Overview of Presentation. Case presentationSuicide and assisted suicideDiscussion: should assisted suicide be legalised in the UK?. Case presentation Presenting complaint. I was asked to see 61 year old man as part of liason duty at KCHExpressed suicidal ideation to medical teamTo assess patient
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1. Case Presentation: An ethical dilemma Dr Rosalind Powell
2. Overview of Presentation Case presentation
Suicide and assisted suicide
Discussion: should assisted suicide be legalised in the UK?
3. Case presentation Presenting complaint I was asked to see 61 year old man as part of liason duty at KCH
Expressed suicidal ideation to medical team
To assess patient for underlying psychiatric illness
4. History of presenting complaint Diagnosed 3 years ago as having metastatic prostate cancer – on drug trial
1 week progressive weakness in legs and unable to walk
Admitted to KCH: diagnosed with spinal cord compression
Confided in junior doctor would take own life when discharged.
5. History of presenting complaint Long term supporter of voluntary euthanasia
3 years ago decided when time came he may choose to end his life
6/12 found ‘exit international’ website promoting euthanasia.
Bought recommended book
Daughter aware and supportive
6. Exit International The Peaceful Pill eHandbook (by Dr Philip Nitschke Dr Fiona Stewart) a "video book" that sets a new international standard in the provision of information detailing how a (seriously ill or elderly) person might obtain a peaceful and dignified death, at a time and place of their choosing. www.exitinternational.net
7. Past Medical History Diagnosed with metastatic prostate cancer 2006
Had debulking operation and chemotherapy with no effect
Steroid induced diabetes mellitus
8. Past psychiatric history nil
9. Drug history Lansoprazole
Prednisolone 10mg od
Pramipexole (dopamine agonist)
Abiraterone/placebo drug trial
10. Personal History Happy childhood, made friends easily
Attended primary and secondary school gained O-levels and A-levels
Degree and Masters in History
2 marriages – 1st ended amicably, 2 daughters, good relationship
Married Latvian woman recently, applying for residency. Unaware of his plans
11. Forensic History Nil
12. Mental state exam Appearance: lying in hospital bed, kempt
Appropriate eye contact and behaviour
Speech: normal in tone/volume/rate/quality/fluency
Mood: subjectively ‘ok’
13. Mental state exam Risk
Thoughts of suicide
Plan in place, chosen method (pills)
Family members aware (except wife)
Sense of control over destiny
No thoughts for other acts DSH/harm to others
14. Mental state exam Denied any obsessions/compulsions
Denied any altered perception
Denied any thought disorder
Cognition and orientation good
Insight - good
15. Biological markers depression Sleep – normal until restless legs
Appetite – good
Weight loss – none recently
No loss emotional reactivity (able to laugh)
No early morning wakening
No anhedonia: able to read books
16. Dilemma… Patient revealed if at home and unable to take his ‘tablets’, would get daughter to assist him.
Aware she may face prosecution but thought this would be unlikely
17. Impression Adverse life events:
Diagnosis prostate cancer
Not improving on drug trial, now unable to walk
Long-held belief in euthanasia
At high risk of suicide/ assisted suicide
No psychiatric diagnosis – not depressed
had capacity to choose method of ending his life
18. Plan Unable to offer any psychiatric treatment as no psychiatric condition
Advise that daughter could face prosecution if assisted him
Advise should tell wife / have open family discussion
Advise team to contact legal department
19. MPS advice Contacted that day
Discussed case and admission that patient’s daughter may assist him
As no crime had yet been committed , nothing more I could do.
Conversation logged for future
20. Suicide Self destruction as a deliberate act oxford concise medical dictionary 1998
Incidence 1% of all deaths (may be under reported)
Three times higher rate in men than women
Suicide rates in young men rising
Highest rates suicide found in the elderly
21. Suicide Aetiology 1. Associated psychiatric disorders
Major depressive disorder (50%)
Schizophrenia personality disorder
Alcoholism substance misuse
2. Biochemical abnormalities – 5HT underactivity
3. Sociological factors
Social disintegration (higher rates in unemployment, lower in wartime)
Isolation from society (living alone, divorced/single, moving house)
For good of society/ altruistic
22. Risk Factors S ex*
P revious attempts
E thanol abuse
R ational thinking loss
S ocial support lacking
O rganised plan*
N o pastimes
23. Legality of suicide Suicide was illegal under English law until the passing of the Suicide Act 1961.
The same act makes it an offence to assist suicide.
Assisted Dying for the Terminally Ill Bill blocked in the House of Lords May 2006 Bill presented by Lord Joffe with focus on Physician Assisted Suicide
24. Assisted Dying for the Terminally Ill Bill The Joffe Bill would “enable an adult who has capacity and who is suffering unbearably as a result of a terminal illness to receive medical assistance to die at his own considered and persistent request” (House of Lords, 2005).
The doctor who agrees to participate in PAS is responsible for determining the following: the patient has a terminal illness that will cause death within six months, the request is voluntary (uncoerced), the patient has mental capacity, and his or her ‘unbearable suffering’ (subjectively defined by the patient and either mental or physical) arises from the terminal illness, regardless of whether suffering can be relieved or treated.
25. Reaction of RCPsych
We recognise that the proposed Bill has been conceived with compassionate intent to help individuals who experience intolerable suffering under very specific circumstances.
However, the Royal College of Psychiatrists is deeply worried about the possible unintended effects of the Assisted Dying for the Terminally Ill Bill if it were to be enacted.
Concerns re. role of doctor, assessment capacity, depression and suicide, coercion. Usually work to prevent suicide.
26. Should assisted suicide be legalised? Arguments for:
Autonomy: ‘just as a person has the right to determine the course of their life, a person has the right to decide the course of their own dying’
27. Should assisted suicide be legalised? Arguments for:
2. Relieve suffering
3. Dying with dignity – article 8 European Convention on Human rights – right to respect for private life
e.g. Dianne Pretty, Debbie Purdy
28. Should assisted suicide be legalised? Arguments against
Slippery slope – may end in non-voluntary euthanasia
Difficult to legislate
Focus will shift away from palliative care
PAS – against Hippocratic oath
Sanctity of life
29. Who has the answers? Netherlands
1995: 2.4% deaths result voluntary euthanasia
0.8% deaths result non-voluntary euthanasia*
Termination of life on request and Assisted Suicide Act 2002.
Euthanasia and PAS legalised in specific cases
30. Non- Voluntary euthanasia in Netherlands – Slippery slope? Neonates
In 1995 90 neonates were administered a drug for intentional termination of life. 1000 neonates die before 1st birthday (all causes) = 9% of all neonatal deaths.1
Psychiatrist Dr Chabot helped a depressed (physically healthy) 50 year old woman to commit suicide. Found in favor by Supreme Court. Later reprimanded by medical disciplinary board.
4 cases of psychiatric patients assisted suicide each year2
31. U.S.A. Death with dignity act 1997 Oregon
Washington Death with Dignity Act 2008
Allows terminally ill residents to end their lives with prescribed medication
Patient administers own medication
32. Oregon Death with dignity
33. Oregon Death with dignity During 2008, 88 prescriptions for lethal medications
total of 60 DWDA deaths
corresponds to estimated 19.4 DWDA deaths per 10,000 total deaths. (0.19%)
34. Conclusion A difficult case
PAS and assisted suicide illegal in UK
Current case in House of Lords
Multiple arguments for and against assisted suicide
Model in Netherlands may confirm ‘slippery slope’
Emotive area of medicine
35. Discussion Who is for and who is against assisted suicide?
36. Any Questions?