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Cited by 13Suicide and Self-Harm StudiesPalliative and Oncologic CarePalliative Care and End-of-Life Issues

“Nothing Hurts Less Than Being Dead”: Psychological Pain in Case Descriptions of Psychiatric Euthanasia and Assisted Suicide from the Netherlands: « Rien ne fait moins mal qu’être mort »: La douleur psychologique dans les descriptions de cas d’euthanasie et de suicide assisté psychiatrique aux Pays-Bas

Open access
Lengvenyte, Aiste, Strumila, Robertas, Courtet, Philippe, Kim, Scott Y. H., Olié, Emilie·2020·The Canadian Journal of Psychiatry
DOI 10.1177/0706743720931237PMC PMC7485035
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Abstract

Objectives: Euthanasia and assisted suicide (EAS) of individuals with mental disorders is a growing practice in several countries, including the Netherlands. Here, we aimed to identify the most frequent dimensions of and associated factors to psychological pain, which has been associated with suicidality, in individuals undergoing psychiatric EAS. Methods: An exploratory retrospective content analysis of the English translation of 66 digital case records of individuals who died by EAS in the Netherlands between 2011 and 2014 was performed. Nine standard psychological pain dimensions (irreversibility, loss of control, emptiness, emotional flooding, freezing, social distancing, narcissistic wounds, confusion, and self-estrangement), illness, and sociodemographic variables were evaluated by 2 independent raters using a premade data abstraction form (Kohen κ > 0.8 in all cases). Results: The mean number of dimensions was 4.64 ± 1.20 (median = 5), out of 9. The most frequent dimensions were irreversibility, loss of control, emptiness, and emotional flooding, in decreasing order. Past treatment refusal and the mention of social connections in case descriptions were related to the higher number of psychological pain dimensions (4.89 ± 1.24 vs. 4.31 ± 1.07, P = 0.03 and 5.05 ± 1.17 vs. 4.43 ± 1.17, P = 0.03, respectively). Emotional flooding was the only dimension specifically associated with specific psychiatric conditions, namely posttraumatic phenomena and personality disorders. Conclusions: Numerous psychological pain dimensions were detected in case descriptions of individuals who underwent EAS before the procedure. Subjective nature of the study precludes definite conclusions but suggest that future studies should explore psychological pain and the role of interventions targeting it in patients requesting EAS.

AI snapshot

Written from the paper’s full text.

TL;DR

This exploratory content analysis of 66 Dutch case records of psychiatric euthanasia and assisted suicide (EAS) found that psychological pain was multidimensional, with a mean of 4.64 ± 1.20 (median 5) of 9 Orbach/Mikulincer dimensions present per case. Past treatment refusal and mention of social connections were each associated with a higher number of dimensions.

Key findings

  • Irreversibility was present in 100% (66/66) of case summaries; the next most frequent dimensions were loss of control (83.3%), emptiness (63.6%), and emotional flooding (59.1%); self-estrangement was least frequent (18.2%).
  • Past treatment refusal was associated with more psychological pain dimensions (4.89 ± 1.24 vs. 4.31 ± 1.07, P = 0.03, Cohen d = 0.50), and emptiness was more frequent in that group (75.7% vs. 48.3%, P = 0.022).
  • Mention of social connections was associated with more dimensions (5.05 ± 1.17 vs. 4.43 ± 1.17, P = 0.03, Cohen d = 0.59), with confusion more common when social connections were mentioned (40.9% vs. 15.9%, P = 0.025).
  • Emotional flooding was the only dimension tied to specific conditions: more common in PTSD/posttraumatic residua (92.3% vs. 50.9%, P = 0.01) and personality disorder (76.0% vs. 48.8%, P = 0.029), less common in bipolar disorder (14.3% vs. 64.4%, P = 0.016), and related to number of psychiatric conditions (42.1%, 43.5%, 87.5% for 1, 2, and ≥3 conditions, P = 0.001).

