Commentary: Assessment of Clinical Depression in Patients Who Request Physician-Assisted Death. References

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1 474 Ethics Rounds Vol. 19 No. 6 June 2000 likely to have exacerbated her hopelessness. This transmission of hopelessness and helplessness to spouse, family, other care-providers, and the community becomes a systemic problem necessitating a family-centered approach to care, usually supported by a well-functioning multidisciplinary team. Alas, care of this quality was not available to this patient or her family. Clearly, medical practitioners have a responsibility to monitor their personal attitudes to a patient and the clinical problem to ensure that they do not unwittingly transmit negative countertransference feelings in a harmful manner. The clinical experience observed during the brief life of the ROTI Act could be regarded as an experiment in which the legislation that supported the practice of euthanasia can be examined for its effectiveness. 4 This patient generated a range of ethical concerns regarding the nature and quality of her medical care. Her story demonstrated the inadequacy of the provisions of the ROTI Act and suggested that the vulnerable cannot be safely protected by such legislation. References 1. Rights of the Terminally Ill Act Northern Territory of Australia. Darwin: Government Printer, Oregon Death with Dignity Act, Oregon Revised Statute Ganzini L, Fenn DS, Lee MA, et al. Attitudes of Oregon psychiatrists toward physician-assisted suicide. Am J Psychiatry 1996;153: Kissane DW, Street A, Nitschke P. Seven deaths in Darwin: case studies under the Rights of the Terminally Ill Act, Northern Territory, Australia. Lancet 1998;352: PII S (00) Commentary: Assessment of Clinical Depression in Patients Who Request Physician-Assisted Death Linda Ganzini, MD The Northern Territory and the state of Oregon have experimented with legislation allowing physician-assisted death, but authors of both laws included safeguards meant to ensure that a terminally ill person s decision about assisted suicide or euthanasia does not result from a mental illness. Kissane 1 questions whether the psychiatric safeguard in the Rights of the Terminally Ill Act (ROTI) 2 sufficiently protected the patient he presents in this issue of the Journal. If not, how could safeguards be more effective? The ROTI Act, before it was repealed, required an evaluation by a psychiatrist in order to determine whether or not a patient requesting euthanasia was suffering from a treatable clinical depression. Consistent with the law, all seven people who chose physician-assisted death while the ROTI Act was in effect were assessed by a psychiatrist. 3 Under the Oregon Death with Dignity Act, 4 an evaluation by a psychiatrist or psychologist is required only if the attending or consulting physician believes that the patient may suffer from a psychiatric or psychological disorder or depression causing impaired judgment. In the first year of the Oregon law, only 4 of 23 patients who received a lethal prescription underwent mental health evaluation. 5 In the Netherlands, where assisted suicide and euthanasia are not legal but tolerated under certain conditions, only 3% of all patients who receive physician-assisted death are evaluated by a mental health professional. 6 Why should a person with a mental disorder be excluded from physician-assisted death, especially since mental disorders may compound a terminally ill person s suffering? First, psychiatric disorders such as delirium, dementia, psychoses and depression may impair a person s capacity to make a rational, autonomous decision. This is the basis of the Oregon safeguard. Depressed people often focus on the worst possible outcomes and are impaired by apathy, pessimism, and low self-esteem. 7,8 Psychiatric evaluations are required because mental health Linda Gazini, MD, is Director, Geriatric Psychiatry, Portland Veterans Affairs Medical Center, Portland, Oregon, USA, and a Faculty Scholar of the Open Society Institute s Project on Death in America Address reprint requests to: Linda Ganzini, MD, Mental Health Division, P-7-1DMH, Portland VAMC, P.O. Box 1034, Portland, OR.

