 sourceNot checked yet

  Not checked in the free run.

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

One psychiatrist reported two final outcomes, as the adult with psychiatric conditions had withdrawn the euthanasia request a few weeks prior to suicide.

“One psychiatrist reported two final outcomes, as the APC had withdrawn the euthanasia request a few weeks prior to suicide.”

May combine two claims.

Our study revealed that relatives are often involved and can add pressure on psychiatrists during the assessment.

“while our study revealed that they are often involved and can add pressure on psychiatrists during the assessment.”

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

Anecdotal accounts reveal that suicide risk may be one of the reasons responding psychiatrists feel pressured by the APC into granting the request.

“Anecdotal accounts reveal that suicide risk may be one of the reasons responding psychiatrists feel pressured by the APC into granting the request.”

May combine two claims.

Of the 46 APC applying for euthanasia in this study, two-thirds obtained at least two positive advices and could be considered formally approved for euthanasia.

“Of the 46 APC applying for euthanasia in this study, two-thirds obtained at least two positive advices and could be considered formally approved for euthanasia.”

May combine two claims.

When the euthanasia request culminated in the performance of euthanasia, the entire procedure spanned an average of 13 months (much longer than the legally required 1 month) and entailed multidisciplinary consultations including with family and friends (not required by law).

“When the euthanasia request culminated in the performance of euthanasia, the entire procedure spanned an average of 13 months (which is much longer than the legally required 1 month) and entailed multidisciplinary consultations (e.g. psychologists, palliative care team), including with family and friends (which is not required by law).”

May combine two claims.

Both reduced suicidality and opportunities for rehabilitation during euthanasia assessment were reported.

“both reduced suicidality and opportunities for rehabilitation during euthanasia assessment were reported”

• cites [13] Thienpont L Verhofstadt M Van Loon T, et al. Euthanasia requests, procedures and outcomes for 100 Belgian patients suffering from psychiatric disorders: a retrospective, descriptive study. BMJ Open 2015; 5(7): e007454. PMC4530448 26216150 sourceNot checked yet

  Not checked in the free run.

• cites [19] Onwuteaka-Philipsen BD Legemaate J van der Heide A, et al. Derde Evaluatie Wet Toetsing Levensbeëindiging Op Verzoek En Hulp Bij Zelfdoding. Den Haag: ZonMw; 2017. https://publicaties.zonmw.nl/derde-evaluatie-wet-toetsing-levensbeeindiging-op-verzoek-en-hulp-bij-zelfdoding/. 16223080Not checked yet

  Not checked in the free run.

• cites [22] Verhofstadt M Thienpont L Peters G-JY. When unbearable suffering incites psychiatric patients to request euthanasia: qualitative study. Br J Psychiatry 2017; 211(4): 238– 245. 28970302 PMC5623879 sourceNot checked yet

  Not checked in the free run.

May combine two claims.

Euthanasia assessment in APC involves people with long histories of medical diagnoses and treatment, and assessment requires a large amount of time.

“Not only does it involve people with long histories of medical diagnoses and treatment, but assessment also requires a large amount of time.”

May combine two claims.

Few Belgian studies have investigated the reasons that adults with psychiatric conditions request euthanasia, and none have focused in detail on the challenge of the assessment for the psychiatrists involved.

“So far, few Belgian studies have investigated the reasons that APC request euthanasia, and none have focused in detail on the challenge of the assessment for the psychiatrists involved.”

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

The manual check revealed no duplicates, so all reported cases were included in the study.

“As the manual check revealed no duplicates, all reported cases were included in this study.”

Classified as probably not a substantial claim.

A recent Belgian survey study found psychiatrists struggle with these practices due to difficulties reconciling euthanasia assessment with the patient-psychiatrist relationship.

