Trudo Lemmens: Medicl Aid in Dying in Canada: A Case Raises Questions About Its Use in Patients with Disability and Mental Illness
Comments by Madelyn Hsiao-Rei Hicks
The case study of euthanasia described by Trudo Lemmens illustrates some of the issues that can be anticipated to follow Canada’s legalization of medically assisted suicide and euthanasia for individuals suffering from mental illness which will be implemented beginning on March 17, 2023, under its “Medical Assistance in Dying” (MAiD) law (Government of Canada 2022).
The Government of Canada provides two types of medical assistance in dying. The first is when a physician or nurse practitioner directly administers to the patient a substance that causes death such as an injection of a drug, which the government calls “clinician-administered medical assistance in dying,” a process also known as euthanasia. The second is when a physician or nurse practitioner provides or prescribes a drug that the patient takes themselves to cause their own death, which the government calls “self-administered medical assistance in dying,” a process also known as “physician-assisted suicide” or “physician-assisted death” (Denys 2018; Government of Canada 2022; Sulmasy and Mueller 2017; Thienpont, Verhofstadt, Van Loon et al. 2015). The sequence of events in this case is provided below along with points relevant to the application of Canada’s MAiD law to persons experiencing mental illness.
Mr. N. was a 62-year-old single man who lived alone, with a past medical history of astrocytoma treated at age 12 years by the surgical removal of two brain tumors, a procedure that resulted in the need for a cochlear implant due to loss of hearing; a stroke some years prior with recovery of physical mobility; a history of seizures up to 10 years prior which then required no seizure medication treatment; and depression. On June 16, 2019, Mr. N. was brought by ambulance to a hospital Emergency Department in British Columbia, Canada, after a neighbor contacted police for a wellness check because Mr. N. had not been seen for several days. According to the patient’s medical records, when assessed by the emergency room physician Mr. N. was found to be upset about being taken from his home and expressed suicidal ideation. Mr. N. was involuntarily admitted to hospital under British Columbia’s Mental Health Act for his own safety (Government of British Columbia 2022).
To be involuntary admitted under the Mental Health Act, Mr. N. must have met criteria of: suffering from a mental disorder that seriously impaired his ability to react appropriately to his environment or to associate with others; required psychiatric treatment in or through a designated facility; required care, supervision and control in or through a designated facility to prevent his substantial mental or physical deterioration or for his own protection or the protection of others; and was not suitable as a voluntary patient. A physician’s assessment of these criteria is based on information from their examination of the patient and preferably includes information received from family members, health care providers or others involved with the person (British Columbia Ministry of Health 2005). According to the patient’s surviving family, prior to his admission for suicidality on June 16, 2019, Mr. N. experienced several recent changes in his support system. He reportedly expressed anger when he learned that a brother who visited weekly and assisted Mr. N. with shopping and errands was leaving for a cross-Canada trip, during which his support would be replaced by that of other family; a neighbor who looked in on him planned to move; and the grocery where he did his weekly shopping had closed.
On Day 1 of his involuntary admission under the Mental Health Act due to suicidal ideation (June 16, 2019), the emergency room physician-initiated treatment with an antidepressant medication and Nr. N. accepted the first dose.
On Day 2 of his admission (June 17, 2019), the patient took the second dose of antidepressant medication. He was transferred from the Emergency Department to the Psychiatric unit. The patient requested information about Medical Assistance in Dying and was provided with materials on MAiD. As reported by the hospital’s Patient Care Quality Officer in their written response to the family’s questioning of the hospital’s provision of MAiD over treatment for suicidality, “Within 24 hours of his admission, he had calmed down significantly and was no longer upset, agitated and showed no signs or symptoms of depression.” This timing was concurrent with having been provided with information on MAiD, a method to end his life.
On Day 3 (June 18, 2019), following receipt of information on MAiD, the patient no longer took antidepressants.
On Day 6 (June 21, 2019), the patient was transferred from the Psychiatric unit to the Patient Assessment and Transition to Home (PATH) unit.
On Day 10 (June 25, 2019), the patient formally completed the MAiD request form and according to the hospital’s Patient Care Quality Officer the hospital care team followed guidelines for his assessment to determine his eligibility to receive MAiD.