2 Vol. 19 No. 6 June 2000 Ethics Rounds 475 professionals have the greatest expertise in making these types of determinations. Second, mental disorders are strongly associated with suicide and are often treatable. With successful treatment, the suicide ideation abates. In the decade following a suicide attempt, only 10 14% of persons complete suicide, suggesting that the desire to die for most suicidal persons is not permanent. 9 Among elderly patients, 60 65% remain well for several years following treatment for depression; one-quarter to one-third remain depressed, relapse or die. 10 This treatability of both depression and suicidality is the basis of the psychiatric safeguard in the ROTI Act. What is the relationship between depression and interest in physician-assisted death in terminally ill patients? Psychological autopsy studies indicate that 80% of people with cancer who commit suicide have depression or substance abuse. 11 Studies of ill persons interest in hastened death, physician-assisted suicide, or euthanasia have more varied results. For example, in a study of Oregonians with amyotrophic lateral sclerosis, depression was not associated with intent to request a lethal prescription. 12 In contrast, studies of dying cancer patients reveal that between % of patients wanting hastened death have major depressive disorder. 13,14 Chochinov et al. 15 reported that a dying patient s will to live fluctuates substantially and, when measured 1 2 weeks after admission to an inpatient palliative care unit, is highly correlated to depressed mood. The ROTI Act specifically singles out a treatable clinical depression as the disorder that precludes physician-assisted death. What is a treatable clinical depression in a terminal or preterminal patient? In fact, depression, according to the DSM-IV, 16 is a family of disorders. Major depressive disorder is the most clinically significant. Other potentially treatable mood disorders in ill patients include dysthymic disorder (chronic depressive symptoms less severe than major depressive disorder), mood disorder secondary to a general medication condition, and adjustment disorder with depressed mood (significant hopelessness, tearfulness, or depression, less severe than major depressive disorder, in response to a stressor 16 ). Although most expert commentary on the relationship between depression and assisted death is focused on major depressive disorder, a minority of psychiatrists believe that these other disorders constitute important treatable conditions in the case of assisted suicide. For example, in a study of U.S. forensic psychiatrists, 29% of respondents believed that a terminally ill person should be automatically deemed incompetent to choose assisted suicide if they were diagnosed with dysthymic disorder, and 29% if the patient was diagnosed with an adjustment disorder. Forensic psychiatrists who were morally opposed to assisted suicide were much more likely to endorse that these other mood disorders should preclude assisted suicide. 17 In the absence of a consensus on this issue, I will focus on major depressive disorder, the mood disorder most often referred to as clinical depression, as the most significant mood syndrome that might influence a patient s decision about physician-assisted death. Major depressive disorder is a syndrome marked by pervasive low mood or loss of interest or pleasure, associated with worthlessness, guilt, poor concentration, suicidality, and vegetative symptoms such as weight loss, fatigue, and poor sleep. Symptoms are present nearly every day for at least 2 weeks and associated with a change from previous functioning (DSM-IV). Because the response to pharmacotherapy in patients considered to have reactive depressions is as good as those with endogenous depressions, such a distinction is no longer made. In terminally ill patients, however, distinguishing normal sadness from a psychopathological mood disorder continues to pose a clinical challenge. 18 Bukberg and colleagues 19 found that eliminating vegetative symptoms such as weight loss and fatigue from diagnostic criteria (because they could be attributed to medical illness) halved the point prevalence of depression in cancer inpatients from 42% to 24%. Important work by Chochinov and colleagues 20 demonstrated that when using a high severity threshold for psychological criteria, classification of somatic symptoms no longer influenced depression diagnosis. In other words, whether or not the patient is eating or has fatigue is not as important as the severity of depressed mood and anhedonia. In the case presented by Kissane, it is not clear how pervasive, persistent, and severe the patient s low mood and anhedonia were. Was illness-related fatigue a factor in her lack of interest in hobbies and desire to lay in bed or a

