Psychiatric conditions less likely to be granted physician-assisted suicide

1. Despite existing to reassess and potentially allow euthanasia or physician-assisted suicide to patients who were previously rejected by their physician, only 25% of requests to the End-of-Life-Clinic were granted.

2. Conditions more likely to be associated with a granted request were cognitive decline and somatic conditions. Requests from those with psychological conditions and those tired of living were least likely to be granted.

Evidence Rating Level: 2 (Good)

Study Rundown: Physician-assisted suicide (PAS) has been legal in the Netherlands since 2002. However, patients must meet stringent legal criteria. The Netherland’s End-of-Life-Clinic is an organization that provides euthanasia or PAS for patients whose regular physicians rejected their request based on principle or because they believed the due criteria were not met. These patients are often those with less common situations, such as psychiatric patients, patients with dementia, or those tired of living. It is unclear, however, how the presence of the End-of-Life-Clinic has impacted the overall access to euthanasia and PAS after initial rejection. This study aimed to determine 1) how often applications for euthanasia or PAS at the End-of-Life-Clinic are granted or rejected, and 2) which factors are associated with each outcome of an application.

Fewer than 50% of applications were ultimately refused, whereas 25% requests were granted. Patients with cognitive decline or a somatic condition had the highest percentage of granted requests, whereas patients with psychological conditions had the smallest. Factors independently associated with granted requests included having more than one child and having tiredness and loss of autonomy. Factors independently associated with rejected requests included being single, having a psychological condition, and having loneliness or loss of mental capacity. Strengths of this study include having access to the original patient applications and all sociodemographic and clinical information. However, it would have been interesting for these applications to contain information on reasons for application withdrawal, thus allowing study to further understand patient preferences regarding PAS and euthanasia.

Click to read the study, published in JAMA Internal Medicine

Relevant Reading: Trends in end-of-life practices before and after the enactment of the euthanasia law in Netherlands from 1990 to 2010: a repeated cross-sectional survey

In-Depth [retrospective cohort]: This retrospective cohort study used data from all End-of-Life-Clinic’s application registration files from March 2012 to March 2013, the clinic’s first year of operation. Each file contains the original application form with patient, relatives, and physician information and final outcome. Patient applications were coded into type of medical condition. Four outcomes of a request were identified: patient received euthanasia or PAS, patient had been refused by the clinic, patient withdrew the application, or patient died of cause other than PAS or euthanasia. Statistical analysis includes bivariate crosstab analysis and χ² or Fisher exact significance testing and multivariate analysis.

During the year of study, 709 applications were received, from which 645 applications were available for analysis. Of those, 162 requests (25.1%) were granted, 300 requests (46.5%) were refused, 124 (19.2%) died before the request was assessed, and 59 patients (9.1%) withdrew their requests. Patients with cognitive decline or somatic conditions were more likely to get their request granted, in contrast to those with psychological conditions or those who were tired of living. Patient factors associated with granted requests were older age (p < 0.001). However, patients with rejected requests were more likely to be single (p < 0.001) and without children (p < 0.001). Among the patients with rejected requests, a majority of patients identified psychological suffering and loneliness as their type of suffering. Factors independently associated with granted requests from multivariate analysis included having more than one child (OR 2.35, 95%CI 1.31-4.23; p = 0.004), having tiredness (OR 3.62, 95%CI 1.88-6.97; p < 0.001), or loss of autonomy (OR 3.41, 95%CI 1.89-6.16; p < 0.001).

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