“A recent Belgian survey study gauging psychiatrists’ attitudes and experiences on this topic pointed out that psychiatrists struggle with these practices, due to the difficulties of reconciling euthanasia assessment with the patient-psychiatrist relationship.14,15”

• cites [14] Verhofstadt M Audenaert K Van den Broeck K, et al. Belgian psychiatrists’ attitudes towards, and readiness to engage in, euthanasia assessment procedures with adults with psychiatric conditions: a survey. BMC Psychiatr 2020. doi: 10.1186/s12888-020-02775-x PMC7364603 32678038 sourceNot checked yet

  Not checked in the free run.

• cites [15] Verhofstadt M Audenaert K Van den Broeck K, et al. The engagement of psychiatrists in the assessment of euthanasia requests from psychiatric patients in Belgium: a survey study. BMC Psychiatr 2020. doi: 10.1186/s12888-020-02792-w PMC7414658 32770966 sourceNot checked yet

  Not checked in the free run.

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

The research project was performed in accordance with the Declaration of Helsinki and received ethical approval from the Medical Ethics Committee of Brussels University Hospital and the Medical Ethics Committee of Ghent University Hospital.

“This research project was performed in accordance with the Declaration of Helsinki and received ethical approval from the Medical Ethics Committee of the Brussels University Hospital with reference BUN 143201837302 and the Medical Ethics Committee of the Ghent University Hospital with reference 2018-1165.”

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

No sample size calculation or power analysis was done because the study intended to survey the entire eligible professional group.

“No sample size calculation/power analysis was done, as we intended to survey the entire eligible professional group.”

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

The practice of euthanasia in adults with psychiatric conditions remains subject to controversy, fiercely dividing clinical and ethical opinions, and sometimes resulting in legal examination.

“As some contest whether and when an APC can meet all legal requirements, the practice remains subject to controversy, fiercely dividing clinical and ethical opinions,2–7 and sometimes resulting in legal examination.8,9”

• cites [2] Cheng M. Doctors clash over euthanasia for mentally ill. London, UK: Associated Press, 2017. https://apnews.com/article/e44827ae3daf471596546e924165d234Not checked yet

  Not checked in the free run.

• cites [3] Braeckman J Ravelingien A Boudry M. “Don’t trivialize psychological suffering” (open response letter, translated by Trudo Lemmens), https://trudolemmens.wordpress.com/2015/12/14/dont-trivialize-psychological-suffering/ (2015, accessed 14 December 2017).Not checked yet

  Not checked in the free run.

• cites [4] Bazan A Van de Vijver G Lemmens W. “Remove Euthanasia on the basis of purely psychological suffering from the legislation” (open letter, translated by Trudo Lemmens), (2015). https://trudolemmens.wordpress.com/2015/12/09/translation-of-an-open-letter-of-8-december-2015-by-belgian-psychiatrists-psychologists-philosophers-and-others-re-psychological-suffering-in-belgian-euthanasia-legislation-translation/ (2015, accessed 1 June, 2020).Not checked yet

  Not checked in the free run.

• cites [5] Gale C Barak Y. Euthanasia, medically assisted dying or assisted suicide: time for psychiatrists to say no. Australas Psychiatry 2020; 28(2): 160– 163. 31573331 sourceNot checked yet

  Not checked in the free run.

• cites [6] Schuklenk U. The ethical case against assisted euthanasia has not been made. J Thorac Cardiovasc Surg 2015; 149: 1685– 1686. 26060015 sourceNot checked yet

  Not checked in the free run.

• cites [7] Rooney W Schuklenk U van de Vathorst S. Are concerns about irremediableness, vulnerability, or competence sufficient to justify excluding all psychiatric patients from medical aid in dying? Health Care Anal 2018; 26: 326– 343. 28624976 sourceNot checked yet

  Not checked in the free run.

• cites [8] Kulczyk P. The ECHR is looking into the abuses of euthanasia in Belgium. https://eclj.org/euthanasia/echr/the-echr-is-looking-into-the-abuses-of-euthanasia-in-belgium (2019, accessed 10 May, 2020).Not checked yet

  Not checked in the free run.

