Mental Health Professionals – here is the form the state requires you to complete. Psychiatric / Psychological Consultant’s Compliance Form
FROM THE: The Oregon Death with Dignity Act: A Guidebook for Health Care Professionals, Written: February 1998; Revised: October 2004, March 2005, September 2007, December 2008
The Oregon Death with Dignity Act outlines a specific role for psychiatrists and psychologists. If the attending or consulting physician believes that the patient may be suffering from a “psychiatric or psychological disorder, or depression causing impaired judgment,” a mental health evaluation is mandated. Either a licensed psychiatrist or licensed psychologist may perform the evaluation. Once the patient is referred, the attending physician may write a prescription under the Oregon Act only if the mental health professional assesses that the patient is not suffering from a psychiatric or psychological disorder or depression causing impaired judgment. In addition, the mental health professional should evaluate if the person is “capable,” that is, “has the ability to make and communicate health care decisions, including communication through persons familiar with the patient’s manner of communication if those persons are available.”1 The mental health consultation as outlined in the Oregon Act, is a form of a capacity or competence evaluation, specifically focused on capacity to make the decision to hasten death by self-administering a lethal dose of medication. In the first ten years after enactment of the Oregon Death with Dignity Act, 11% of persons who died by a lethal dose of medication were evaluated by a mental health professional.2 None of the 49 people who died by lethal prescription in 2007 were referred for a mental health evaluation.3
Mental health professionals may choose not to provide this type of consultation for conscientious reasons (see Conscientious Practice). In a survey of 290 U.S. forensic psychiatrists, 24% believed that psychiatric consultation for the purposes of determining competence for ingesting a lethal dose of medication was unethical.4 Oregon psychiatrists and psychologists are divided on the ethical permissibility of the Oregon Death with Dignity Act. A 1995 survey of Oregon psychiatrists revealed that 56% support the implementation of the Oregon Act, but one third endorse that legal ingestion of a lethal dose of medication should never be permitted.5 In a 1996 survey of Oregon psychologists, 78% supported enactment of the Oregon Death with Dignity Act.6
The American Psychological Association (APA) “Working Group on Physician Assisted Suicide” neither supports nor decries the Oregon Act, but encourages psychologists to be informed about policy and research related to the Oregon Act, to be aware of their own views and possible biases regarding eligibility for the option, and to be sensitized to possible social pressures that may contribute to the perception that vulnerable populations are more expendable. Psychologists are also advised to “fully explore alternative interventions (including hospice/palliative care, and other end-of-life options such as voluntarily stopping eating and drinking) for clients considering” this alternative.7
Mental health professionals’ views on the ethical permissibility of the Oregon Act are likely to influence the standards used in diagnosing a mental disorder and determining whether the mental disorder causes impaired judgment. In the survey of U.S. forensic psychiatrists, those who were morally opposed to the Oregon Act were more likely to advocate a more stringent standard for evaluating competence and more likely to believe that depressive disorders would automatically render a patient incompetent to choose ingestion of a lethal dose of medication.4 Oregon psychiatrists’ and psychologists’ positions on legalization of the Oregon Act influenced their willingness to evaluate patients who request a prescription under the Oregon Act and how they would follow up an evaluation. For example, 72% of psychiatrists opposed to the Oregon Act would refuse to perform this type of evaluation, compared to only 33% of those who favored the Act.5 Despite majority support for legalization of the Oregon Act, only 36% of psychologists in Oregon were willing to perform these evaluations.6 Interviews with physicians in Oregon who have received requests under the Oregon Act confirm their difficulties in finding a mental health professional to evaluate the patient, especially if a home visit is required (Ganzini, unpublished data). Most psychiatrists and psychologists who opposed the Oregon Act would work to prevent the patient from taking the medication to end his/her life, even if they found the patient competent. These data suggest that mental health professionals who are either strong proponents or opponents of this Oregon Act may have difficulty objectively evaluating patients and should consider declining. The mental health professional should disclose personal biases to the attending physician at the time of referral. The patient’s therapist should not serve in this capacity, though he/she may provide invaluable insights to the mental health consultant.8
The Evaluation Process
The psychiatrist/psychologist should hold a valid Oregon license and have experience in psychiatric diagnosis, capacity evaluations, and evaluation of medically ill patients. Experience in working with dying patients in other settings may be helpful. Mental health professionals are qualified to evaluate capacity because of their expertise in diagnosing psychiatric disorders, examining mental status, and understanding irrational forces that influence decision-making. The consultation will usually include a record review, discussion with the referring physician, patient interview and assessment, and caregiver and family interviews (with the patient’s consent). Eighty-six percent of patients who die by ingestion of medication under the Oregon Act are enrolled in hospice2 and hospice practitioners may have important insights into potentially reversible conditions and mental state. If the mental health consultant perceives a conflict of interest, financial or otherwise, which might influence his/her decision-making, he/she should decline to perform the evaluation. Mental health professionals may decline to evaluate the patient or to even suggest colleagues who could evaluate the patient for conscientious reasons.