On Day 13 (June 28, 2019), a psychiatric evaluation found that the patient was competent to make his decision for MAiD.
On Day 34, Week 4 of admission (July 19, 2019), the patient was prepared to receive clinician-administered medical assistance in dying under MAiD by placement of a needle site in his left arm in readiness for a lethal injection. However, when the Nurse Practitioner authorized to administer MAiD for the region arrived at the hospital, she did not administer the injection because she determined that the hospital had not satisfied the criteria and protocols required for MAiD.
On Day 37, Week 5 of admission (July 22, 2019), Mr. N.’s physician contacted the patient’s family as a courtesy with the patient’s consent to inform them of the patient’s intent to die by receipt of MAiD on July 26, 2019.
On Day 40, Week 5 of admission (July 25, 2019), during a family visit, relatives expressed concern that the patient’s only mode of communication was by written notes on an erasable board, as he had declined to utilize his cochlear implant for deafness. A relative described, “He was happy to see us...We spent this final day with (him) imploring him to reconsider the alternatives. He ate all meals and snacks with much joy, he walked around the unit with his walker, walking faster than I could keep up with him. We shared lots of laughter and reminisced about family times.” As the family asked about his end-of-life wishes, Mr. N’s presentation changed. He became agitated, angry and expressed paranoid ideation. He shouted, “It took them three days to do my will (the hospital had assisted with making a will). Just wait and see. Canada’s going to pay for butchering me! They’re not going to be happy.” He lowered his voice and told his family that he didn’t trust anyone in the hospital, that it was better to keep quiet and sometimes it was better not to say anything.
On Day 41, July 26, 2019, Mr. N. was scheduled for the second time to receive MAiD. His family joined him for breakfast at 7:30 a.m. Mr. N. declined to look at messages his family wrote on the whiteboard. He became agitated and shouted, “It’s too late! This is my moment. This is supposed to be about me. You aren’t going to take this away from me.” His family spoke privately with his physician and asked for more time to attempt to convince Mr. N. to try alternatives to MAiD such as assisted living, having someone live with him, living with the family or placing him in a secure facility if the hospital was too concerned that he would harm himself. His physician told the family that she tried to convince the patient to consider assisted living, but each time the patient said that he would rather die. His physician returned to the patient’s room and wrote on his whiteboard, “Your family tells me they would like to try and re-build their relationship with you.” Mr. N. became enraged. He screamed, “No! This is my moment! They can’t stop this. It’s too late! You are supposed to be my doctor, not (my relative)’s doctor!” Mr. N. then shouted paranoid, delusional statements, “They aren’t even my blood relatives! They don’t even have the same blood as me!” He added, “If you can’t do this, then put me in a hospital where they will!” His physician wrote the following statement on the whiteboard, “(Mr. N.), I know they are not lying.” At 10:05 a.m. Mr. N. was administered the intravenous injection that resulted in his death under MAiD.
At the time of Mr. N.’s death by MAiD in 2019, MAiD was legally being administered to persons whose natural death was foreseeable within an undetermined timeframe due to a flexible combination of medical reasons. As noted by the Health Authority’s Medical Director for Medical Assistance in Dying in the hospital’s written response to Mr. N.’s family, additional factors that can be considered in qualifying for MAiD are health-related factors such as frailty and dependency on others for activities of daily living. At the time, MAiD was not legal for reasons of mental illness, but this case highlights issues that can be expected to arise when MAiD for mental illness becomes legal in Canada in 2023.
First, there can be lack of understanding among those involved in assessment and provision of MAiD of the presentation of depression in suicidal individuals after they have determined a plan for suicide. The hospital described as a justification for MAiD that within 24 hours of admission, Mr. N. had calmed down, was no longer upset or agitated, “and showed no signs or symptoms of depression.” This was the same timeframe in which he and some of his clinicians focused on the option of ending his life by medical administration or provision of a lethal dose of a drug. It is well-known in psychiatry that a suicidal individual in severe emotional pain and distress can feel relief and calm after having arrived upon a decision and a plan to carry out suicide. It is for this reason that sudden improvement is identified as a warning sign, and not a contradiction, of increased severity of depression and increased risk for suicide in Canadian men and in individuals generally who suffer from depression (Haberman, MacLellan and Tindall 2011; Hunt, Wilson, Caputi et al. 2017; Jacobs, Baldessarini, Conwell et al. 2003; Simon and Gutheil 2009; Zaheer, Eynan, Links and Kurdyak 2017).