• cites [9] Day M. Three Belgian doctors are investigated over euthanasia of woman with Asperger’s. BMJ 2018; 363. (accessed 10 May, 2020). 30504182Not checked yet

  Not checked in the free run.

May combine two claims.

Performed euthanasia cases in adults with psychiatric conditions concerned adults of different ages, mostly women, suffering from multiple chronic psychiatric disorders, mainly major depressive and personality disorders.

“The performed euthanasia cases concerned adults of different ages, mostly women, suffering from multiple chronic psychiatric disorders, mainly major depressive and personality disorders.10,13”

• cites [10] Dierickx S Deliens L Cohen J, et al. Euthanasia for people with psychiatric disorders or dementia in Belgium: analysis of officially reported cases. BMC Psychiatry 2017; 17(1): 203. 28641576 PMC5481967 sourceNot checked yet

  Not checked in the free run.

• cites [13] Thienpont L Verhofstadt M Van Loon T, et al. Euthanasia requests, procedures and outcomes for 100 Belgian patients suffering from psychiatric disorders: a retrospective, descriptive study. BMJ Open 2015; 5(7): e007454. PMC4530448 26216150 sourceNot checked yet

  Not checked in the free run.

May combine two claims.

Only two retrospective studies on Belgian euthanasia practice with adults with psychiatric conditions exist, one only reporting performed euthanasia cases and the other only requests from a single practice.

“To our knowledge, only two retrospective studies exist, which were limited in scope because one only reported about performed euthanasia cases, and the other only reported about requests from a single practice.10,13”

• cites [10] Dierickx S Deliens L Cohen J, et al. Euthanasia for people with psychiatric disorders or dementia in Belgium: analysis of officially reported cases. BMC Psychiatry 2017; 17(1): 203. 28641576 PMC5481967 sourceNot checked yet

  Not checked in the free run.

• cites [13] Thienpont L Verhofstadt M Van Loon T, et al. Euthanasia requests, procedures and outcomes for 100 Belgian patients suffering from psychiatric disorders: a retrospective, descriptive study. BMJ Open 2015; 5(7): e007454. PMC4530448 26216150 sourceNot checked yet

  Not checked in the free run.

May combine two claims.

One study found that of 100 euthanasia requests, 48 were accepted, 73% were carried out, 21% were withdrawn voluntarily, 2% were withdrawn due to imprisonment, and 4% of requestors died by suicide.

“The study also showed that, whilst 48 of 100 euthanasia requests were accepted, 73% had been carried out, 21% had been withdrawn voluntarily, 2% had to be withdrawn due to imprisonment, and 4% of the requestors died by suicide.13.”

• cites [13] Thienpont L Verhofstadt M Van Loon T, et al. Euthanasia requests, procedures and outcomes for 100 Belgian patients suffering from psychiatric disorders: a retrospective, descriptive study. BMJ Open 2015; 5(7): e007454. PMC4530448 26216150 sourceNot checked yet

  Not checked in the free run.

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

One study found the consultation process takes an average of 9 months, involving an average of four consultation sessions with multiple actors.

“One study revealed that the consultation process takes an average of 9 months, involving an average of four consultation sessions with multiple actors (e.g. patient, clinicians, family and friends).”

• cites [13] Thienpont L Verhofstadt M Van Loon T, et al. Euthanasia requests, procedures and outcomes for 100 Belgian patients suffering from psychiatric disorders: a retrospective, descriptive study. BMJ Open 2015; 5(7): e007454. PMC4530448 26216150 sourceNot checked yet

  Not checked in the free run.

Classified as probably not a substantial claim.

A manual check was performed to identify duplicate euthanasia cases by crossing psychiatrist, procedure, and adult-patient characteristics.

“As duplicate cases could occur (i.e. the same individual euthanasia case being reported by at least two psychiatrists), we performed a manual check to identify euthanasia cases with identical or near-identical data by crossing the values of the following variables: (1) specific characteristics of the responding psychiatrists (e.g. specific role in the euthanasia procedure), (2) specific char”

Classified as probably not a substantial claim.