The evaluation should focus on assessing for mental disorders such as depression and delirium, the patient’s decision-making capacity, and factors that limit decision-making capacity such as mental disorders, knowledge deficits, and coercion. Dementia may co-occur with a terminal illness. Mild dementia does not automatically disqualify a terminally ill person from Oregon’s law; the evaluator must determine whether the patient retains capacity for medical decisions. The ability to understand the nature of the intervention, risks, and benefits of a prescription under the Oregon Act may be straightforward, but the ability to understand the risks and benefits and likelihood of success of alternative interventions can be difficult, especially for very ill patients, and should be a focus of the interview. Patients should be able to appreciate the information as shown by the ability not only to understand the facts but also to apply the information to his or her own situation.
The mental health professional is obligated to maximize the patient’s ability to perform well on the examination.9 The patient should be seen individually, as he/she may feel more comfortable talking about concerns such as being a burden to others. Many patients imagine an adversarial process. Rapport is important. Ill patients may tire easily. The examiner should be prepared to modify the examination based on the patient’s tolerance. An extended evaluation may not always be feasible, depending on the patient’s preferences, physical condition, limited time to live, financial constraints, and geographic location. Seeing the patient in his/her residence rather than the mental health professional’s office may diminish the patient’s exhaustion. Instruments such as the Geriatric Depression Scale,10 the Folstein Mini-Mental State Examination,11 or the Neurobehavioral Cognitive Status Examination12 may be useful adjuncts to assess mood and cognition.
In the absence of a mental disorder, evidence of coercion or knowledge deficits, most patients will qualify for the Oregon Act. Attending physicians are unlikely to refer patients whom they know well or who are calm, lucid, and rational to a mental health professional. At the other end of the spectrum, physicians are likely to refer patients with severe depression or delirium for treatment, not a capacity evaluation. Cases in which some psychological symptoms are present and decision-making capacity is questionable or marginally compromised are the most likely to need referral. Although mental health professionals are skilled in diagnosing mental disorders, determining the role of a mental disorder such as depression on decision making is more difficult, even by expert assessment. In surveys of Oregon mental health professionals, only 6% of psychiatrists and psychologists were very confident that they could determine whether a mental disorder was influencing the judgment of a person requesting a prescription under the Oregon Act, if they only saw the patient once.5,6 They were more confident about assessing decision-making capacity over an extended period of time.5,6 In a study of 290 U.S. forensic psychiatrists, “58% indicated that the presence of a major depressive disorder should result in an automatic finding of incompetence for the purposes of obtaining assisted suicide”.4 As such, of the two components of the mental health assessment (presence of a mental disorder and determination of its influence) the greatest weight in determining eligibility for obtaining medication under the Oregon Act should be on whether or not a mental disorder such as depression can be diagnosed.13
The consulting mental health professional should feel free to communicate to the attending physician the standard he/she used for capacity and his/her degree of confidence regarding the determination of capacity.4,5,14 Even if the evaluator cannot say with confidence whether the patient has or lacks decisional capacity, the attending physician will be able to use the information that the mental health professional provides. The consultant can suggest interventions to enhance capacity, ask to reevaluate the patient after treatment is provided, or recommend a second opinion from another mental health professional.15 Once the patient is referred for a mental health evaluation, the attending physician may write a prescription for a lethal dose of medication only if the mental health professional can state that within his/her standards, the patient meets the criteria of the Oregon Death with Dignity Act.