Methods

  • Retrospective multiple case analysis / directed content analysis of the English translation of 66 digital case records of individuals who died by EAS in the Netherlands between 2011 and early 2014, identified as psychiatric EAS by the 5 Dutch regional euthanasia review committees (RTE).
  • Two independent raters (medical doctors with ≥2 years clinical psychiatry practice) coded a premade data abstraction form covering 9 psychological pain dimensions (from the Orbach & Mikulincer Mental Pain Questionnaire), illness, and sociodemographic variables; inter-rater reliability Kohen κ > 0.8 for all applicable measures (irreversibility had 100% agreement), with consensus meetings for disagreements.
  • Group comparisons used t-tests or general linear models when normality/equal variance held, and Mann-Whitney U or Kruskal-Wallis otherwise; Cohen d for effect sizes; two-tailed P < 0.05; no correction for multiple comparisons given the exploratory aim.

Limitations

  • Stated by the authors: the Orbach/Mikulincer-based measure does not capture all debate on the psychological pain concept; results cannot be generalized to patients who requested but were not granted EAS; the retrospective exploratory design precludes causal assumptions; RTE reports are written to assess due care criteria rather than to describe psychopathology, which may have affected the number of dimensions described; evaluation was relatively subjective (e.g., social connections identified only by mention in text); possible cohort effect, since End-of-Life Clinics have grown since 2012 and may be less reticent in mental suffering cases.
  • Evident from the text: the sample is small (N = 66) and drawn from a single country and a specific publication window; the authors note the social-connections finding could be an artefact of sparse psychosocial/family history in the summaries; no control for multiple comparisons means the reported P values are uncorrected.

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Integrity signals

Registry

Crossref · 10.1177/0706743720931237

Cites

42 of 42 references verified0 citation errors · 0 not checkable

Statistics

Claims the paper makes

0 of 28 cited sources checked · 0 supported · 0 flagged

  • Findingown data
    § Discussion

    Individuals with mental disorders who requested and were granted EAS had frequent hospitalizations.

    “individuals with mental disorders who requested and were granted EAS experienced various dimensions of psychological pain and also had frequent hospitalizations, past suicide attempts, social isolation, and personality problems.”
    Quote in the paperNot a substantial claim
  • Findingown data
    § Discussion

    Individuals with mental disorders who requested and were granted EAS had social isolation.

    “individuals with mental disorders who requested and were granted EAS experienced various dimensions of psychological pain and also had frequent hospitalizations, past suicide attempts, social isolation, and personality problems.”
    Quote in the paperNot a substantial claim
  • Findingown data
    § Results

    Social distancing was present in 28 (42.4%) of case summaries.

    “Social distancing 28 (42.4%)”
    Quote in the paperNot a substantial claim
    • Rests on an assumption: The published RTE case summaries contain sufficient information to retrospectively evaluate psychological pain dimensions.
    • Rests on an assumption: The presence of a psychological pain dimension in a case summary indicates that the patient experienced that dimension.
  • Findingown data
    § Results

    Narcissistic wounds was present in 21 (31.8%) of case summaries.

    “Narcissistic wounds 21 (31.8%)”
    Quote in the paperNot a substantial claim
    • Rests on an assumption: The published RTE case summaries contain sufficient information to retrospectively evaluate psychological pain dimensions.
    • Rests on an assumption: The presence of a psychological pain dimension in a case summary indicates that the patient experienced that dimension.
  • Findingown data
    § Abstract

    Emotional flooding was the only psychological pain dimension specifically associated with specific psychiatric conditions, namely posttraumatic phenomena and personality disorders.

    “Emotional flooding was the only dimension specifically associated with specific psychiatric conditions, namely posttraumatic phenomena and personality disorders.”
    Quote in the paperNot a substantial claim
    • Rests on an assumption: The published RTE case summaries contain sufficient information to retrospectively evaluate psychological pain dimensions.
    • Rests on an assumption: The presence of a psychological pain dimension in a case summary indicates that the patient experienced that dimension.
  • Classified as probably not a substantial claim. 28
  • May combine two claims. 11

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

    Study design and conductown data
    § Methods

    The data abstraction form was developed by one rater based on previous publications examining the same study population and on initial screening of the first 5 cases.