The finding that in 5 of 23 performed euthanasia cases not all legal criteria were sufficiently met may raise questions about the legality of some euthanasia cases in APC.

“This may raise questions about the legality of some euthanasia cases in APC.”

May combine two claims.

The study did not gauge the opinion of other clinicians involved in those cases, and the necessary formal advices were obtained in all cases.

“we have not gauged the opinion of the other clinicians involved in those cases, and we do know that the necessary formal advices were obtained in all cases.”

May combine two claims.

These cases illustrate the complexity of the procedures and the likely lack of consensus between the physicians involved, primarily concerning the incurability of the condition and the lack of reasonable perspectives for improvement.

“These cases again illustrate the complexity of the procedures and therefore the likely lack of consensus between the physicians involved,14,15 which, according to our study, primarily concerns the incurability of the condition and the lack of reasonable perspectives for improvement.”

• cites [14] Verhofstadt M Audenaert K Van den Broeck K, et al. Belgian psychiatrists’ attitudes towards, and readiness to engage in, euthanasia assessment procedures with adults with psychiatric conditions: a survey. BMC Psychiatr 2020. doi: 10.1186/s12888-020-02775-x PMC7364603 32678038 sourceNot checked yet

  Not checked in the free run.

• cites [15] Verhofstadt M Audenaert K Van den Broeck K, et al. The engagement of psychiatrists in the assessment of euthanasia requests from psychiatric patients in Belgium: a survey study. BMC Psychiatr 2020. doi: 10.1186/s12888-020-02792-w PMC7414658 32770966 sourceNot checked yet

  Not checked in the free run.

May combine two claims.

It is highly unlikely that a violation of the minimum waiting period occurred in practice; it is more plausible that the question was accidentally answered from the sole perspective of the individual psychiatrist and their task-specific involvement, instead of for the entire assessment procedure.

“However, this is highly unlikely to occur in practice; it is more plausible that the question was accidentally answered from the sole perspective of the individual psychiatrist and their task-specific involvement, instead of for the entire assessment procedure.”

May combine two claims.

Symptoms of psychiatric disorders tend to change over time, even leading in some cases to remission and clinical and/or social rehabilitation.

“Symptoms of psychiatric disorders tend to change over time – even leading, in some cases, to remission and clinical and/or social rehabilitation”

• cites [14] Verhofstadt M Audenaert K Van den Broeck K, et al. Belgian psychiatrists’ attitudes towards, and readiness to engage in, euthanasia assessment procedures with adults with psychiatric conditions: a survey. BMC Psychiatr 2020. doi: 10.1186/s12888-020-02775-x PMC7364603 32678038 sourceNot checked yet

  Not checked in the free run.

• cites [15] Verhofstadt M Audenaert K Van den Broeck K, et al. The engagement of psychiatrists in the assessment of euthanasia requests from psychiatric patients in Belgium: a survey study. BMC Psychiatr 2020. doi: 10.1186/s12888-020-02792-w PMC7414658 32770966 sourceNot checked yet

  Not checked in the free run.

May combine two claims.

The study confirms that euthanasia assessment in adults with psychiatric conditions entails a lengthy process with diverse complexities.

“This study confirms that euthanasia assessment in APC entails a lengthy process with diverse complexities”

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

The findings point to the responsibility of societies, not only the field of psychiatry, to address problems that confront APC such as loneliness.

“These findings point to the responsibility of our societies (and thus not only of the field of psychiatry) to address the problems that confront APC such as loneliness.”

May combine two claims.

The long duration of euthanasia assessment procedures can be related to the APC not being expected to die in the foreseeable future and to some mental disorders fluctuating in severity or resolving over time, which warrants extreme caution.