Mr. N.’s course during his hospitalization was consistent with that described by Hunt, Wilson, Caputi et al. (2017): “Signs of suicidal ideation in men were: social withdrawal, anger and reduced problem solving capacity. Signs of suicide attempts in men were: statements of suicidal intent, calmness, anger...hopelessness...and appearing ‘at peace’. Signs preceding death by suicide in men were: desperation and frustration in the face of unsolvable problems... statements of suicidal intent, and emergence of a positive mood state.” The positive mood state prior to death by suicide is consistent with Mr. N.’s relative’s observation that on the day before his scheduled death by MAiD, Mr. N. “...ate all meals and snacks with much joy... shared lots of laughter and reminisced about family times.”
Second, the case of Mr. N. shows how MAiD can function in suicidal individuals as a mood-congruent alternative to treatment. It also shows the incompatible alternatives faced by clinicians of treating suicidality versus providing medical assistance for suicide under MaiD. On Day 1, Mr. N. was hospitalized under the Mental Health Act for depression and suicidal ideation and he was started on antidepressant medication treatment by the assessing physician. After taking one more dose on Day 2, Mr. N. decided instead on death by MaiD. Four days later, he was transferred off the Psychiatric unit to await MaiD on a “transition to home” unit with no further psychiatric treatment. Both the suicidal patient and a sufficient number of hospital clinicians made the decision to address his suicidal ideation with medically assisted dying rather than with treatment for depression. From March 17, 2023, when Canadian clinicians meet a patient struggling with mental illness and severe suicidality in clinics, emergency departments and inpatient units, they will have to make a choice between joining a suicidal patient in enabling a medically assisted death or providing psychiatric treatment for their patient’s suicidality. This choice will conflict not only with the individual and professional ethics and goals of many clinicians but will also conflict with public health and hospital mandates to decrease rates of suicide, such as by utilization of the Zero Suicide approach. This choice may also be complicated by the stigma of mental illness, by the difficulties of recognizing the cognitive and psychological effects of psychiatric symptoms on the patient’s decision-making and by the difficulty of clinicians in recognizing the effects of countertransference on the clinician’s own decision-making in regard to the patient (Back, Starks, Hsu et al. 2002; Denys 2018; Dom, Stoop, Haekens and Sterckx 2020; Ganzini, Leong, Fenn et al. 2000; Hicks 2006; Links, Eynan and Shah 2019; Ontario Hospital Association 2017; Sprung, Somerville, Radbruch et al. 2018; Varghese and Kelly 1999).
Third, although Mr. N. was an example of the most common presentation of an individual with high suicide risk, that being a single, older man with depressive disorder and multiple comorbidities, Canadian clinicians can anticipate being faced with the choice of providing medically assisted death or treating a patient’s mental illness for patients with a wide variety of psychiatric conditions. In the Netherlands, Belgium, Switzerland and Luxembourg, where medically assisted death for mental illness is allowed, requests for euthanasia and clinician-assisted suicide are made for the following psychiatric conditions: major depressive disorder, bipolar disorder, personality disorders, dementia, schizophrenia and other psychotic disorders, PTSD, dissociative disorders, anxiety, somatoform disorders, eating disorders, OCD, complicated grief, substance use disorders, ADHD, autism spectrum disorder and Asperger’s syndrome. Patients requesting euthanasia or clinician-assisted suicide for psychiatric conditions are most often women and middle-aged, although also include young adults. Requests have increased over time (Calati, Olié, Dassa et al. 2021; Dierickx, Deliens, Cohen and Chambaere 2017; Dom Stoop, Haekens and Sterckx 2020; Groenewoud, van der Heide, Tholen et al. 2004; Guérinet and Tournier 2021; Kim, De Vries and Peteet 2016; Mangino, Nicolini, De Vries and Kim 2020; Nicolini, Peteet, Donovan and Kim 2020; Thienpont, Verhofstadt, Van Loon et al. 2015).
