January 9, 2019

How Should Clinicians Respond to Decisionally Capable Patients Who Wish to End Their Own Lives?

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Joel Yager, MD; Linda Ganzini, MD, MPH; Dan H. Nguyen, MD; and Erica K. Rapp, MD

University of Colorado School of Medicine, Aurora (Drs Yager and Rapp); VA Portland Healthcare System & Oregon Health & Science University (Dr Ganzini); Kaiser Permamente, Denver, Colorado (Dr Nguyen)​​


We recently published an article about how clinicians should respond to decisionally capable patients with advanced medical illnesses who are determined to end their lives. Sometimes these patients not only wish to inform their physicians of their plans, but also invoke their clinicians’ support to assist them and their families throughout and following these processes. However, respecting such patients’ wishes to control the circumstances of their death might well conflict with one’s usual approaches to suicide prevention, stirring up all sorts of ethical, legal, psychological, social, and clinical concerns.

Since the term “suicide” evokes negative connotations, scholars increasingly refer to “physician-assisted death” or “medical assistance in dying” to describe acts whereby clinicians actively assist terminally ill individuals who wish to die. Most psychiatrists abhor the thought of actively administering lethal medications or prescribing medications to end life. And—to be clear—that is not what we advocate.

How then might clinicians respond to such patients? Prudent clinicians will first assess whether reversible mental illness is distorting the patient’s authentic decision-making, study local laws and practices regarding end-of-life care, and reflect on their own ethical and moral positions concerning self-initiated deaths in such circumstances. Clinicians also need to examine their own self-protective biases driven by desires to minimize their legal and financial risks, interpersonal conflicts, and social disapproval. Clinicians should not put their own interests above their patients. At one extreme, they might hospitalize them involuntarily, adding insult to injury. Ethically, clinicians should never hold competent patients lacking mental illness involuntarily or violate their confidentiality. Alternatively, clinicians may discharge them from their care without taking further action.

But better options exist. Clinicians can encourage patients to delay their actions to take time for reflection to ensure determination without vacillation. Clinicians can also offer palliative psychiatric care including pre-terminal consultations to emotionally prepare family members—facilitating reconciliations, handling unfinished business, saying goodbyes, perhaps negotiating the family’s presence and participation in the final act, and offering survivors emotional care following death.

In summary, we are not advocating a laissez faire attitude toward suicide for patients with limited life expectancy. However, we do believe that honoring such patients’ wishes concerning planned death and even collaborating with them, enhancing—and not hindering—these important life transitions by adopting perspectives from palliative care, might be much more compassionate than always interfering with their plans.

Clinicians should always carefully document conversations with patients and family members, limitations in therapeutic options, consultations (with physicians, attorneys, ethics committees, risk-management), and rationales for their decisions and actions. And, if conflicted, they should always seek consultation from the wisest available professionals.

Finally, we are not advising that psychiatrists prescribe or propose lethal medications as options to their patients. We believe our views are consistent with the original Hippocratic Oath and its contemporary versions, the Declaration of Geneva and the Oath of Maimonides.

Financial disclosure:Dr Yager is an associate editor for Journal Watch for Psychiatry and a section editor for Up To Date. Dr Ganzini has received grant/research support from VA Portland HCS/VA. DrsRapp and Nguyen have no relevant personal financial relationships to report.

The views expressed in this article are those of the authors and do not necessarily reflect the position or policy of the Department of Veterans Affairs or the United States government.

Category: Medical Conditions , Mental Illness , Prescribing , Suicide
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Related to “Working With Decisionally Capable Patients Who Are Determined to End Their Own Lives.”

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