“This can be related to the APC not being expected to die in the foreseeable future, and that some mental disorders tend to fluctuate in severity or even resolve over time, which warrants extreme caution.”

May combine two claims.

An assessment concluded in less than 2 weeks would be a violation of the Law, which requires a minimum waiting period of 1 month between the formal request and the performance of euthanasia.

“This would be a violation of the Law, which requires a minimum waiting period of 1 month between the formal request for, and the performance of, euthanasia.”

Classified as probably not a substantial claim.

The survey did not gauge for past suicide attempts or actual suicide risk.

“we gauged neither for past suicide attempts nor for actual suicide risk in this survey.”

Probably not a substantial claim: may not pass S2 (checkable), S4 (based). May combine two claims.

It remains unclear whether the support available to psychiatrists is sufficient and which aspects of the assessment cause the most emotional strain.

“it remains unclear whether the support available to psychiatrists is sufficient and which aspects of the assessment cause the most emotional strain.”

May combine two claims.

Some results should be interpreted with caution due to potential sources of bias: response bias given low response rates, and selection bias as respondents often refrained from reporting about concluded cases where the APC are still alive.

“Some results should be interpreted with caution due to the potential sources of bias: response bias given low response rates, but also selection bias as we suspect respondents often refrained from reporting about concluded cases where the APC are still alive.”

Probably not a substantial claim: may not pass S2 (checkable), S3 (load-bearing). May combine two claims.

The same need for refinement or alternative legal term could apply to reasonable state-of-the-art treatment options, given the proximity of therapeutic tenacity and therapeutic negligence and psychiatry's lack of objective knowledge regarding prognoses and treatment outcomes.

“The same could be said about ‘reasonable state-of-the-art treatment options’– with the inherent relative proximity of ‘therapeutic tenacity’ and ‘therapeutic negligence’– in the context of psychiatry’s lack of objective knowledge regarding prognoses and treatment outcomes.”

May combine two claims.

Only one Dutch and one Belgian study have shown that the assessment of mental capacity differs among individual physicians, partly due to personal values and belief systems, and in some cases seems flawed, leading to dissensions among physicians on the evaluation outcome.

“To our knowledge, only one Dutch and one Belgian study on this topic have shown that the assessment of this criterion differs among individual physicians (i.e. to some extent due to their personal values and belief system), 32 and, in some cases, seems even flawed, which has led to dissensions among physicians on the evaluation outcome. 17”

• cites [32] Schweitser F Stuy J Distelmans W, et al. Assessment of patient decision-making capacity in the context of voluntary euthanasia for psychic suffering caused by psychiatric disorders: a qualitative study of approaches among Belgian physicians. J Med Ethics. Epub ahead of print 3 August 2020. DOI: 10.1136/medethics-2019-105690. 32747525 sourceNot checked yet

  Not checked in the free run.

• cites [17] Doernberg SN Peteet JR Kim SYH. Capacity evaluations of psychiatric patients requesting assisted death in the Netherlands. Psychosomatics 2016; 57(6): 556– 565. 27590345 PMC5097685 sourceNot checked yet

  Not checked in the free run.

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

Belgian guidelines on euthanasia stress that the nature of some psychiatric diagnoses cannot be grounds to rule out all APC for euthanasia by definition.

“it has been stressed in all Belgian guidelines on euthanasia 31 that this cannot be grounds to rule out all APC for euthanasia by definition.”

• cites [31] Verhofstadt M Van Assche K Sterckx S, et al. Psychiatric patients requesting euthanasia: Guidelines for sound clinical and ethical decision making. Int J Law Psychiatry 2019; 64: 150– 161. 31122625 sourceNot checked yet

  Not checked in the free run.

May combine two claims.

The study gathered information on 46 assessed cases and 23 performed euthanasia cases predominantly based on psychiatric disorders, checked for uniqueness by crossing essential variables.

“We gathered information on 46 assessed cases and 23 performed euthanasia cases predominantly based on psychiatric disorders that were checked for uniqueness by crossing essential variables.”

