Case Presentation: An ethical dilemma

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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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Case Presentation: An ethical dilemma

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1. Case Presentation: An ethical dilemma Dr Rosalind Powell GPST1 Psychiatry

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 Considered Zurich 6/12 found ‘exit international’ website promoting euthanasia. Bought recommended book Purchased tablets 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 Having radiotherapy Steroid induced diabetes mellitus Restless legs

8. Past psychiatric history nil

9. Drug history Lansoprazole Prednisolone 10mg od Tamsulosin Diclofenac Gliclazide 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 Immigration officer 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 Restless legs Speech: normal in tone/volume/rate/quality/fluency Mood: subjectively ‘ok’ objectively euthymic

13. Mental state exam Risk Thoughts of suicide Plan in place, chosen method (pills) Family members aware (except wife) ‘An option’ 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 Good concentration

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 Contact MPS

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* A ge D epression P revious attempts E thanol abuse R ational thinking loss S ocial support lacking O rganised plan* N o pastimes S ickness*

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 Psychiatric patients 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?

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