2014-70, general practitioner, psychiatric disorders, unbearable suffering without prospect of improvement, voluntary and well-considered request

KEY POINT: psychiatric disorder

The patient, a woman in her thirties, suffered from borderline personality disorder, post-traumatic stress disorder and a tendency to dissociate and self-harm that was related to the personality disorder. She also felt depressed, without suffering from clinical depression. The patient had spent years in psychiatric institutions in connection with suicide attempts, self-harm, feelings of depression, depersonalisation and helplessness. She underwent all treatments offered to her, but the symptoms did not improve. The physician, her attending psychiatrist, requested a second opinion from another psychiatrist. The second psychiatrist concluded that the patient’s request was voluntary and well-considered, that her suffering was unbearable, and that there was no prospect of improvement. The independent physician confirmed the physician’s assessment that the due care criteria had been complied with.

The patient, a woman in her thirties, suffered from borderline personality disorder, posttraumatic stress disorder and a tendency to dissociate and self-harm related to the personality disorder. She also felt depressed, without suffering from clinical depression.

In the 20 years before her death, the patient had spent 14 years in psychiatric institutions in connection with suicide attempts, self-harm, and strong feelings of depression, depersonalisation and helplessness. During that long period in the institutions there was no real improvement in her symptoms and her ability to function socially deteriorated rather than improved. She then moved to sheltered housing, where she was treated by a clinical psychologist/psychotherapist, a mental health nurse and the physician, a psychiatrist. In that period she received EMDR therapy, emotion regulation skills training, a  stabilisation course and day treatments focusing on structure, and she was admitted several times, for instance to adjust her medication. She underwent all treatments offered to her, and made every effort to engage with therapy, but the symptoms did not improve.

About a year before her death the patient attempted suicide. After that she made a request for euthanasia to her attending physicians, including the notifying physician. The patient was then treated with lithium and quetiapine, but this did not have the desired effect. An intensive treatment was suggested for her personality disorder, but treatment was not possible in a setting that was feasible to the patient.

According to the physician, the patient had received all the necessary treatments focused on reducing the symptoms or gaining more control over them, but they had had no effect and in any event had not relieved her suffering. The physician requested a second opinion from another psychiatrist, who confirmed that the relevant treatments had been given. The patient’s suffering consisted of almost constant tension, severe problems with emotion regulation and the reliving of events, such as bullying, which she was unable to manage and which overwhelmed her. She experienced feelings of emptiness and dissociation. She suffered from inner pain and reliving deep and severe traumas. She also suffered from nightmares and the noises in her head; as a result she never had any rest and had become exhausted. The patient felt inferior and was unable to correct her self-image. She often experienced contact with other people as a threat and everyday life to her was a constant, almost impossible challenge. She felt powerless to change her situation. She coped with stress and feelings of emptiness by self-harming. She also suffered from eating problems and compulsive thoughts and actions.

The patient had wanted to die for a very long time and had expressed that wish consistently over the past years. After she had decided not to commit suicide, she discussed euthanasia with the physician for the first time, eight months before her death.

A month and a half before her death, the patient asked the physician to perform the procedure to terminate her life. More than a month before the patient’s death, the physician requested a second opinion from another psychiatrist. After examining the patient, the second psychiatrist concluded that the patient’s request was voluntary and persistent, and that it was based on suffering experienced as unbearable, as a result of a psychiatric disorder that was without prospect of improvement in terms of treatment. According to the psychiatrist, the patient grasped the consequences of her request. After examining the medical record, the psychiatrist was satisfied that the relevant treatments had taken place.
The patient’s family backed her request and the psychiatrist believed that her request could be fulfilled.

The physician found that the patient was decisionally competent and the request was voluntary and well-considered. He was also satisfied that the patient’s suffering was unbearable to her and with no prospect of improvement according to prevailing medical opinion.

The committee noted that physicians must exercise particular caution when dealing with a euthanasia request from a patient suffering from a psychiatric disorder. It found that in the case under review the physician did so. In addition to the SCEN physician, the physician consulted another psychiatrist, who gave his opinion on the patient’s decisional competence and concluded that there were no relevant treatment options left. The patient was able to understand the consequences of her decision, her wish was consistent and it had existed for a long time.

The independent physician confirmed the physician’s assessment that the statutory due care criteria had been complied with and that the patient’s suffering was without prospect of improvement, particularly after a life in psychiatric institutions; he further confirmed that her wish had existed for a very long time and was well-considered, and that there were no longer any real alternatives in her situation.