Establishing irremediable psychiatric suffering in the context of medical assistance in dying in the Netherlands: a qualitative study

Background:Establishing irremediability of suffering is a central challenge in determining the appropriateness of medical assistance in dying (MAiD) for patients with a psychiatric disorder. We sought to evaluate how experienced psychiatrists define irremediable psychiatric suffering in the context of MAiD and what challenges they face while establishing irremediable psychiatric suffering.Methods:We conducted a qualitative study of psychiatrists in the Netherlands with experience assessing irremediable psychiatric suffering in the context of MAiD. We collected data from in-depth, semistructured interviews focused on the definition of irremediable psychiatric suffering and on the challenges in establishing irremediability. We analyzed themes using a modified grounded theory approach.Results:The study included 11 psychiatrists. Although irremediable psychiatric suffering is a prospective concept, most participants relied on retrospective dimensions to define it, such as a history of failed treatments, and expressed that uncertainty was inevitable in this process. When establishing irremediable psychiatric suffering, participants identified challenges related to diagnosis and treatment. The main diagnostic challenge identified was the frequent co-occurrence of more than 1 psychiatric diagnosis. Important challenges related to treatment included assessing the quality of past treatments, establishing when limits of treatment had been reached and managing “treatment fatigue.”Interpretation:Challenges regarding the definition, diagnosis and treatment of irremediable psychiatric suffering complicate the process of establishing it in the context of MAiD. Development of consensus clinical criteria for irremediable psychiatric suffering in this context and further research to understand “treatment fatigue” among patients with psychiatric disorders may help address these challenges. Registration: This study was preregistered under osf.io/2jrnd.

Medical assistance in dying (MAiD), also known as physician-assisted death, has been legalized in an increasing number of jurisdictions around the world.¹ In 2023, Canada will join a small group of countries that allow MAiD for people with mental illness, more commonly referred to as persons with a psychiatric disorder. ² In the Netherlands, MAiD for irremediable psychiatric suffering has been approved by jurisprudence since the 1990s and it has been regulated by law since 2002. The last decade has seen a marked increase in MAiD for irremediable psychiatric suffering; in 2020, MAiD was performed 88 times for psychiatric suffering (1.3% of all MAiD cases), compared with just 2 instances in 2010.³ The number of requests by patients with a psychiatric disorder is much higher, but 90% of requests do not end in MAiD. Sometimes, they are retracted by patients, but most are denied by psychiatrists.⁴The main legal requirements for MAiD in the Netherlands are that the patient must be able to make a competent request, that the patient’s suffering must be unbearable and irremediable, and that the patient and physician agree that there are no other reasonable treatment options. The process for MAiD requires an assessment by an independent physician and, in the case of psychiatric suffering, a third assessment by an independent psychiatrist, preferably one with specific expertise regarding the patient’s disorder.⁵ The Canadian legal requirements under the amended Bill C-7, which will come into effect in 2023, will be largely similar to the Dutch requirements.⁶ However, Canadian legislation, which does not yet permit MAiD for mental illness, has 1 important difference: patients with decision-making capacity can qualify for MAiD if they refuse treatments that they do not find acceptable. It is as yet unknown whether this approach to refusal of treatment will also be applied to MAiD where mental illness is the sole underlying condition.Although there are concerns about decision-making capacity, the central dilemma of MAiD for patients with a psychiatric disorder appears to revolve around applying the concept of irremediability to psychiatric disorders. The 2018 guideline by the Dutch Psychiatry Association defines irremediable psychiatric suffering in the context of MAiD as follows: “irremediability means that there is no longer any prospect of alleviating, mitigating, enduring or removing suffering. There is no longer a reasonable treatment perspective.”⁷ Elsewhere, the guideline states that reasonable treatment perspective means that “there is a prospect of improvement with adequate treatment, within a foreseeable period, and with a reasonable ratio between the expected results and the burden of the treatment for the patient.”⁷A recent scoping review identified a multitude of conceptual articles addressing irremediability in the context of psychiatric MAiD but few empirical studies.¹ This suggests that the assessment of irremediable psychiatric suffering is particularly difficult relative to suffering arising from other types of conditions.Surveys estimate that 46% of psychiatrists in the Netherlands have received an explicit MAiD request at least once in their career, and 4% actually assisted in the death of a patient with a psychiatric disorder.⁸ The experiences of psychiatrists who have handled MAiD requests can be seen as an important source of knowledge about the challenges of establishing irremediable psychiatric suffering in practice. The aim of this study was to learn how experienced psychiatrists define psychiatric suffering as irremediable in the context of a MAiD request and what challenges they face while establishing irremediable psychiatric suffering.