Depression and Terminal Illness
Below is an excerpt from an OnMedica editorial entitled, “Psychiatrists oppose assisted dying bill“.
The article defines PAS (physician-assisted suicide) as follows: “PAS is when a doctor prescribes a patient a lethal dose of medication for self-administration with the specific goal of enabling the patient to commit suicide.” It is euthanasia when someone other than the patient administers the lethal drugs, usually by injection.
“Problems of physical and mental health often coexist. As specialists who frequently work at the interface of these problems, we are well aware of the effects of disempowerment, despair, fear of the future and fear of being a burden to others. We are also aware that people who are sick are often less able to obtain for themselves the effective treatments which they require to alleviate their disempowerment and suffering. We are also well aware of the ways in which, so often, the experience of illness is substantially different from that which is anticipated.
“The college believes that psychiatric issues are of crucial importance when PAS is considered, and point out that, while clear diagnoses of severe depression or psychosis may occur in this group of people, more frequently, judgement may be coloured by mild depression, mild cognitive impairment and pressure from others. Depression is a subtle insidious condition, which hugely influences people’s psychological processes. Depression frequently gains an insidious foothold in people with physical illness. Spotting this will always be challenging, and this difficulty means that PAS will put such people at risk.
“In the general population, suicidal thoughts and urges are common symptoms of depression, and serious suicidal thoughts rarely arise apart from depression.[1. Meltzer, 2002] Studies using systematic assessments in terminally ill patients have clearly shown that depression is strongly associated with the desire for a hastened death, including the wish for PAS or euthanasia. This is true for the top three diseases for which patients request PAS: Cancer, motor neuron disease and HIV/AIDS.[2. Achille & Ogloff, 2004; Block, 2000; Block & Billings, 1994; Breitbart et al., 2000; Chochinov et al., 1995; Emanuel et al., 1996; Emanuel, Fairclough, & Emanuel, 2000; Ganzini et al., 1998; Ganzini, Silveira, & Johnston, 2002; Haverkate et al., 2000; Kelly et al., 2004; Ransom et al., 2006; Rosenfeld et al., 1999; van der Lee et al., 2005] Patients with mental illness who then develop a terminal physical disease can receive substandard treatment for psychiatric relapses after requesting PAS, partly because doctors become confused by the competing processes of PAS and psychiatric clinical care.[3. Hamilton & Hamilton, 2005]
“Once a person’s depression is treated effectively most (98-99%) will subsequently change their minds about wanting to die.[4. Hawton & Fagg, 1998] In persons suffering with painful, disabling and terminal illnesses, depression is very common. Depression, pain and desperation generally underlie suicidal thoughts, which can generally be relieved by appropriate support and by effective treatments for depression in the terminally ill, including antidepressants, anxiolytics, psychostimulants, electroconvulsive therapy and psychotherapy[5. Zaubler & Sullivan, 1996] and relief of pain by diamorphine often lifts depressive ideation. Requests for PAS should trigger effective treatment of depression and its causes – not actual PAS. (emphasis ours)
“Many doctors do not recognise depression or know how to assess for its presence in terminally ill patients. [6. Bowers & Boyle, 2003; Kissane & Kelly, 2000; Passik et al., 1998; Stiefel et al., 2001; Thompson et al., 2000] Even when recognized, doctors often take the view that “understandable depression” cannot be treated, does not count or is in some way not real depression. So in terminally ill patients, depression often goes untreated and in some cases PAS or euthanasia is provided anyway.[7. Dinwiddie, 1999; Groenewoud et al., 2004; Meier et al., 2003] In addition, in requests for PAS, the influence of a psychiatric condition in making the request can be underestimated.[8. Bannink, et al., 2000]
“In terminally ill patients, depression often fluctuates with pain, as well as altering the perception of the pain and subjective views of the future. The desire to die has been found to decrease over time in terminally ill persons.[9. Chochinov et al., 1995] Specifically, the wish for euthanasia or PAS changes over time in a large proportion of terminally ill patients, and decision instability is particularly associated with depressive symptoms.[10. Emanuel, Fairclough, & Emanuel, 2000] Improvement in depression is generally accompanied by an increased desire for life-sustaining interventions in the elderly and the terminally ill.[11. Fogel & Mor, 1993; Ganzini et al., 1994; Hooper et al., 1996; Rosenfeld et al., 1996] And when fears and palliative care needs are addressed, the request for an assisted death usually disappears.[12. Hamilton & Hamilton, 2005: Hendin, 1999] Pain alleviation resulted in 85% of patients withdrawing their requests for euthanasia or PAS in a Netherlands study.[13. Van der Maas et al., 1991] As does depression and suicidality, mental capacity fluctuates, thus one assessment for PAS is insufficient.”