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Patients who are ineligible for a medically-assisted death may be at risk of self-harm

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Written by Paul Taylor

Question: My uncle suffers from manic depression. He wants a medically assisted death, but he doesn’t have a terminal disease. Should I be worried about how he might react if it is not an option for him?

Answer:  For those who are considering medical assistance in dying, also known as MAID, it is important and beneficial to connect with their health-care providers in order to learn more about the process so that they are not surprised or disappointed if their MAID application is found ineligible.

Canadian law doesn’t preclude people with mental illnesses – including manic depression or bipolar disorder – from seeking MAID, but they must meet specific criteria.  In particular, a patient must have an incurable illness, and natural death must be reasonably foreseeable. Furthermore, individuals must have the mental capacity to make an informed decision.

Among some health-care professionals, there is a growing awareness that patients can be psychologically vulnerable in the period immediately after their application has been denied.

In a recently published study, a Toronto team of MAID assessors and providers report that three patients attempted suicide soon after they were deemed ineligible for an assisted death. In two of the cases, the patients didn’t have a foreseeable death. The third patient lacked mental capacity.

“We were, frankly, a bit caught off guard when it happened the first time,” says Sally Bean, one of the co-authors of the study and an ethicist at Sunnybrook Health Sciences Centre. “It wasn’t something we had anticipated.”

The three individuals had several things in common, says Dr. Elie Isenberg-Grzeda, lead author of the study and a staff psychiatrist at Sunnybrook.

They all had a history of depression and also suffered from mild cognitive impairment. Two of them had previously attempted suicide.

“The core features of depression are hopelessness about the future, suicidal thoughts and sometimes inflexibility in thinking,” explains Dr. Isenberg-Grzeda. “Similarly, cognitive impairment can prevent people from processing information clearly.” Both these conditions may increase the likelihood of self-harm.

To prevent further suicide attempts, the Sunnybrook clinicians revised their MAID process to identify in advance individuals who might be at risk.

“We started doing pre-assessments, looking at patients’ (medical) charts, and then managing the patients’ expectations,” says Dr. Isenberg-Grzeda.

They also put together support plans for people whose MAID requests are turned down.

The efforts appear to have paid off. There hasn’t been another suicide attempt since the process was changed over a year ago.

The study, published in the Journal of Pain and Symptom Management, “sheds light on an important issue,” says Dr. Stefanie Green, president of the Canadian Association of MAID Assessors and Providers in Victoria, B.C.

She says she is aware of other patients who died by suicide after being denied MAID.

“Probably the hardest thing we have to do is tell some people they are ineligible for assisted death,” adds Dr. Green.

“These are people who obviously believe they are suffering intolerably, and who are asking for our help, yet we are unable to aid them.”

Ms. Bean says many of the patients who seek MAID are highly independent individuals with long-held beliefs in the right to die. “They feel they should be able to control the circumstances of their death.”

What’s more, some of them are under the false assumption that they become eligible for MAID by simply signing a request form, which is available online.

The reality is very different. The requests go through a formal assessment to determine whether they meet the qualifications set out in legislation passed by the federal government in 2016.

“It would be a pretty devastating blow to be found ineligible,” says Ms. Bean. “They had hoped MAID would end their suffering and then told it’s not an option.”

Based on the MAID assessment study done at Sunnybrook, Dr. Isenberg-Grzeda believes numerous patients who don’t qualify for an assisted death could be at risk of self-harm.

He notes that the three attempted-suicide cases make up only 2.8 per cent of the 107 patients assessed for MAID eligibility during the study period from June 2016 to April 2019.

However, he adds, they represent 30 per cent of the 10 deemed ineligible for MAID. “This is a substantial proportion (of the rejected cases) and I think that is what makes this so significant.”

He believes it’s critically important for MAID assessors and providers to ensure that patients have realistic expectations and are supported through the process.

If you think your uncle is in an emergency situation, urge him to call 911 or visit his local hospital emergency department.

You can also let him know that help is available through community resources:

          Phone: 24-hour, toll-free 1-833-456-4566 

          Text: 45645 (4:00 p.m. – midnight Eastern Time)

About the author

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Paul Taylor

Paul Taylor, Sunnybrook’s Patient Navigation Advisor, provides advice and answers questions from patients and their families, relying heavily on medical and health experts. Email your questions to AskPaul@sunnybrook.ca
and follow me on Twitter @epaultaylor