Background
Methods
Sample
Procedure
Survey and case vignettes
Case 1: 37-year-old female with anorexia nervosa, onset at age 11 | |
Symptoms: general muscle weakness; loss of bone density; amenorrhea; current weight 24 kg/52 lbs.; BMI 9.5 kg/m2; no recent weight gain or stabilization; no acute danger of dying, as her body is adapted to being underweight. The patient underwent 10 previous inpatient treatments (in both somatic and psychiatric hospitals), three of which were in specialized psychiatric institutions. Throughout the course of disease, different intensive psychotherapies have been tried, without success. During hospitalizations, the patient underwent several artificial re-feedings, sometimes under sedation. The patient now refuses artificial re-feeding and treatment. She states that, for years, her life has been focused exclusively on trying to overcome her anorexia, leaving her without friends or hobbies. She suffers from the physical symptoms, including general muscle weakness and loss in bone density, saying that she would rather die than undergo further treatment and wishes to be left in peace. She does not want to be forced into eating anymore. Two experts have declared that the patient has decision-making capacity to refuse further treatment, with consequent risk of dying. | |
Case 2: 33-year-old male with schizophrenia, onset at age 17, no significant comorbidities | |
Positive symptoms: auditory and visual hallucinations, persecutory delusions. Negative symptoms: apathy, social withdrawal, poverty of speech (all rated severe). Despite long-lasting, high-dose pharmacological treatment (several atypical neuroleptics, haloperidol, clozapine and combinations of these), as well as electro-convulsive therapy, the patient has never been free from positive or negative symptoms. Multiple psychotherapies of various kinds have also failed to stabilize the patient or to improve his quality of life. He does not wish to continue assertive community treatment because he feels it is too intrusive. While the positive symptoms were more dominant in the first years following initial diagnosis, he went on to develop severe negative symptoms, as well as aggression and self-injurious behavior such as burning himself with cigarettes. The negative symptoms and his strong functional deficits are exacerbated by chronic unemployment and inability to live independently, and the patient has no family system. His persisting illness has left him completely isolated, with no social contacts and no hobbies or interests. Two experts have declared that he possesses decision-making capacity in respect of his illness and its treatment. | |
Case 3: 40-year-old male with major depressive disorder, no significant comorbidities | |
Symptoms: energy loss, insomnia, fatigue, persistent suicidal ideation over 20 years, current acute and concrete suicidal intent. The patient underwent different intensive, evidence-based, long-term psychotherapies, including specialized treatment approaches such as CBASP and IPT. His depression was not improved either by psychotherapy alone or in combination with adequate treatment trials of antidepressants (selective serotonin reuptake inhibitors, tricyclic antidepressants, venlafaxine, augmentation with lithium and antipsychotic medications (quetiapine and aripiprazole)). The patient experienced significant adverse effects with several of the medications. Exhausted and as a last resort, he has decided to undergo electro-convulsive therapy. However, maintenance electro- convulsive therapy proved equally ineffective in preventing the reappearance of suicidal ideation; indeed, the symptoms worsened. The patient experiences severe hopelessness and states that his quality of life is very poor, that he doesn’t want to deal with his illness anymore, and that he plans to commit suicide in the near future. Two experts have declared that he possesses decision-making capacity regarding his illness and its treatment. |
I: Questions on the treatment of patients with severe and persistent mental illness (SPMI) | |
In the treatment of patients with severe and persistent mental illness (SPMI), how important is: | |
A) curing the illness | |
B) reduction of suffering | |
C) the patient’s ability to function in daily life | |
D) the patient remaining autonomous in their decision making | |
E) impeding suicide | |
According to the World Health Organization (WHO), palliative care ‘is an approach that improves the quality of life of patients and their families facing the problem associated with life-threatening illness, through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychosocial and spiritual’. | |
How strongly do you agree or disagree with the following. | |
F) For me, the term ‘palliative’ relates directly to end of life. | |
G) For some SPMI patients, palliative care is indicated. | |
H) In psychiatry, applying a palliative care model is important in providing optimal support for certain patients without a life-limiting medical illness. | |
I) In severe, chronic and therapy-refractory anorexia nervosa, a palliative approach would be suitable. | |
J) In severe, chronic and therapy-refractory schizophrenia, a palliative approach would be suitable. | |
K) In severe, chronic and therapy-refractory depression, a palliative approach would be suitable. | |
L) In severe, chronic and therapy-refractory bipolar disorder, a palliative approach would be suitable. | |
M) In severe, chronic and therapy-refractory substance disorder, a palliative approach would be suitable. | |
How strongly do you agree or disagree with the following. | |
N) SPMI can be a terminal illness. | |
O) Sedation for the reduction of unbearable refractory psychological symptoms is justifiable in certain cases of SPMI. | |
P) I would generally be willing to perform sedation as mentioned above in ‘O’. | |
Q) I generally advocate access to assisted suicide for patients with SPMI. | |
R) If physician-assisted suicide was legally permitted for SPMI, I would support my patients in seeking this intervention as the physician of record or by referring them to another physician. | |
II: Questions about the three case vignettesa | |
Please evaluate the case vignettes as below. | |
S) I would not be surprised if this patient died within the next 6 months. | |
T) For this patient, further interventions to cure the anorexia would most likely be futile. | |
U) In this case, I would be comfortable with a reduction of life expectancy in order to increase or maintain quality of life if consistent with the patient’s goals. | |
V) In this case, I would accept a temporary decrease in quality of life due to coercive measures. | |
W) In this case, I would not proceed against the patient’s wishes. | |
X) In this case, sedation to reduce an unbearable refractory symptom is reasonable. | |
Y) If physician-assisted suicide was legally permitted, I would support this patient if this was her explicit and enduring wish, referring her to appropriate care. |