Hostname: page-component-cd9895bd7-q99xh Total loading time: 0 Render date: 2024-12-17T14:35:17.412Z Has data issue: false hasContentIssue false
  • English
  • Français

Euthanasia and assisted suicide of persons with psychiatric disorders: the challenge of personality disorders

Published online by Cambridge University Press:  04 March 2019

Marie E. Nicolini Open the ORCID record for Marie E. Nicolini [Opens in a new window] ,
John R. Peteet ,
G. Kevin Donovan  and
Scott Y. H. Kim
Marie E. Nicolini*
Affiliation:
Interfaculty Center for Biomedical Ethics and Law, KU Leuven, Kapucijnenvoer 35 – Box 7001, 3000 Leuven, Belgium Department of Bioethics, National Institutes of Health, 10 Center Drive, Room 1C118, Bethesda, Maryland20892, USA
John R. Peteet
Affiliation:
Department of Psychiatry, Harvard Medical School and Brigham and Women's Hospital, 75 Francis Street, Boston, Massachusetts02115, USA
G. Kevin Donovan
Affiliation:
Center for Clinical Bioethics, Georgetown University, Bldg. D., Suite 236, 4000 Reservoir Road, Washington D.C. 20007, USA
Scott Y. H. Kim
Affiliation:
Department of Bioethics, National Institutes of Health, 10 Center Drive, Room 1C118, Bethesda, Maryland20892, USA
*
Author for correspondence: Marie E. Nicolini, E-mail: marie.nicolini@kuleuven.be
Get access Rights & Permissions [Opens in a new window]

Abstract

Background

Euthanasia or assisted suicide (EAS) for psychiatric disorders, legal in some countries, remains controversial. Personality disorders are common in psychiatric EAS. They often cause a sense of irremediable suffering and engender complex patient–clinician interactions, both of which could complicate EAS evaluations.

Methods

We conducted a directed-content analysis of all psychiatric EAS cases involving personality and related disorders published by the Dutch regional euthanasia review committees (N = 74, from 2011 to October 2017).

Results

Most patients were women (76%, n = 52), often with long, complex clinical histories: 62% had physical comorbidities, 97% had at least one, and 70% had two or more psychiatric comorbidities. They often had a history of suicide attempts (47%), self-harming behavior (27%), and trauma (36%). In 46%, a previous EAS request had been refused. Past psychiatric treatments varied: e.g. hospitalization and psychotherapy were not tried in 27% and 28%, respectively. In 50%, the physician managing their EAS were new to them, a third (36%) did not have a treating psychiatrist at the time of EAS request, and most physicians performing EAS were non-psychiatrists (70%) relying on cross-sectional psychiatric evaluations focusing on EAS eligibility, not treatment. Physicians evaluating such patients appear to be especially emotionally affected compared with when personality disorders are not present.

Conclusions

The EAS evaluation of persons with personality disorders may be challenging and emotionally complex for their evaluators who are often non-psychiatrists. These factors could influence the interpretation of EAS requirements of irremediability, raising issues that merit further discussion and research.

Keywords

Assisted suicideeuthanasiaclinical ethicspsychiatrypersonality disorders
Type
Original Articles
Information
Psychological Medicine , Volume 50 , Issue 4 , March 2020 , pp. 575 - 582
Copyright
Copyright © Cambridge University Press 2019

Access options

Get access to the full version of this content by using one of the access options below. (Log in options will check for institutional or personal access. Content may require purchase if you do not have access.)