3 476 Ethics Rounds Vol. 19 No. 6 June 2000 result of true anhedonia and depression? Was her hopelessness a realistic appraisal of her future or a pathologically negative assessment? Was her poor concentration a result of depression or benzodiazepine use and anticholinergic adverse effects of the doxepin? The psychiatrist who evaluated her has a significant advantage in determining this and it is difficult to say, based on the information given, that he did not meet a standard of care. What can we advise our terminally ill patients regarding the likelihood of successful treatment of their depression? The experience of palliative care psychiatrists is that depression treatment is effective in terminally ill patients, 21 but the empiric database to support this impression is regrettably sparse. To date, there is only one double-blind, placebo-controlled study of antidepressants in cancer patients. 22 Some recent data published on antidepressant treatment in the dying are alarming. Lloyd-Williams et al. 23 reported that 7% of 1026 patients admitted to four inpatient palliative care units in England were prescribed antidepressants. Seventy-three percent of the patients died within 2 weeks of starting these medications and 52% within 1 week. One-quarter were prescribed low-dose tricyclic antidepressants and three-quarters a selective serotonin reuptake inhibitor both drugs that have an onset of action of more than 2 weeks. Currently, specialists in psychiatric care of dying patients recommend psychostimulants such as methylphenidate for treatment of depression, as onset of action is within 1 3 days. 21 Macleod 24 reported that of 25 hospice inpatients treated with methylphenidate for major depressive disorder, 46% improved; however, only 7% of those within 6 weeks of death improved. Rigorous studies of the natural history and persistence of depression and the efficacy of antidepressant medications and psychotherapy in terminally ill patients are needed. The time to death may be an important variable in predicting efficacy of treatment. When asked the proportion of dying patients who will respond to depression treatment, clinicians should have difficulty answering with any precision. With even these qualifications, Kissane paints a convincing picture of a patient who may meet threshold criteria for major depressive disorder that has been inadequately treated. With a median life expectancy of 9 months, it is premature to say that she is not treatable. As such, the safeguard may have failed, and allowed a person with a treatable depressive disorder to obtain euthanasia. How then might safeguards be improved and what are the risks of improved safeguards? First, some caveats. Hendin 25 has argued that no psychiatric safeguard can protect patients, because of the interactive nature of the decision-making process that is at the heart of euthanasia and its abuse. These arguments propose that neither assessments of competence nor treatability can suffice to ensure that patients are protected. Others believe that because physician-assisted death is unethical, psychiatric evaluation is also unethical. For example, in the survey of forensic psychiatrists, 24% believed that participation by psychiatrists in determining competence for assisted suicide was unethical. 17 Elsewhere, I and others have argued that psychiatric safeguards based on determining whether a depression is influencing the decision are problematic. Competence itself is a complex concept, determinations of decision-making capacity are not clear-cut, and the relationship between mental illness and decision-making capacity in dying patients is not clearly understood. 26 When a patient is severely depressed or entirely without depressive symptoms, elaborate safeguards may not be necessary. 26 But for patients in the gray zones as was, perhaps, the patient presented by Kissane standards for evaluation may be helpful, but require consensus among experts. Should we use a restrictive or inclusive diagnosis for depression? Should the standard be so stringent that some otherwise competent or untreatable persons would not be allowed physician-assisted death? Or a less stringent standard that might allow some depressed persons who are potentially treatable to slip through? Can we define how many courses of unsuccessful depression treatment qualify as treatment-resistant depression in a dying patient? Should the psychiatrist have special training in making these determinations, even if the need for such training might restrict access for otherwise eligible patients? Should there be more than one independent examiner or judicial review, even though the burden to ill patients, the expense and time would again likely restrict access to some patients? How, then, would we resolve disagreement among independent examiners? In the