    “The data abstraction form was developed by one of the raters (AL). It was based on previous publications that examined the same study population and on the initial screening of the first 5 cases to understand what information is available.”
    Quote in the paperNot a substantial claim

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

    Premisecitation
    § Background

    Psychological pain is a widely accepted transdiagnostic dimension with specific neurobiological bases and validated measurement tools.

    “Psychological pain describes a widely accepted transdiagnostic dimension9 with specific neurobiological bases10,11 and validated measurement tools.8,12”
    Quote in the paperNot a substantial claim0 of 3 sources checked
    • cites [9] 9. Fava GA, Tomba E, Brakemeier EL, et al. Mental pain as a transdiagnostic patient-reported outcome measure. Psychother Psychosom. 2019;88(6):341–349. 2019 Nov 1 [Epub ahead of print]. doi:10.1159/000504024. [DOI] [PubMed] [Google Scholar] source

      Not checked in the free run.

    • cites [10] 10. Meerwijk EL, Ford JM, Weiss SJ. Resting-state EEG delta power is associated with psychological pain in adults with a history of depression. Biol Psychol. 2015;105:106–114. [DOI] [PMC free article] [PubMed] [Google Scholar] source

      Not checked in the free run.

    • cites [11] 11. van Heeringen K, Van den Abbeele D, Vervaet M, et al. The functional neuroanatomy of mental pain in depression. Psychiatry Res. 2010;181(2):141–144. [DOI] [PubMed] [Google Scholar] source

      Not checked in the free run.

  • Classified as probably not a substantial claim.

    Study design and conductcitation
    § Methods

    Two independent raters performed directed content analysis of the case summaries following a previously prepared data abstraction form that included the 9 psychological pain dimensions.

    “Two independent raters (AL and RS) performed the directed content analysis21 of the case summaries following a previously prepared data abstraction form that included the 9 psychological pain dimensions (see data abstraction form in the Supplementary Material).”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [21] 21. Hsieh H-F, Shannon SE. Three approaches to qualitative content analysis. Qual Health Res. 2005;15(9):1277–1288. [DOI] [PubMed] [Google Scholar] source

      Not checked in the free run.

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

    Study design and conductreasoning
    § Methods

    No statistical procedure was used to control for multiple comparisons because it was deemed too conservative for the exploratory goal of the study.

    “No statistical procedure was used to control for multiple comparisons because it was deemed too conservative for the exploratory goal of the present study.”
    Quote in the paperNot a substantial claim

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

    Premisecitation
    § Background

    Orbach et al. operationalized psychological pain in 9 dimensions: lack of control, irreversibility of pain, emotional flooding, estrangement, confusion, social distancing, freezing, narcissistic wounds, and emptiness.

    “Orbach et al. operationalized psychological pain in 9 dimensions: lack of control, irreversibility of pain, emotional flooding, estrangement, confusion, social distancing, freezing, narcissistic wounds, and emptiness.8”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [8] 8. Orbach I, Mikulincer M, Sirota P, Gilboa-Schechtman E. Mental pain: a multidimensional operationalization and definition. Suicide Life Threat Behav. 2003;33(3):219–230. [DOI] [PubMed] [Google Scholar] source

      Not checked in the free run.

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

    Premisecitation
    § Discussion

    Currently, psychological pain is mostly described in association with suicidal behavior, to which it is independently associated.

    “Currently, psychological pain is mostly described in association with suicidal behavior, to which it is independently associated.13”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [13] 13. Ducasse D, Holden RR, Boyer L, et al. Psychological pain in suicidality: a meta-analysis. J Clin Psychiatry. 2018;79(3):8 doi: 10.4088/JCP.16r10732. [DOI] [PubMed] [Google Scholar]

      Not checked in the free run.

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

    Study design and conductnone given
    § Methods

    After data abstraction by each observer, disagreements were discussed in targeted consensus meetings.

    “After data abstraction by each observer, disagreements were discussed in targeted consensus meetings.”
    Quote in the paperNot a substantial claim

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

    Study design and conductnone given
    § Methods

    Inter-rater reliability was very high (Kohen κ > 0.8) for all measures where it was applicable.

    “The inter-rater reliability was very high (Kohen κ > 0.8) for all measures where it was applicable.”
    Quote in the paperNot a substantial claim

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

    Study design and conductnone given
    § Methods

    Both raters were medical doctors with at least 2 years of practice in clinical psychiatry.