Fourth, the case of Mr. N. shows how the assessment process for decision-making capacity is easily compromised in the process of providing MAiD for an individual who is experiencing a psychiatric illness. Numerous psychiatric symptoms indicated that a major mental illness was present in the case of Mr. N before and after his hospitalization for suicidality: impaired self-care, poor food intake, social withdrawal, irritability, low frustration tolerance, hopelessness, negativism, agitation, outbursts of anger and calm after identifying a method of death. Particularly remarkable, however, was the new onset of psychotic symptoms consisting of paranoia and delusional ideation. On Day 40 of his hospitalization, the day before he received MAiD, he had a sudden change of mental state and became agitated, shouting paranoid ideations about Canada and about the hospital staff: “Just wait and see. Canada’s going to pay for butchering me! They’re not going to be happy.” He lowered his voice and told his family that he didn’t trust anyone in the hospital, that it was better to keep quiet and sometimes it was better not to say anything. On the next day in the hours before he received MAiD, he again shouted delusional ideations: “They aren’t even my blood relatives! They don’t even have the same blood as me!” These beliefs were so obviously delusional that his physician attempted to reassure him that his family was not lying about being related to him.
Altered mental state and new psychotic symptoms are classic indicators of possible delirium and require medical and psychiatric workups. This patient was at higher risk of delirium due to his age, deafness, prolonged inpatient hospitalization and medical comorbidities. A psychiatric evaluation was also important to assess whether the patient had an alternative diagnosis of untreated major depression with psychotic symptoms. Following these basic medical and psychiatric evaluations, Mr. N. should have had a reassessment of his decision-making capacity for requesting MAiD; the last assessment having occurred a full four weeks earlier, prior to the significant change in his psychiatric presentation. The assessment of decision-making capacity for MAiD in medically ill patients and in patients with psychiatric illnesses is known to be complex (Dom, Stoop, Haekens and Sterckx 2020; Doernberg, Peteet and Kim, 2016; Ganzini, Fenn, Lee et al. 1996; Groenewoud, van der Heide, Tholen et al. 2004; Guérinet and Tournier 2021; Hicks 2006), yet Mr. N.’s decision-making capacity for MAiD was not professionally questioned or re-evaluated, despite the onset of new, recognizable psychotic symptoms. He did not even receive the standard level of care for his new psychiatric presentation.
This case illustrates the general pattern found in which presumed safeguards written into MAiD legislature do not prevent a recurrent pattern of clinical misapplication of MAiD in individuals with mental illnesses (Denys 2018; Doernberg, Peteet and Kim 2016; Ganzini, Goy and Dobscha 2008; Groenewoud, van der Heide, Tholen et al. 2004; Hamilton and Hamilton 2005; Hicks 2006). As described for the provision of MAiD to individuals experiencing psychiatric illnesses in other nations, the process for assessing capacity in Mr. N. seemed to be “a procedural protection system that puts priority on ensuring access” to euthanasia and medically assisted suicide (Doernberg, Peteet and Kim 2016).
Access to medically assisted dying is growing rapidly in Canada. Under the current law allowing MAiD for medical reasons, MAiD accounted for 1.5% of all deaths in Canada in 2018, increased to 2.0% of all deaths in 2019 and increased to 2.5% of all deaths in Canada in 2020 (Government of Canada 2020, 2021). In contrast, rates of death by non-MAiD suicide decreased in Canada during that period, with non-MAiD suicide accounting for 1.6% of all deaths in Canada in 2018, 1.6% of all deaths in 2019 and then 1.2% of all deaths in Canada in 2020 (Statistics Canada 2022). It is unknown what relationship there may be, if any, between rates of death using MAiD and rates of death using non-MAiD methods of suicide. For deaths by MAiD for medical reasons, British Columbia, where Mr. N. lived, has the highest rate of death by MAiD among all Canadian provinces, with MAiD being the cause of 3.3% of all deaths in British Columbia in 2019 and the cause of 4% of all deaths in British Columbia in 2020 (Government of Canada 2021). In Canada and all its provinces, rates of death by MAiD will further increase following March of 2023 when the MAiD law will facilitate patients with mental illnesses to end their lives using the methods of clinician-administered euthanasia and clinician-assisted suicide. For individuals experiencing mental illnesses, equal access to MAiD may be a false substitute for receiving equitable standards of care, attention and professional respect.
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May 5, 2022