Even when a mental disorder is absent and decision-making appears intact, psychotherapeutic interventions may relieve suffering. The mental health clinician’s traditional role includes helping patients with coping and decision-making. As such, it is important for the mental health
professional to understand the patient’s overall situation and factors contributing to his/her request for medication with which to end life. These factors may include the patient’s access to or attitudes about medical care, communication with the attending physician, his/her quality of life, belief system, life history, financial and family issues and experiences with deaths of others (see Hospice, Palliative Care, and Comfort Care and Financial Issues). The mental health consultant should explore with the patient the attitudes of family members or a decision to conceal the request for a prescription under the Oregon Act from the family (see Family Needs and Concerns). The mental health professional should also assess communication in the relationship between the attending physician and the patient.
The mental health consultant should support autonomous choice and attenuate the anguish of the dying process.14 The patient may dread particular aspects of the future; struggle to find meaning in remaining life; feel guilt, low self-worth, anger, or worry about being a burden to others. Previous experiences with other dying persons may distort the patient’s understanding of alternatives. Illness or personality may impede the patient’s ability to think flexibly or to consider other alternatives. The request for a prescription under the Oregon Act may be an attempt to cope with loss of control and pending dependence on others.16-19 The mental health consultant can help by reframing alternatives for the patient, exploring other methods for the patient to maintain control, and countering negative thinking.17 The patient may question the mental health professional’s motives, however, if the consultant puts too much emphasis on finding alternatives.19
Many patients may qualify under the Oregon Act yet still benefit from supportive counseling. The mental health consultant may choose to recommend individual supportive psychotherapy, family therapy, or referral to spiritual or other support services. Many of these services are available to those enrolled in hospice. If the mental health professional finds the patient competent and without a mental disorder that is influencing the desire to obtain a lethal dose of medication, refusal of further mental health treatment by the patient does not constitute a legal barrier to receiving a prescription for a lethal dose of medication.
Mental Disorders that may Influence Decision-Making
Mental disorders are the most common reasons why decision-making capacity is impaired, but not all psychiatric disorders automatically impair decision-making abilities. Disorders such as Alzheimer’s disease occur in half of people over age 85 causing both difficulty in remembering the details of the illness and impairing the patient’s ability to weigh risks and benefits and, applying the information to his/her own situation.20,21 Studies of geriatricians, psychiatrists, and neurologists show high levels of disagreement among these professionals when assessing the ability of persons with mild Alzheimer’s disease to make medical treatment decisions, though consistency can be improved when clinicians are made aware of applicable legal standards.22,23 Some very physically ill patients will have mild cognitive impairments not meeting the criteria for dementia. These patients may not be impaired in their capacity to understand the risks and outcome of ingesting a lethal dose of medication or to recite the alternatives (e.g., hospice), but their ability to truly appreciate complicated palliative alternatives with their attendant uncertainties may be taxed.
Delirium is common in the final weeks of life, especially when high doses of opioids are needed to control pain.24,25 Delirium is characterized by problems with attention, concentration, and memory. Delirium almost universally impairs decision-making capacity, and even when subtle can affect a patient’s ability to see options clearly and make an informed decision and may lower inhibitions to ingesting a lethal dose of medication.23 However, impairments in decision-making capacity due to delirium can wax and wane. Some patients will have suffered delirium during some portion of their treatment and may miss critical information regarding their disease. This lack of information can be overcome with patient education after the delirium has resolved.
Alcohol misuse may continue into the terminal period. Although the patient may meet the criteria under the Oregon Act for a prescription, he/she may impulsively ingest the medication. The attending physician should be advised of these concerns.