    “Both raters were medical doctors with at least 2 years of practice in clinical psychiatry.”
    Quote in the paperNot a substantial claim

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

    Study design and conductown data
    § Methods

    Kohen κ was calculated for each psychological pain dimension measurement except irreversibility, which displayed 100% agreement.

    “To establish the interobserver reliability, the Kohen κ was calculated for each psychological pain dimension measurement but for the irreversibility dimension that displayed 100% agreement.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Premisecitation
    § Methods

    The Orbach & Mikulincer Mental Pain Questionnaire measures psychological pain that is dissociable from negative emotions related to depressive and anxiety disorders and is specifically associated with suicidality.

    “It was chosen because psychological pain measured by this instrument is dissociable from the negative emotions related to depressive and anxiety disorders and is specifically associated with suicidality.8,11”
    Quote in the paperSubstantial claim0 of 2 sources checked
    • cites [8] 8. Orbach I, Mikulincer M, Sirota P, Gilboa-Schechtman E. Mental pain: a multidimensional operationalization and definition. Suicide Life Threat Behav. 2003;33(3):219–230. [DOI] [PubMed] [Google Scholar] source

      Not checked in the free run.

    • cites [11] 11. van Heeringen K, Van den Abbeele D, Vervaet M, et al. The functional neuroanatomy of mental pain in depression. Psychiatry Res. 2010;181(2):141–144. [DOI] [PubMed] [Google Scholar] source

      Not checked in the free run.

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

    Premisecitation
    § Discussion

    Frequent hospitalizations, past suicide attempts, social isolation, and personality problems are recurring findings in suicidal individuals.

    “These are recurring findings in suicidal individuals.22”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [22] 22. Lopez-Castroman J, Nogue E, Guillaume S, et al. Clustering suicide attempters. J Clin Psychiatry. 2016;77(06):e711–e718. [DOI] [PubMed] [Google Scholar] source

      Not checked in the free run.

  • Classified as probably not a substantial claim.

    Study design and conductnone given
    § Abstract

    The subjective nature of the study precludes definite conclusions.

    “Subjective nature of the study precludes definite conclusions but suggest that future studies should explore psychological pain and the role of interventions targeting it in patients requesting EAS.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S2 (checkable), S4 (based).

    Interpretationreasoning
    § Background

    Understanding the different facets of psychological pain in individuals who are granted EAS might help to determine whether the person's suffering is truly without prospect of improving.

    “Understanding the different facets of psychological pain in individuals who are granted EAS might help to determine whether the person’s suffering is truly without prospect of improving.”
    Quote in the paperNot a substantial claim
    • Rests on an assumption: Psychological pain in EAS has never been studied.
    • Rests on an assumption: There is no universally accepted definition or measure of unbearable suffering, and no study has provided a comprehensive explanation of its neurobiological basis.

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

    Premisecitation
    § Discussion

    Loneliness has been identified as a predictive factor of assisted suicide in Switzerland.

    “loneliness has been identified as a predictive factor of assisted suicide in Switzerland.35”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [35] 35. Steck N, Junker C, Zwahlen M. Increase in assisted suicide in Switzerland: did the socioeconomic predictors change? Results from the Swiss National Cohort. BMJ Open. 2018;8(4):1–11. [DOI] [PMC free article] [PubMed] [Google Scholar] source

      Not checked in the free run.

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

    Study design and conductreasoning
    § Discussion

    The finding of more psychological pain dimensions when social connections were mentioned could be an artefact because the published care summaries contain very little information on the psychosocial and family histories.

    “as the published care summaries contain very little information on the psychosocial and family histories, this finding could be an artefact.”
    Quote in the paperNot a substantial claim

  • Classified as probably not a substantial claim.

    Premisecitation
    § Discussion

    Low social integration is related to suicidality.

    “the consensus that low social integration is related to suicidality.34”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [34] 34. Cáceda R, James GA, Stowe ZN, Delgado PL, Kordsmeier N, Kilts CD. The neural correlates of low social integration as a risk factor for suicide. Eur Arch Psychiatry Clin Neurosci. 2020;270(5):619–631. [DOI] [PMC free article] [PubMed] [Google Scholar] source

      Not checked in the free run.