4 Vol. 19 No. 6 June 2000 Ethics Rounds 477 study of U.S. forensic psychiatrists, 17 there was no agreement among experts on whether or not a psychiatric evaluation should even be required. Determining these standards will require more research on the relationship between mental disorders and interest in physicianassisted death in the terminally ill, the variability of interest in physician-assisted death over time, and the effect of depression treatment on desire for hastened death. But our views about the morality of this act and the degree to which we see it as a grave harm or a potential good, will influence these standards separately from any studies on the issue. 26 In the study of forensic psychiatrists, those who were morally opposed to assisted suicide were more likely to advocate a mandatory examination, a more stringent standard for competence evaluations, and more independent examiners than those who were supportive of legalization. 17 Treatability is a relative term. Those who support the option of assisted suicide may be influenced by information on the proportion of patients who are not successfully treated, the varied effect of depression on competency, and the fact that continued unsuccessful efforts to treat depression may worsen suffering. Those who oppose assisted suicide may focus on the chance, even when small, that the patient s depression could be successfully treated and the proportion of patients whose desire for physician-assisted death diminishes over time. The debate about these standards will require honesty about our values and how they influence our assessment of competence and treatability with regard to physician-assisted death. References 1. Kissane DW. A case of euthanasia: the Northern Territory, Australia. J Pain Symptom Manage 2000;19: Rights of the Terminally Ill Regulations 1996, Northern Territory of Australia. Darwin, Government Printer, Kissane DW, Street A, Nitschke P. Seven deaths in Darwin: case studies under the Rights of the Terminally Ill Act, Northern Territory, Australia. Lancet 1998;352: Oregon Death with Dignity Act Rev. Stat. SS , Chin AE, Hedberg K, Higginson GK, et al. Legalized physician-assisted suicide in Oregon: the first year s experience. N Engl J Med 1999;340: Groenewoud JH, van der Maas PJ, van der Wal G, et al. Physician-assisted death in psychiatric practice in the Netherlands. N Engl J Med 1997;336: Ganzini L, Lee MA. Psychiatry and assisted suicide in the United States (editorial). N Engl J Med 1997;336: Ganzini L, Lee MA, Heintz RT, et al. The effect of depression treatment on elderly patients preferences for life-sustaining medical therapy. Am J Psychiatry 1994;151: Diekstra R. An international perspective on the epidemiology and prevalence of suicide. In: Blumenthal SJ, Kupfer DJ, eds. Suicide over the life cycle: risk factors, assessment and treatment of suicidal persons. Washington, DC: American Psychiatric Press, 1990: Murphy E. The course and outcome of depression in late life. In: Schneider LS, Reynolds III CF, Lebowitz BD, Friedhoff AJ, eds. Diagnosis and treatment of depression in late life: results of the NIH Consensus Development Conference. Washington, DC: American Psychiatric Press, 1994: Henriksson MM, Isometsa ET, Hietanen PS, et al. Mental disorders in cancer suicides. J Affect Disord 1995;36: Ganzini L, Johnston WS, McFarland BH, et al. Attitudes of patients with amyotrophic lateral sclerosis and their care givers toward assisted suicide. N Engl J Med 1998;339: Chochinov HM, Wilson KG, Enns M, et al. Desire for death in the terminally ill. Am J Psychiatry 1995;152: Brown JH, Henteleff P, Barakat S, et al. Is it normal for terminally ill patients to desire death? Am J Psychiatry 1986;143: Chochinov HM, Tataryn D, Clinch JJ, et al. Will to live in the terminally ill. Lancet 1999;354: American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, IV. Washington, DC: American Psychiatric Press, Ganzini L, Leong GB, Fenn DS, et al. Evaluation of competence to consent to assisted suicide: views of forensic psychiatrists. Am J Psychiatry 2000;157: Lynch ME. The assessment and prevalence of affective disorders in advanced cancer. J Palliat Care 1995;11: Bukberg J, Penman D, Holland JC. Depression in hospitalized cancer patients. Psychosom Med 1984;46: Chochinov HM, Wilson KG, Enns M, et al. Prevalence of depression in the terminally ill: effects of diagnostic criteria and symptom threshold judgments. Am J Psychiatry 1994;151: Breitbart W, Chochinov HM, Passik S. Psychiatric aspects of palliative care. In: Doyle D, Hanks

5 478 Ethics Rounds Vol. 19 No. 6 June 2000 GWC, MacDonald N, eds. Oxford textbook of palliative medicine, 2nd ed. New York: Oxford University Press, 1998: Massie MJ, Gagnon P, Holland JC. Depression and suicide in patients with cancer. J Pain Symptom Manage 1994;9: Lloyd-Williams M, Friedman T, Rudd N. A survey of antidepressant prescribing in the terminally ill. Palliat Med 1999;13: Macleod AD. Methylphenidate in terminal depression. J Pain Symptom Manage 1998;16: Hendin H. Physician-assisted suicide: the Dutch case (Letter). J Am Med Assoc 1997;278: Sullivan M, Ganzini L, Youngner SJ. Should psychiatrists serve as gatekeepers for physician assisted suicide? Hastings Center Report 1998;28: PII S (00)