Depression is a common diagnosis among terminally ill patients desiring hastened death.17,26-28 Oregon primary care physicians have appropriately expressed doubt about their ability to diagnose depression in these patients,29 though in a recent survey of physicians who received requests, only 9% were uncertain if the patient had depression and no patient about whom the physician was uncertain received a prescription under the Oregon Act.16 Even for mental health professionals, diagnosing a major depressive disorder in terminally ill persons can be difficult. What appear to be depressive vegetative symptoms such as weight loss and loss of energy may be due to the underlying disease in terminally ill patients. Mild psychological symptoms such as sadness, hopelessness, and difficulty experiencing pleasure may be realistic responses to a terminal prognosis and the limitations of severe medical illness. Unremitting low mood and anhedonia, despair, despondency, and pervasive low self-esteem are hallmarks of significant depression. Psychotherapy and medications are effective for treatment of depression in terminally ill persons. The patient’s life expectancy and ability to tolerate antidepressant medications may limit treatment options. While psychostimulants are effective within several days of initiation, other medications take several weeks to be effective.25
Depression may impair patients’ ability to understand their options, diminish the ability to appreciate the benefits of life, and magnify the burdens. Studies of elderly patients interested in life-sustaining medical treatment indicates that mild-moderate depression has little effect on patients’ treatment decisions, but severe depression has a substantial effect.28,30 A survey of Oregon physicians about their experiences with requests for prescriptions under the Oregon Act suggests that most proceed cautiously. Although 20% of patients who requested a prescription were depressed, none received a prescription from the surveyed physicians.16 However, in a study of 58 individuals seeking a prescription under the Oregon Act, one in four were assessed to have major depressive disorder.31 Of the 18 who received a lethal prescription, 15 (83%) had no evidence of a mood disorder, but three were diagnosed with major depression. All three died by lethal ingestion within two months of the research interview. This suggests that the practice of the Oregon Death with Dignity Act through 2006 did not include adequate assessment of all patients for mental health conditions that could impair judgment. Specifically, more vigilance and systematic examination for depression for these patients is needed.
Outside the context of terminal illness, the relationship between suicide and depression is very strong: some psychiatric disorder is present at the time of death in 90% of completed suicides.13 Treatment of psychiatric disorders in those who attempt suicide is very effective in abolishing suicidal ideation. This is the basis for our recommendation that patients who request a medication for the purpose of ending life be systematically screened for depression and referred for a mental health evaluation if screening indicates depression. Screening instruments that could be used include the Patient Health Questionnaire-9 (PHQ-9), which is reliable, validated, and easy to administer. Further study is needed to determine whether depression treatment will alter desire for a prescription under the Oregon Act in terminally ill patients.
Guidelines
9.1 We strongly recommend that all patients who request a lethal prescription under the Oregon
Act be screened for depression with a validated instrument such as the PHQ-9. Other possible instruments could be used. If the screening indicates possible depression, the person should be referred to a psychiatrist or a psychologist.
9.2 Mental health professionals with strong personal biases for or against the Oregon Act should consider declining the consultation. Biases should be disclosed to the attending physician at the time of the referral.
9.3 The mental health consultant has two roles. The first, as outlined in the Oregon Death with Dignity Act, is to determine the patient’s specific capacity to make the decision to hasten death by self-administering a lethal dose of medication. The second, a traditional role, is to evaluate for any remediable sources of suffering.
9.4 Mental health professionals may decline to participate in any aspect of the Oregon Act.
9.5 When a mental health consultant cannot make a determination of capacity with confidence, the consultant can suggest treatments, reevaluate, or recommend a second mental health evaluation.
References
1. Oregon Death with Dignity Act Rev. Stat. SS 127.800-.897, 19942.
2. Oregon Department of Human Services. Sixth Annual Report on the Oregon Death with
Dignity Act. March 2004. http://www.oregon.gov/DHS/ph/pas/index.shtml
3. Oregon Department of Human Services. Tenth Annual Report on the Oregon Death with Dignity Act. March 2008. http://www.oregon.gov/DHS/ph/pas/index.shtml
4. Ganzini L, Leong GB, Fenn DS, Silva JA, Weinstock R. Evaluation of competence to consent to assisted suicide: views of forensic psychiatrists. Am J Psychiatry. 2000;157:595-600.
5. Ganzini L, Fenn DS, Lee MA, Heintz RT, Bloom JD. Attitudes of Oregon psychiatrists toward physician-assisted suicide. Am J Psychiatry. 1996;153:1469-1475.
6. Fenn DS, Ganzini L. Attitudes of Oregon psychologists toward physician-assisted suicide. Prof Psychol Res Pract. 1999;30:235-244.
7. APA Working Group on Assisted Suicide and End-of-Life Decisions: http://www.apa.org/pi/aseol/introduction.html
8. Farrenkopf T, Bryan J. Psychological consultation under Oregon’s 1994 Death with Dignity Act: ethics and procedures. Prof Psychol Res Pract 1999;30:245-249.
9. Grisso T, Appelbaum PS. Assessing Competence to Consent to Treatment: A Guide for Physicians and Other Health Professionals. New York: Oxford University Press, 1998.
10. Yesavage JA, Brink TL, Rose TL, Lum D, Huang V, Aden M, Leiver VO. Development and validation of a geriatric depression screening scale: a preliminary result. J Psychiatr Res. 1983;17:37-49.