  • May combine two claims.

    Premisecitation
    § Discussion

    No major legislation changes have been made during or after the period 2011-2015, and major characteristics of patients have not changed between 2015 and 2017.

    “No major legislation changes have been made during or after this period, major characteristics of patients have not changed between 2015 and 2017 (article in Dutch).39”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [39] 39. Mangalam A, Shahi SK, Luckey D, et al. Human gut-derived commensal bacteria suppress CNS inflammatory and demyelinating disease. Cell Rep. 2017;20(6):1269–1277. [DOI] [PMC free article] [PubMed] [Google Scholar] source

      Not checked in the free run.

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

    Premisecitation
    § Discussion

    Psychological pain, measured by the Orbach et al. scale, was similarly elevated in borderline personality disorder and depressive disorder.

    “a previous study, which has found that psychological pain, measured by the Orbach et al. scale,8 was similarly elevated in borderline personality disorder and depressive disorder.28”
    Quote in the paperNot a substantial claim0 of 2 sources checked
    • cites [8] 8. Orbach I, Mikulincer M, Sirota P, Gilboa-Schechtman E. Mental pain: a multidimensional operationalization and definition. Suicide Life Threat Behav. 2003;33(3):219–230. [DOI] [PubMed] [Google Scholar] source

      Not checked in the free run.

    • cites [28] 28. Fertuck EA, Karan E, Stanley B. The specificity of mental pain in borderline personality disorder compared to depressive disorders and healthy controls. Borderline Personal Disord Emot Dysregul. 2016;3:2 doi:10.1186/s40479-016-0036-2 [DOI] [PMC free article] [PubMed] [Google Scholar] source

      Not checked in the free run.

  • May combine two claims.

    Premisecitation
    § Discussion

    Only about 40% of all individuals and 49% of individuals with depressive disorders underwent electroconvulsive therapy, one of the most effective treatment options for major depressive disorder.

    “only about 40% of all individuals and 49% of individuals with depressive disorders underwent electroconvulsive therapy, one of the most effective treatment options for major depressive disorder.38”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [38] 38. Bauer M, Severus E, Köhler S, et al. World federation of societies of biological psychiatry (WFSBP) guidelines for biological treatment of unipolar depressive disorders. part 2: Maintenance treatment of major depressive disorder-update 2015. World J Biol Psych. 2015;16(2):76–95. [DOI] [PubMed] [Google Scholar] source

      Not checked in the free run.

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

    Premisecitation
    § Discussion

    End-of-life Clinics focus more on the autonomous wish of the patient and have been reported to be less reticent in cases of mental suffering.

    “End-of-life Clinics focus more on the autonomous wish of the patient and have been reported to be less reticent in cases of mental suffering.20”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [20] 20. Snijdewind MC, Willems DL, Deliens L, Onwuteaka-Philipsen BD, Chambaere K. A study of the first year of the end-of-life clinic for physician-assisted dying in the Netherlands. JAMA Intern Med. 2015;175(10):1633. [DOI] [PubMed] [Google Scholar] source

      Not checked in the free run.

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

    Study design and conductnone given
    § Discussion

    The retrospective exploratory design precludes any assumptions of causality.

    “the retrospective exploratory design precludes any assumptions of causality.”
    Quote in the paperNot a substantial claim

  • Classified as probably not a substantial claim.

    Premisecitation
    § Discussion

    Orbach et al. found that the difference in psychological pain rating between suicide attempters and nonattempters reflected the unique contribution of irreversibility, loss of control, and emptiness.

    “Orbach et al. have found that the difference in psychological pain rating between suicide attempters and nonattempters reflected the unique contribution of irreversibility, loss of control, and emptiness.8”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [8] 8. Orbach I, Mikulincer M, Sirota P, Gilboa-Schechtman E. Mental pain: a multidimensional operationalization and definition. Suicide Life Threat Behav. 2003;33(3):219–230. [DOI] [PubMed] [Google Scholar] source

      Not checked in the free run.