May combine two claims.

Previous research shows that some patients die by suicide even when the euthanasia request has been granted, suggesting that these APC perceived the euthanasia procedure to be too long and/or too arduous.

“Previous research shows that some patients die by means of suicide, even when the euthanasia request has been granted, which suggests that these APC perceived the euthanasia procedure to be too long and/or too arduous.”

• cites [13] Thienpont L Verhofstadt M Van Loon T, et al. Euthanasia requests, procedures and outcomes for 100 Belgian patients suffering from psychiatric disorders: a retrospective, descriptive study. BMJ Open 2015; 5(7): e007454. PMC4530448 26216150 sourceNot checked yet

  Not checked in the free run.

• cites [25] Rai D Stansfeld S Weich S, et al. (2016) Comorbidity in mental and physical illness.’ In: McManus S Bebbington P Jenkins R Brugha T (eds.) Mental health and wellbeing in England:Adult Psychiatric Morbidity Survey 2014. Leeds: NHS Digital. https://pure.ulster.ac.uk/ws/files/11652887/apms-2014-comorbidity.pdfNot checked yet

  Not checked in the free run.

Classified as probably not a substantial claim.

The findings indicate that psychiatrists require support in more than one respect if euthanasia requests by APC are to be handled adequately.

“Our findings indicate that psychiatrists require support in more than one respect if euthanasia requests by APC are to be handled adequately”

May combine two claims.

According to the latest official Euthanasia Review Committee Report, 27 APC died in 2016 and 26 in 2017 by means of euthanasia.

“according to the latest official Euthanasia Review Committee Report, 27 APC died in 2016 and 26 in 2017 by means of euthanasia 12 (p. 46).”

• cites [12] Federal Control and Evaluation Committee for Euthanasia. Ninth report to the Belgian Parliament, 2020. Federal Control and Evaluation Committee for Euthanasia (FederaleControle- enEvaluatieCommissieEuthanasie, FCECE), Brussels, Belgium. https://leif.be/data/press-articles/Wilsverklaringen/FCEE_-_Verslag_2020_cijfers_2018-2019.pdfNot checked yet

  Not checked in the free run.

May combine two claims.

The study has revealed the complexity of euthanasia assessment in APC, due to the variety of comorbid diagnoses and often severe somatic co-diagnoses, the variety of reasons for requesting euthanasia, the difficulties in assessing legal and due care criteria, and the emotional impact on psychiatrists.

“This study has revealed the complexity of euthanasia assessment in APC, due to the variety of (comorbid) diagnoses and often severe somatic co-diagnoses, the variety of reasons for requesting euthanasia (also appealing to the responsibility of our society), the difficulties in assessing the legal and due care criteria, and the emotional impact of euthanasia assessment on psychiatrists.”

May combine two claims.

The result that two-thirds obtained at least two positive advices may suggest a high approval rate, but that is misleading, as prior evidence indicates that the vast majority of requests are denied, rejected, or withdrawn before a formal outcome is reached.

“This result may suggest a high approval rate – but that is misleading, as prior evidence indicates that the vast majority of requests are denied, rejected, or withdrawn before a formal outcome is reached.”

• cites [13] Thienpont L Verhofstadt M Van Loon T, et al. Euthanasia requests, procedures and outcomes for 100 Belgian patients suffering from psychiatric disorders: a retrospective, descriptive study. BMJ Open 2015; 5(7): e007454. PMC4530448 26216150 sourceNot checked yet

  Not checked in the free run.

• cites [19] Onwuteaka-Philipsen BD Legemaate J van der Heide A, et al. Derde Evaluatie Wet Toetsing Levensbeëindiging Op Verzoek En Hulp Bij Zelfdoding. Den Haag: ZonMw; 2017. https://publicaties.zonmw.nl/derde-evaluatie-wet-toetsing-levensbeeindiging-op-verzoek-en-hulp-bij-zelfdoding/. 16223080Not checked yet

  Not checked in the free run.