11. Folstein MF, Folstein SE, McHugh PR. Mini-mental state: a practical method for grading the cognitive state of patients for the clinician. J Psychiatry Res. 1974;12:189-198.
12. Kiernan RJ, Meuller J, Langston JW, Van Dyke C. The neurobehavioral cognitive status examination: a brief but quantitative approach to cognitive assessment. Ann Intern Med. 1987;107:481-485.
13. Ganzini L, Lee MA. Psychiatry and assisted suicide in the United States. N Engl J Med. 1997;336:1824-1826.
14. Sullivan MD, Ganzini L, Youngner SJ. Should psychiatrists be gatekeepers for assisted suicide? Hastings Cent Rep. 1998;28:14-22.
15. Werth J, Benjamin A, Farrenkopf T. Requests for physician-assisted death: guidelines for assessing mental capacity and impaired judgment. Psychology, Public Policy and Law. 2000;6(2):348-372.
16. Ganzini L, Nelson HD, Schmidt TA, Kraemer DF, Delorit MA, Lee MA: Physicians’ experiences with the Oregon Death with Dignity Act. N Engl J Med. 2000;342:557-563.
17. Block SD, Billings JA. Patient requests for euthanasia and assisted suicide in terminal illness: the role of the psychiatrist. Psychosomatics. 1995;36:445-457.
18. Ganzini L, Harvath TA, Jackson A, Goy ER, Miller LL, Delorit MA. Experiences of Oregon nurses and social workers with hospice patients who requested assistance with suicide. N Engl J
Med. 2002;347(8):582-588.
19. Ganzini L, Dobscha SK, Heintz RT, Press N. Oregon physicians’ perceptions of patients who request assisted suicide and their families. Journal of Palliative Medicine. 2003;6:381-390.
20. Evans DA, Funkenstein HH, Albert MS, et al. Prevalence of Alzheimer’s disease in a community population of older persons: higher than previously reported. JAMA. 1989;262:2551- 2556.
21. Ebly EM, Parhad IM, Hogan DB, et al. Prevalence and types of dementia in the very old: results from the Canadian Study of Health and Aging. Neurology. 1994;44:1593-1600.
22. Marson DC, McInturff B, Hawkins L, Bartolucci A, Harrell LE. Consistency of physician judgments of capacity to consent in mild Alzheimer’s disease. J Am Geriatr Soc. 1997;45:453- 457.
23. Marson DC, Earnst KS, Jamil F, Bartolucci A, Harrell LE. Consistency of physicians’ legal standard and personal judgments of competency in patients with Alzheimer’s disease. J Am Geriatr Soc. 2000;48:911-918.
24. Massie MJ, Holland J, Glass E. Delirium in terminally ill cancer patients. Am J Psychiatry. 1983;140:1048-1050.
25. Breitbart W, Chochinov HM, Passik S. Psychiatric aspects of palliative care. In: Doyle D, Hanks GWC, MacDonald N, eds. Oxford Textbook of Palliative Medicine. 2nd ed. New York: Oxford University Press, 1998:933-954.
26. Breitbart W, Rosenfeld BD, Passik SD. Interest in physician-assisted suicide among ambulatory HIV-infected patients. Am J Psychiatry. 1996;153:238-242.
27. Chochinov HM, Wilson KG, Enns M, Mowchun N, Lander S, Levitt M, Clinch JJ. Desire for death in the terminally ill. Am J Psychiatry. 1995;152:1185-1191.
28. Sullivan MD, Youngner SJ. Depression, competence, and the right to refuse life saving medical treatment. Am J Psychiatry. 1994;151:971-978.
29. Lee MA, Nelson HD, Tilden VP, Ganzini L, Schmidt TA, Tolle SW. Legalizing assisted
suicide: views of physicians in Oregon. N Engl J Med. 1996;334:310-315.
30. Ganzini L, Lee MA, Heintz RT, Bloom JD, Fenn DS. The effect of depression treatment on elderly patients’ preferences for life-sustaining medical therapy. Am J Psychiatry 1994;151:1631-1636.
31. Ganzini, L, Goy, E, Dobscha, S. Prevalence of depression and anxiety in patients requesting physicians’ aid in dying: cross sectional survey. BMJ. 2008:337;a1682