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

    Study design and conductnone given
    § Discussion

    RTE reports are written to inform whether the due criteria were met and not to describe the complex psychopathology of individuals extensively. This might have affected the numbers of dimensions described.

    “RTE reports are written to inform whether the due criteria were met and not to describe the complex psychopathology of individuals extensively. This might have affected the numbers of dimensions described.”
    Quote in the paperNot a substantial claim

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

    Study design and conductreasoning
    § Discussion

    It is possible that only the social contacts that either are involved in EAS or surpass a certain quality or intensity threshold are mentioned.

    “It is also possible that only the social contacts that either are involved in EAS or surpass a certain quality or intensity threshold are mentioned.”
    Quote in the paperNot a substantial claim

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

    Interpretationreasoning
    § Discussion

    It is possible that the procedure has become more liberal.

    “it is possible that the procedure has become more liberal.”
    Quote in the paperNot a substantial claim

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

    Study design and conductcitation
    § Discussion

    The choice of psychological pain measure, based on the Orbach and Mikulinec scale, does not necessarily reflect all existing debate regarding the concept of psychological pain.

    “the choice of psychological pain measure, based on the Orbach and Mikulinec scale,8 does not necessarily reflect all existing debate regarding the concept of psychological pain.”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [8] 8. Orbach I, Mikulincer M, Sirota P, Gilboa-Schechtman E. Mental pain: a multidimensional operationalization and definition. Suicide Life Threat Behav. 2003;33(3):219–230. [DOI] [PubMed] [Google Scholar] source

      Not checked in the free run.

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

    Premisecitation
    § Discussion

    The anterior insular response has been associated with psychological pain during social inclusion.

    “The anterior insular response has been associated with psychological pain during social inclusion”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [34] 34. Cáceda R, James GA, Stowe ZN, Delgado PL, Kordsmeier N, Kilts CD. The neural correlates of low social integration as a risk factor for suicide. Eur Arch Psychiatry Clin Neurosci. 2020;270(5):619–631. [DOI] [PMC free article] [PubMed] [Google Scholar] source

      Not checked in the free run.

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

    Premisecitation
    § Discussion

    In a Dutch end-of-life clinic, requests for euthanasia by single and childless people are less likely to be granted.

    “It has been demonstrated that in a Dutch end-of-life clinic, requests for euthanasia by single and childless people are less likely to be granted.20”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [20] 20. Snijdewind MC, Willems DL, Deliens L, Onwuteaka-Philipsen BD, Chambaere K. A study of the first year of the end-of-life clinic for physician-assisted dying in the Netherlands. JAMA Intern Med. 2015;175(10):1633. [DOI] [PubMed] [Google Scholar] source

      Not checked in the free run.

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

    Study design and conductreasoning
    § Discussion

    The identification of existing social connections was based solely on their mention in the text, and connections that were not deemed important by the person who described the case might not have been included.

    “the identification of existing social connections was based solely on their mention in the text, and connections that were not deemed important by the person who described the case might not have been included.”
    Quote in the paperNot a substantial claim

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

    Study design and conductreasoning
    § Discussion

    Given the limited information available in some cases as well as possible judgment and coding by the RTE problems, the general evaluation was relatively subjective.

    “Given the limited information available in some cases as well as possible judgment and coding by the RTE problems, the general evaluation was relatively subjective.”
    Quote in the paperNot a substantial claim
31 of 31

  • The paper relies on this without support.

    Psychological pain in EAS has never been studied.

    “However, psychological pain in EAS has never been studied.”

  • The paper relies on this without support.

    There is no universally accepted definition or measure of unbearable suffering, and no study has provided a comprehensive explanation of its neurobiological basis.

    “there is no universally accepted definition or measure of unbearable suffering, although it has been evaluated using qualitative research methods, and consequently no study has provided comprehensive explanation of the neurobiological basis of this concept yet.”

  • The paper relies on this without support.

    The English translation of the Dutch case records accurately reflects the original records.

    “we analyzed documents that were professionally translated in English, as previously described.5”

  • The paper relies on this without support.

    The published RTE case summaries contain sufficient information to retrospectively evaluate psychological pain dimensions.

