The art of letting go: A study on irremediable psychiatric suffering in the context of physician assisted death

In the Netherlands, physician assisted death (PAD) is possible for patients who are competent in their death wish and who suffer from a medical condition that is unbearable and irremediable. These criteria, which are codified in the 2002 law on euthanasia, are the outcome of a long societal debate that started in the 1970s, when physicians emphasized the tension between the duty to alleviate suffering and the duty to preserve life. They argued that in certain cases actively assisting in the death of a patient was the only merciful option. Although the debate mainly focused on patients suffering from somatic suffering, PAD is legally allowed for psychiatric suffering since the 1990s. Only a very limited number of cases have been reported until 2011. From then on, there has been a rise in assisted deaths for patients with a psychiatric disorder. The increasing clinical experience accompanying the rise in PAD-requests made it clear that psychiatrists struggle with establishing irremediability. This dissertation therefore examines the concept of irremediable psychiatric suffering (IPS) in the context of PAD. We do this in three steps. First, we establish the moral relevance of IPS in the context of PAD. Secondly, we identify the main challenges clinicians face while establishing IPS in the context of PAD. And finally, we establish consensus criteria for IPS in the context of PAD. Based on this dissertation we recommend that clinicians adopt a retrospective view when establishing irremediability in the context of PAD. We also suggest that they are mindful of ‘treatment fatigue’ when working with patients that have a PAD request or persistent psychiatric complaints. On an organizational level we suggest that the consensus criteria can be used when the Dutch and Belgian guidelines on PAD for PPD are updated. For future research we recommend to include the perspectives of other stakeholders, especially patients, on IPS. Also, we recommend to repeat the research in other countries. We suggest to study treatment fatigue in patients with persistent psychiatric complaints and recommend to make the national registry of the Regional Euthanasia Review Boards available for in-depth research. In conclusion; establishing IPS in the context of PAD is a morally relevant and complex activity. Psychiatrists are asked to make a life-or-death decision while facing profound uncertainty. However, by engaging in a meaningful dialogue with the patient and by adopting a retrospective view on irremediability, it is possible to come to a careful decision that finds the right middle between carelessness and overcautiousness. Consensus criteria are now available to help the psychiatrist with the challenging - but not impossible - task of establishing the irremediability of psychiatric suffering in the context of physician assisted death.