Trudo Lemmens: Medical Aid in Dying in Canada: A Case Raises Questions About Its Use in Patients with Disability and Mental Illness

 

Mark S. Komrad’s Comment

 

        Aside from being an illustration of the flaws and inadequacies of Canada’s MAiD practices, the Nichols’ case seems to demonstrate how inadequate clinical practice can short-circuit a patient’s difficult case into euthanasia. This is a vulnerability of psychiatric cases, in which there is a wide breadth of potentially effective interventions, which are often not pursued due to limitations of access to care, time available to treaters, financial constraints, limitations in clinician training and difficulty accessing deeper level clinician expertise than is available outside of academic tertiary care centers.    

        There are many questions about the Nichols case that raise the specter that care was beneath reasonable clinical standards, a signal of potential medical malpractice and an ethical conundrum in the face of a request for euthanasia. Detailed examination of the medical record, of course, would be necessary to completely answer these questions. There is an indication that this hospitalization was not necessarily voluntarily. If so, that ipso facto raises the question of the patient’s capacity, a critical issue for eligibility for MAiD in any jurisdiction in the world.

        The ER hospitalized him despite his family’s report that he objected and asked to be “broken out” of the ER when brother came to visit. There is no evidence that the patient’s condition improved over the course of his hospital stay. So we must ask — when and how did his condition go from that initial level of incapacity to a level of capacity sufficient to give appropriate consent for MAiD?   Moreover, capacity evaluation is a SUB-specialty skill in the broader specialty of psychiatry, typically done by consultation-liason specialists or forensic specialists. Robust and experienced capacity evaluation is called for in conundrums of patient decision-making of far lesser import than whether there is sufficient capacity to make such a monumental decision to ask for help to suicide.

        The techniques for determining capacity in the context of MAiD in psychiatric patients have yet to be developed (Appelbaum 2018; Charland, Lemmens and Wada 2016). It’s unclear what experienced, skilled sub-specialists were involved in the conclusion that Mr. Nichols ultimately had capacity to consent to MAiD.   In general, psychiatric patients who are ill enough to be hospitalized often do not give a complete or accurate history, particularly those with communication impairments (Øhre, Volden, Falkum and von Tetzchner 2017). Outside informants are critical for drawing diagnostic conclusions, appropriate therapeutic plans and information about the patient’s baseline (Achenbach 2006).

        Sometimes patients prohibit their teams’ contact with outside informants. That is a signal to work with the patient to open up that contact as a treatment goal, in his own best interest. It is unclear if that was a treatment goal for Mr. Nichols in hospital. Failure to allow family input until the last few days, in the face of such a monumental decision, is a significant clinical oversight.

        It is beneath the standard of practice that it took a week to return the family’s call about the patient. To get a critical upload of information from the family is ethically and legally acceptable, even if a patient doesn’t, or can’t give permission for a download of information from the treaters to the family. In addition, it is standard practice for a physician who goes on vacation to provide patients with coverage from a colleague and to respond to family calls. Dr. Y appeared to have no such coverage to return brother’s request to provide information. 

        Space limits other critical questions about the way in which the conduct of this case may fall beneath ordinary standards of care. This begs the question of standards of care in the face of requests for euthanasia in psychiatrically and cognitively ill patients. These have yet to be established, but that is the challenge that lies ahead in Canada over the next two years, with the passing of the C-7 bill — permitting eligibility of psychiatric conditions for MAiD at that time.

        This case gives a closeup view of some of the ways that MAiD can go horribly wrong, with even slight deviations from accepted standards of practice and sloppy clinical practice. The consequences of inadequate and substandard care in the face of MAiD are not simply inadequate stabilization and recovery, but unnecessary death — in the hands of the very team charged with the patient’s care and healing.

 

References:

 

Achenbach TM. As others see us: Clinical and research implications of cross-informant correlations for psychopathology. Current Directions in Psychological Science 2006;15(2):94-8.  

Appelbaum PS. Physician assisted death in psychiatry. World Psychiatry 2018;17(2):145–6. 

Charland LC, Lemmens LL, Wada K. Decision-Making Capacity to Consent to Medical Assistance in Dying for Persons with Mental Disorders. Journal of Ethics in Mental Health. Special Themed Issue: II Medical Assistance in Dying. May 26, 2016. jemh.ca/issues/v9/documents/JEMH_Open-Volume_Benchmark_Decision_Making_to_Consent_to_Medical_Assistance_in_Dying-May2016-rev.pdf. 

Øhre B, Volden M, Falkum E, von Tetzchner S.   Mental disorders in deaf and hard of hearing adult outpatients: A comparison of linguistic subgroups. Journal of Deaf Studies and Deaf Education 2017; 22(1):105–17. 

 

December 9, 2021