    “The data abstraction form was developed by one of the raters (AL). It was based on previous publications that examined the same study population and on the initial screening of the first 5 cases to understand what information is available.”

  • The paper relies on this without support.

    The 66 published case summaries are representative of psychiatric EAS cases in the Netherlands between 2011 and early 2014.

    “the analysis concerned 66 digital records of individuals who died by EAS in the Netherlands between 2011 and early 2014 and that were identified as cases of psychiatric EAS by the 5 Dutch regional euthanasia review committees (Regionale Toetsingscommissies Euthanasie [RTE]).”

  • The paper relies on this without support.

    The presence of a psychological pain dimension in a case summary indicates that the patient experienced that dimension.

    “The self-rated Orbach & Mikulincer Mental Pain Questionnaire, which measures current and lifetime psychological pain,8 was used as the basis for the retrospective evaluation of the psychological pain dimensions.”

  • The paper relies on this without support.

    The Orbach & Mikulincer Mental Pain Questionnaire dimensions are applicable to individuals requesting psychiatric EAS.

    “The self-rated Orbach & Mikulincer Mental Pain Questionnaire, which measures current and lifetime psychological pain,8 was used as the basis for the retrospective evaluation of the psychological pain dimensions.”

  • The paper relies on this without support.

    This is the first attempt to explore the different dimensions of psychological pain in individuals who requested and later underwent EAS.

    “To our knowledge, this is the first attempt to explore the different dimensions of psychological pain in individuals who requested and later underwent EAS.”

  • The paper relies on this without support.

    The patient's perception of irreversibility is a necessary (though not sufficient) criterion for EAS in the Netherlands.

    “the patient’s perception of irreversibility is a necessary criterion (although not sufficient) for EAS in the Netherlands.”

  • The paper relies on this without support.

    Patient and physician must conclude that there is no reasonable alternative in the patient’s situation.

    “Patient and physician must conclude that there is no reasonable alternative in the patient’s situation.”

  • The paper relies on this without support.

    Mental illnesses are not generally considered to be terminal diseases, but they become so when the EAS request is granted.

    “Although mental illnesses are not generally considered to be terminal diseases, they become so when the EAS request is granted.”

  • The paper relies on this without support.

    In the Netherlands, physicians are legally allowed to state that there is no alternative if the patient has refused all unused treatment options.

    “While legally physicians in the Netherlands are allowed to state that there is no alternative if the patient has refused all of the unused treatment options”

  • The paper relies on this without support.

    Treatment refusal in the Netherlands is often considered compatible with irremediability.

    “As treatment refusal in the Netherlands is often considered compatible with irremediability”

  • The paper relies on this without support.

    Only a minority of patients with psychiatric conditions are granted EAS in the Netherlands.

    “only a minority of patients with psychiatric conditions are granted EAS in the Netherlands.”

  • The paper relies on this without support.

    The Dutch RTE case summaries are the only representative, patient-level clinical descriptions of persons receiving psychiatric EAS.

    “the Dutch RTE case summaries are the only representative, patient-level clinical descriptions of persons receiving psychiatric EAS.”
15 of 15

Claims other papers make about this one

Each is checked against this paper’s own text: does it say what the citing paper says it does?

  • A Dutch study showed that the most frequent reasons for MAiD-NT were irreversibility, loss of control, emptiness and emotional flooding, freezing, social distancing, narcissistic wounds, confusion, and self-estrangement.

    “A Dutch study showed that the most frequent reasons for MAiD-NT were irreversibility, loss of control, emptiness and emotional flooding, freezing, social distancing, narcissistic wounds, confusion, and self-estrangement [32].”

    From Debating Euthanasia and Physician-Assisted Death in People with Psychiatric Disorders (2022) · cites this paper as [32]

    The Results (Table 2) report all nine listed dimensions of psychological pain in Dutch psychiatric euthanasia and assisted-suicide case summaries. But only irreversibility, loss of control, emptiness, and emotional flooding appeared in more than half the cases; self-estrangement appeared in 18.2%. The paper measured dimensions of psychological pain, not the most frequent reasons for seeking assisted death. (LLM, conf=0.90)

    Experimental — accuracy not yet measured

Statistics recomputed

Every reported test result, recomputed from its test statistic and degrees of freedom. A result shows as not adding up only once an independent check has confirmed it.