References

Ayre, K, Owen, GS and Moran, P (2017) Mental capacity and borderline personality disorder. BJPsych Bulletin 41, 33–36.CrossRefGoogle ScholarPubMed
Bamelis, LL, Evers, SM, Spinhoven, P and Arntz, A (2014) Results of a multicenter randomized controlled trial of the clinical effectiveness of schema therapy for personality disorders. American Journal of Psychiatry 171, 305–322.CrossRefGoogle ScholarPubMed
Bateman, A and Fonagy, P (2009) Randomized controlled trial of outpatient mentalization-based treatment versus structured clinical management for borderline personality disorder. The American Journal of Psychiatry 166, 1355–1364.CrossRefGoogle ScholarPubMed
Bateman, A and Fonagy, P (2015) Borderline personality disorder and mood disorders: mentalizing as a framework for integrated treatment. Journal of Clinical Psychology 71, 792–804.CrossRefGoogle ScholarPubMed
Bateman, AW, Gunderson, J and Mulder, R (2015) Treatment of personality disorder. Lancet (London, England) 385, 735–743.CrossRefGoogle ScholarPubMed
Berghmans, RLP, Huisman, J, Legemaate, J, Nolen, WA, Polak, F, Scherders, MJWT and Tholen, AJ (2009) Richtlijn verzoek om hulp bij zelfdoding door patiënten met een psychiatrische stoornis. De Tijdstroom, U.Google Scholar
Bernal, M, Haro, JM, Bernert, S, Brugha, T, de Graaf, R, Bruffaerts, R, Lepine, JP, de Girolamo, G, Vilagut, G, Gasquet, I, Torres, JV, Kovess, V, Heider, D, Neeleman, J, Kessler, R and Alonso, J (2007) Risk factors for suicidality in Europe: results from the ESEMED study. Journal of Affective Disorders 101, 27–34.CrossRefGoogle ScholarPubMed
Blikshavn, T, Husum, TL and Magelssen, M (2017) Four reasons why assisted dying should not be offered for depression. Journal of Bioethical Inquiry 14, 151–157.CrossRefGoogle Scholar
Cristea, IA, Gentili, C, Cotet, CD, Palomba, D, Barbui, C and Cuijpers, P (2017) Efficacy of psychotherapies for borderline personality disorder: a systematic review and meta-analysis. JAMA Psychiatry 74, 319–328.CrossRefGoogle ScholarPubMed
den Hartogh, G (2017) Stervenshulp holt zolgvuldigheidseisen uit. Medisch Contact 2017;02(07):34–36.Google Scholar
Doernberg, SN, Peteet, JR and Kim, SY (2016) Capacity evaluations of psychiatric patients requesting assisted death in the Netherlands. Psychosomatics 57, 556–565.CrossRefGoogle ScholarPubMed
Gastmans, C (2018) Levenseindezorg voor niet-terminale patiënten met ernstige psychiatrische aandoeningen. Brussels: Zorgnet Icuro. Available at https://www.zorgneticuro.be/sites/default/files/Ethisch%20advies-20-DEF.pdf (Accessed July 2018).Google Scholar
Giourou, E, Skokou, M, Andrew, SP, Alexopoulou, K, Gourzis, P and Jelastopulu, E (2018) Complex posttraumatic stress disorder: the need to consolidate a distinct clinical syndrome or to reevaluate features of psychiatric disorders following interpersonal trauma? World Journal of Psychiatry 8, 12–19.CrossRefGoogle ScholarPubMed
Griffith, J, Weyers, H and Adams, M (2008) Euthanasia and Law in Europe. Portland, OR: Hart Publishing.Google Scholar
Groenewoud, JH, Van Der Heide, A, Tholen, AJ, Schudel, WJ, Hengeveld, MW, Onwuteaka-Philipsen, BD, Van Der Maas, PJ and Van Der Wal, G (2004) Psychiatric consultation with regard to requests for euthanasia or physician-assisted suicide. General Hospital Psychiatry 26, 323–330.CrossRefGoogle ScholarPubMed
Kim, SY, De Vries, RG and Peteet, JR (2016) Euthanasia and assisted suicide of patients with psychiatric disorders in the Netherlands 2011 to 2014. JAMA Psychiatry 73, 362–368.CrossRefGoogle ScholarPubMed
Kurniawan, C and van der Zwaard, R (2018) Euthanasie bij psychiatrie roept vragen op. Medisch Contact 2018;03(10):22–24.Google Scholar
Kvarstein, EH, Pedersen, G, Folmo, E, Urnes, O, Johansen, MS, Hummelen, B, Wilberg, T and Karterud, S (2019) Mentalization-based treatment or psychodynamic treatment programmes for patients with borderline personality disorder – the impact of clinical severity. Psychology and Psychotherapy: Theory, Research and Practice 92, 91–111.CrossRefGoogle ScholarPubMed
