Wednesday, May 23, 2012

Assisted Suicide in Oregon: Evidence of Missed Evaluation for Depression

This article was published by the Charlotte Lozier Institute, May 21, 2012. Link to the article.

By Gene Tarne/CLI Senior Advisor

As required by law, the Public Health Department of the Oregon Health Authority has released its annual report for 2011 on physician-assisted suicides under that state’s Death with Dignity Act (DWDA).

The 1997 law required physicians involved in an assisted suicide to file a number of  standardized forms, providing information on such particulars as sex, age, race and marital status of the patient; type of drug prescribed; reason why the patient was seeking assisted suicide; time between ingestion of drug and death, etc.

For 2011, the numbers for both prescriptions issued and deaths were up over the previous year: 114 prescriptions for lethal doses of barbiturates (up from 97 in 2010) and 71 deaths (up from 65 in 2010).[i]  These are the highest numbers reported for lethal prescriptions and deaths in the 14 years since the law went into effect in 1998. Since 1998, the total number of assisted suicides reported is 596.

But beyond the total number of deaths, the annual report also reveals several disturbing aspects of the law’s implementation.

For instance, the report notes that “nine patients with prescriptions written in previous years ingested the medication in 2011.” “Previous years” means any year prior to 2011. Why is this significant?

A compliance form that physicians who dispense lethal prescriptions are legally required to complete and file requires them to confirm that the patient has a terminal illness and that the patient has “six months or less to live.” As the Oregon-based Physicians for Compassionate Care (which opposes assisted suicide) notes, having a prescription for a lethal drug more than a year before ingestion is “far longer than the law’s 6-month life expectancy guidelines. Clearly, the law’s guidelines are meaningless: not all who receive these prescriptions are terminal.”

More unsettling, given the well-known link between suicide and depression, is how few of those requesting assisted suicide are referred for psychiatric evaluation – not just in 2011, but over the law’s past 14 years.

Under the Oregon law, the proscribing and consulting physicians must determine that the patient requesting a lethal prescription is “capable”; if either believes the patient has a psychiatric or psychological disorder that might impair judgment, then “either physician shall refer the patient for counseling. No medication to end a patient’s life in a humane and dignified manner shall be prescribed until the person performing the counseling determines that the patient is not suffering from a psychiatric or psychological disorder or depression causing impaired judgment (Oregon Revised Statute (ORS) 127.825 s.3.03).”

That there is a link between depression and suicide should not be surprising, and especially in the context of assisted suicide – a diagnosis of a terminal illness with 6 months or less to live is almost certain to trigger a depressive response in the patient.

This link is also well-attested to in literature on the subject. “In this study, psychological factors— nonvegetative depressive symptoms and patients’ sense of a lack of appreciation—were associated with patients’ considerations and planning of euthanasia and PAS” (physician-assisted suicide), according to a study published in 2000 in the Journal of the American Medical Association (JAMA). The study characterized “patient depression” as “the main factor motivating interest in euthanasia or PAS.”

Another study published in JAMA, also from 2000, focused exclusively on terminally ill cancer patients[ii] and found that “[a] SCID[iii] diagnosis of depression was significantly associated with desire for hastened death.” A 1995 study in the American Journal of Psychiatry reported that “the desire for death was correlated with ratings of pain and low family support but most significantly with measures of depression. The prevalence of diagnosed depressive syndromes was 58.8% among patients with a desire to die and 7.7% among patients without such a desire.”?

A fact sheet, “Older Adults: Depression and Suicide Facts” from the National Institute of Mental Health, characterizes depression as: 
“one of the conditions most commonly associated with suicide in older adults.”[iv]
In 2008, researchers from the Oregon Health and Science University (OHSU) reported in the BMJ (formally, the British Medical Journal) that 1 in 4, or 25%, of those seeking assisted suicide in Oregon were depressed. “The current practice of the Death with Dignity Act in Oregon may not adequately protect all mentally ill patients, and increased vigilance and systematic examination for depression among patients who may access legalised (stet) aid in dying are needed,” they concluded.

In 2009, officials with the Oregon Health Department called the ongoing decline in requests for psychiatric evaluation for those seeking assisted suicide a “worrisome trend,” noting that: 
“the decline in formal evaluation raises concerns that depression remains undiagnosed in some patients who request and receive a prescription under the DWDA.”
Yet despite the warning of a “worrisome trend” of declining psychiatric evaluation requests, and despite all the evidence for the linkage between depression and a desire to hasten death, in 2011 only 1 person among the 71 who died was referred for a psychiatric evaluation. This is the same number reported in 2010. In 2007 and 2009, no patients who died were referred for a psychiatric evaluation. Over the 14 years the DWDA has been in place in Oregon, only 40 of the 596 — 6.7% — to die were referred for a psychiatric evaluation.

The absolute number of those seeking assisted suicide in Oregon over the years has been relatively low. Yet among those who do, lethal prescriptions have been issued to those with more than 6 months to live – something clearly proscribed by the DWDA.

More important, the ongoing failure to refer patients seeking assisted suicide for psychiatric evaluation put these patients at risk when there are treatment options available for their depression. As the previously cited JAMA study shows, terminally ill patients’ attitudes towards assisted suicide “appear to be quite unstable.” Of those patients who during an initial interview said they would consider assisted suicide/euthanasia for themselves, about half had changed their minds at a later, follow-up interview. By the same token, some terminally ill patients who had not considered assisted suicide/euthanasia for themselves at the initial interview began to do so at the follow-up interview. The reason? “Depressive symptoms and dyspnea were associated with this instability.” “Thus,” the authors recommend, “physicians who receive requests for euthanasia or PAS should recognize their volatility and not take such requests as settled views but should evaluate patients for depression and unrelieved dyspnea.”

That does not seem to be happening in Oregon.

[i] The state of Washington, which in 2008 adopted an assisted suicide law similar to Oregon’s, reported 70 deaths for 2011 – almost duplicating Oregon’s 14-year high, but doing so in only three years.
[ii] In 2011, 56 of the 71 patients, or 82.4%, who died had some form of cancer. Over the past 14 years, 480 of the total 596, or 80.9%, who died had cancer.
[iii] The Structured Clinical Interview for DSM-IV Axis I Disorders is a diagnostic examination to determine the presence of DSM-IV Axis I mental disorders.
[iv]  In 2011, 49 of the 71 patients, or 69% of those who died, were 65 or older, with the median age being 70. Over the past 14 years, 409 of the 596 patients, or 67.6% who died, were 65 or older, with the median age being 71.

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