  • ConsistentF(4, 61) = 5.51reported p = .001 · recomputed p < .001

    “F (4, 61) = 5.51, p = .001”

1 of 1

Self-check

Percentages, sums and reported differences re-computed from the paper’s own numbers.

Each contradiction between two passages listed here was confirmed by an independent check.

  • Dimension counts imply a different mean

    Minor

    The nine counts in Table 2 sum to 310 dimensions across 66 cases, giving a mean of 4.70 dimensions per case, not the reported 4.64. This affects the paper's principal descriptive result.

  • Study-period endpoint changes in the limitations

    Minor

    The methods identify cases from 2011 to early 2014, but the limitations say the analyzed cases span 2011 to 2015.

  • Age-group standard deviations conflict with the overall standard deviation

    Minor

    Table 3 labels the age-group values as standard deviations. Because the age groups cover all 66 cases and their means are nearly identical, standard deviations of 0.15, 0.29, and 0.16 cannot produce the reported overall standard deviation of 1.20.

3 of 3

Cites

Flagged first, then by citations

Research works printed but not linked: 2

  1. Ducasse D, J Clin Psychiatry. 2018, 79, 8
  2. Jollant F, 2016, Prog Neuropsychopharmacol Biol Psychiatry

Cited by

Sorted by citations

Related

Authors
Lengvenyte, A., Strumila, R., Courtet, P., Kim, S. Y. H., & Olié, E.
Affiliations
  • Department of Psychiatric Emergency and Acute Care, Lapeyronie Hospital, CHRU Montpellier, France
  • Vilnius University (LT)
  • Inserm (FR)
  • National Institutes of Health (US)
ORCID
Venue
The Canadian Journal of Psychiatry
Publisher
SAGE Publications
Published
2020-06-05
Volume
65
Issue
9
Pages
612-620
ISSN
  • 0706-7437 (ISSN-L)
  • 1497-0015
DOI
10.1177/0706743720931237
PMC
PMC7485035
OpenAlex
W3033187256
Cited by
13
References
42
Citations by year
2025: 2 · 2024: 1 · 2023: 3 · 2022: 4 · 2021: 3
FWCI
1.00
Type
journal article
Language
en
Open access
Licence
journals.sagepub.com/page/policies/text-and-data-mining-license (tdm)
Locations
  • The Canadian Journal of Psychiatry (publishedVersion)
  • PubMed Central (publishedVersion)
  • PubMed (publishedVersion)
  • HAL (submittedVersion)
Topics
  • Social Sciences › Psychology › Clinical Psychology › Suicide and Self-Harm Studies
  • Health Sciences › Medicine › Public Health, Environmental and Occupational Health › Palliative and Oncologic Care
  • Health Sciences › Medicine › Public Health, Environmental and Occupational Health › Palliative Care and End-of-Life Issues
Keywords
assisted suicide, psychological suffering, suicidality, case records, irreversibility, loss of control, emotional flooding, emptiness, social distancing, narcissistic injury, self-estrangement, treatment refusal, social connectedness, personality disorders, Netherlands
MeSH terms
Euthanasia, Humans, Netherlands, Pain, Retrospective Studies, Suicide, Assisted

About these checks

Registry, retraction, Cites and statistics results are computed, not judged, with one exception: a printed reference that no index lists is read once by a model before it counts as a citation error. Claims are extracted by a model and kept only when their quote appears verbatim in the text; each cited source is then checked, with a model’s help, for whether it says what the claim relies on. Those verdicts can be wrong — read the claim’s quote and the cited source before relying on one.

Claims read by deepseek-v4.1-flash under definition version 3 (extract-v3) on 2026-10-08.

Classified by jev-1.13-20260917 (gold-guideline-v0.2) on 2026-10-08.

Statistics and arithmetic are recomputed, not judged.

Confidence bands are shown only for fields calibrated on our annotated test set. None is calibrated yet, so no band is shown.

What counts as a claim ›How we measure confidence ›How we check this ›

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