Leichsenring, F and Leibing, E (2003) The effectiveness of psychodynamic therapy and cognitive behavior therapy in the treatment of personality disorders: a meta-analysis. American Journal of Psychiatry 160, 1223–1232.CrossRefGoogle ScholarPubMed
Levenseindekliniek Available at http://www.levenseindekliniek.nl (Accessed July 2018).Google Scholar
Linehan, MM, Tutek, DA, Heard, HL and Armstrong, HE (1994) Interpersonal outcome of cognitive behavioral treatment for chronically suicidal borderline patients. American Journal of Psychiatry 151, 1771–1776.Google ScholarPubMed
Linehan, MM, Comtois, KA, Murray, AM, Brown, MZ, Gallop, RJ, Heard, HL, Korslund, KE, Tutek, DA, Reynolds, SK and Lindenboim, N (2006) Two-year randomized controlled trial and follow-up of dialectical behavior therapy vs therapy by experts for suicidal behaviors and borderline personality disorder. Archives of General Psychiatry 63, 757–766.CrossRefGoogle ScholarPubMed
McMain, SF, Links, PS, Gnam, WH, Guimond, T, Cardish, RJ, Korman, L and Streiner, DL (2009) A randomized trial of dialectical behavior therapy versus general psychiatric management for borderline personality disorder. American Journal of Psychiatry 166, 1365–1374.CrossRefGoogle ScholarPubMed
Meuldijk, D, McCarthy, A, Bourke, ME and Grenyer, BF (2017) The value of psychological treatment for borderline personality disorder: systematic review and cost offset analysis of economic evaluations. PLoS ONE 12, e0171592.CrossRefGoogle ScholarPubMed
Newton-Howes, G, Tyrer, P, Johnson, T, Mulder, R, Kool, S, Dekker, J and Schoevers, R (2014) Influence of personality on the outcome of treatment in depression: systematic review and meta-analysis. Journal of Personality Disorders 28, 577–593.CrossRefGoogle ScholarPubMed
O'Connor, RC, Wetherall, K, Cleare, S, Eschle, S, Drummond, J, Ferguson, E, O'Connor, DB and O'Carroll, RE (2018) Suicide attempts and non-suicidal self-harm: national prevalence study of young adults. BJPsych Open 4, 142–148.CrossRefGoogle ScholarPubMed
Oldham, JM (2006) Borderline personality disorder and suicidality. The American Journal of Psychiatry 163, 20–26.CrossRefGoogle ScholarPubMed
Oldham, J, Gabbard, G, Goin, M, Gunderson, J, Soloff, P, Spiegel, D, Stone, M and Phillips, K (2010) American Psychiatric Association (APA) Practice Guideline for the Treatment of Patients With Borderline Personality Disorder. Available at https://psychiatryonline.org/pb/assets/raw/sitewide/practice_guidelines/guidelines/bpd.pdf (Accessed January 2019)Google Scholar
Onwuteaka-Philipsen, B, Legemaate, J, van der Heide, A, van Delden, H, Evenblij, K, El Hammoud, I, Pasman, R, Ploem, C, Pronk, R, van de Vathorst, S and Willems, D (2017) Derde evaluatie Wet toetsing levensbeëindiging op verzoek en hulp bij zelfdoding. Den Haag: ZonMw.Google Scholar
Owen, GS, Richardson, G, David, AS, Szmukler, G, Hayward, P and Hotopf, M (2008) Mental capacity to make decisions on treatment in people admitted to psychiatric hospitals: cross sectional study. BMJ 337, a448.CrossRefGoogle ScholarPubMed
RTE Regional Euthanasia Review Committees Annual Report (2014) Available at https://www.euthanasiecommissie.nl/de-toetsingscommissies/uitspraken/jaarverslagen/2014/nl/nl/jaarverslag-2014 (Accessed July 2018).Google Scholar
RTE Regional Euthanasia Review Committees Annual Report (2017) Available at https://www.euthanasiecommissie.nl/toetsingscommissies/uitspraken/jaarverslagen/2017/mei/17/jaarverslag-2017 (Accessed July 2018).Google Scholar
Schuklenk, U and van de Vathorst, S (2015) Treatment-resistant major depressive disorder and assisted dying. Journal of Medical Ethics 41, 577–583.CrossRefGoogle ScholarPubMed
Snijdewind, MC, Willems, DL, Deliens, L, Onwuteaka-Philipsen, BD and Chambaere, K (2015) A study of the first year of the End-of-Life Clinic for physician-assisted dying in the Netherlands. JAMA Internal Medicine 175, 1633–1640.CrossRefGoogle ScholarPubMed