• cites [21] Evenblij K Pasman HRW Pronk R, et al. Euthanasia and physician-assisted suicide in patients suffering from psychiatric disorders: a cross-sectional study exploring the experiences of Dutch psychiatrists. BMC Psychiatry 2019; 19: 74. 30782146 PMC6381744 sourceNot checked yet

  Not checked in the free run.

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

For some, the euthanasia procedure itself might reduce the risk of suicide for that period, but for others it could increase the risk of suicide.

“for some, the euthanasia procedure itself might reduce the risk of suicide for that period, but for others it could actually increase the risk of suicide.”

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

The incurability of the disorder criterion has been operationalised in the recently published guidelines, but there may be a need for further refinement or an alternative legal term that better suits the field of psychiatry.

“the ‘incurability of the disorder’ criterion has been operationalised in these guidelines, but there may be a need for further refinement, or maybe even for an alternative legal term that better suits the field of psychiatry.”

• cites [33] Pies R. How ‘objective’ are psychiatric diagnoses?: (guess again). Psychiatry (Edgmont) 2007; 4(10): 18– 22. PMC2860522 20428307Not checked yet

  Not checked in the free run.

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

It is yet unclear whether the psychiatrists were familiar with the guidelines.

“it is yet unclear whether the psychiatrists were familiar with them.”

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

Another likely source of strain is pressure coming from relatives, either to approve or to deny the APC's request.

“Another likely source of strain is pressure coming from relatives, either to approve or to deny the APC’s request.”

Probably not a substantial claim: may not pass S2 (checkable), S3 (load-bearing).

The perceived absence of mental competence in a few cases might suggest the need for a standardised capacity evaluation.

“the perceived absence of mental competence in a few cases might suggest the need for a standardised capacity evaluation.”

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

Due to considerable risk of bias, the analysis should be read as an account of the types of cases and issues encountered in psychiatric euthanasia practice, not necessarily as a reflection of the entire psychiatric euthanasia assessment practice.

“Due to the considerable risk of bias, this analysis should be read as an account of the types of cases and issues encountered in psychiatric euthanasia practice, and not necessarily as a reflection of the entire psychiatric euthanasia assessment practice.”

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

A more robust mapping of euthanasia assessment procedures in APC would be better achieved through studies with large reliable denominators generating estimates of granting rates and insight into factors influencing the granting of requests.

“A more robust mapping of euthanasia assessment procedures in APC would be better achieved through studies with large reliable denominators generating estimates of (e.g.) granting rates and insight into factors influencing the granting of requests.”

Classified as probably not a substantial claim.

Obtaining two positive advices does not automatically mean that the APC have been approved for euthanasia, as the physician entrusted with the clarification of the APC's euthanasia requests may seek to obtain additional advices beyond the two legally required.

“Moreover, obtaining two positive advices does not automatically mean that the APC have been approved for euthanasia, as the physician entrusted with the clarification of the APC’s euthanasia requests may seek to obtain additional (i.e. more than the two legally required) advices.”

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

The data do not readily allow for evaluation of the legality of performed euthanasia cases or the factors predictive of requests leading to euthanasia.

“the data do not readily allow for evaluation of: (a) the legality of performed euthanasia cases, or (b) the factors predictive of requests leading to euthanasia.”

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

This is the first study to provide an in-depth analysis of the experiences of Belgian psychiatrists regarding the complexity of euthanasia practice in adults with psychiatric conditions.

“This is the first study to provide an in-depth analysis of the experiences of Belgian psychiatrists regarding the complexity of euthanasia practice in adults with psychiatric conditions.”

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

Although the survey was pre-tested for cognitive validity, the possibility of misunderstandings remaining with regard to the interpretation of individual items cannot be excluded.

“although the survey was pre-tested for cognitive validity, we cannot exclude the possibility of misunderstandings remaining with regard to the interpretation of individual items.”