Steinbock, B (2017) Physician-assisted death and severe, treatment-resistant depression. The Hastings Center Report 47, 30–42.CrossRefGoogle ScholarPubMed
Swenson, CR and Choi-Kain, LW (2015) Mentalization and dialectical behavior therapy. American Journal of Psychotherapy 69, 199–217.CrossRefGoogle ScholarPubMed
Swildens-Rozendaal, WJC and van Wersch, PJM (2015) Code of Practice. The Hague. Available at https://www.euthanasiecommissie.nl/binaries/euthanasiecommissie/documenten/brochures/brochures/code-of-practice/1/code-of-practice-2015/RTE+Code+of+practice_april+2015.pdf (Accessed July 2018).Google Scholar
Thienpont, L, Verhofstadt, M, Van Loon, T, Distelmans, W, Audenaert, K and De Deyn, PP (2015) Euthanasia requests, procedures and outcomes for 100 Belgian patients suffering from psychiatric disorders: a retrospective, descriptive study. BMJ Open 5, e007454-2014-007454.CrossRefGoogle ScholarPubMed
Trimbos Institute (2008) Trimbos Netherlands Institute of Mental Health and Addiction, Multidisciplinaire Richtlijn Persoonlijkheidsstoornissen (Multidisciplinary Guideline Personality Disorders). Utrecht, the Netherlands.Google Scholar
Tyrer, P, Reed, GM and Crawford, MJ (2015) Classification, assessment, prevalence, and effect of personality disorder. Lancet (London, England) 385, 717–726.CrossRefGoogle ScholarPubMed
Van, HL and Kool, M (2018) What we do, do not, and need to know about comorbid depression and personality disorders. The Lancet. Psychiatry 5, 776–778.CrossRefGoogle Scholar
Van Wel, EB, Bos, EH, Appelo, MT, Berendsen, EM, Willgeroth, FC and Verbraak, MJPM (2009) De effectiviteit van de vaardigheidstraining emotieregulatiestoornis (vers) in de behandeling van de borderlinepersoonlijkheidsstoornis; een gerandomiseerd onderzoek. Tijdschrift voor Psychiatrie 51, 291–301.Google Scholar
Vandenberghe, J, Titeca, K, Matthys, F, Van den Broeck, K, Detombe, T, Claes, S, De Fruyt, J, Hermans, M, Lemmens, G, Peeters, D and Van Buggenhout, R (2017) Hoe omgaan met een euthanasieverzoek in psychiatrie binnen het huidig wettelijk kader? Adviestekst van de Vlaamse Vereniging voor Psychiatrie (VVP) over te hanteren zorgvuldigheidsvereisten. (Accessed July 2018).Google Scholar
Verhofstadt, M, Thienpont, L and Peters, GY (2017) When unbearable suffering incites psychiatric patients to request euthanasia: qualitative study. The British Journal of Psychiatry: The Journal of Mental Science 211, 238–245.CrossRefGoogle ScholarPubMed
WHO (2001) World Health Organization; Department of Mental Health and Substance Dependence; Gender Disparities in Mental Health. Available at http://www.who.int/mental_health/media/en/242.pdf (Accessed July, 2018).Google Scholar
Zanarini, MC (2009) Psychotherapy of borderline personality disorder. Acta Psychiatrica Scandinavica 120, 373–377.CrossRefGoogle ScholarPubMed
Zanarini, MC, Frankenburg, FR, Reich, DB and Fitzmaurice, G (2012) Attainment and stability of sustained symptomatic remission and recovery among patients with borderline personality disorder and axis II comparison subjects: a 16-year prospective follow-up study. American Journal of Psychiatry 169, 476–483.CrossRefGoogle ScholarPubMed
Zimmerman, M, Chelminski, I, Young, D, Dalrymple, K and Martinez, J (2012) Does the presence of one feature of borderline personality disorder have clinical significance? Implications for dimensional ratings of personality disorders. The Journal of Clinical Psychiatry 73, 8–12.CrossRefGoogle ScholarPubMed
Supplementary material: PDF

Nicolini et al. supplementary material

Nicolini et al. supplementary material 1

Download Nicolini et al. supplementary material(PDF)
PDF 166.9 KB
Supplementary material: PDF

Nicolini et al. supplementary material

Nicolini et al. supplementary material 2

Download Nicolini et al. supplementary material(PDF)
PDF 164.6 KB