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RESEARCH: Linda Ganzini, Elizabeth R Goy, and Steven K Dobscha Prevalence of depression and anxiety in patients requesting physicians’ aid in dying: cross sectional survey BMJ 2008; 337: a1682 [Abstract] [Full text]

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Thanatopsis

Hugh Mann   (10 October 2008)

Too depressed to die?

Sahoo Saddichha   (14 October 2008)

Euthanasia and Depression: No Surprise

Tom Koch   (21 October 2008)

Ethical issues and accuracy in diagnosis and conclusions

Adarsh Shetty   (26 October 2008)

Depression in terminal illness

Lesley A M Evans, TA24 8HD   (28 October 2008)

Mandatory psychiatric review in physician assisted death legislation: following the Australian example

Christopher J Ryan, Tarra Shaw   (29 October 2008)

What about patients who don’t take part in research?

Catherine Leask, Jane Gibbins, Gaye Senior-Smith, Charlie Beard, Jennet Williams, Sophy Gretton, Dida Cornish, Tina Quinn, Jo Chambers   (31 October 2008)

BMJ: Tacit Credence to Access

David Todd   (6 November 2008)

Discrimination against terminally ill patients

Anne M Doherty   (6 November 2008)

Compelling reasons to require psychiatric evaluations before aid in dying

Stanley A Terman   (14 November 2008)

Fear of living

Rosemarie Anthony-Pillai   (17 November 2008)

Capacity of the participants

saurabh saxena, Morpeth, NE61 2NU   (12 July 2009)

Thanatopsis 10 October 2008
Hugh Mann, Physician Eagle Rock, MO 65641 USA Send response to journal: Re: Thanatopsis	Don't ask me to say hello I can't say goodbye Don't ask me to say yes I can't say no Don't ask me to hold your hand I can't let go Don't ask me to live It hurts too much Competing interests: None declared
Too depressed to die? 14 October 2008
Sahoo Saddichha, Partner, Division of Clinical Research Emergency Management and Research Institute (EMRI), India Send response to journal: Re: Too depressed to die?	The evaluation of pre-existing depression in patients wishing to end their lives [1] is an eye-opener to all health professionals who may ignore the influence of mental illness in taking a decision to die. The study raises several questions- 1)Why is the Death with Dignity Act not followed as most people are not evaluated by a mental health professional [2]? 2)Even if safeguards are present in the Act, what is the role of psychiatrists/psychologists in taking the final decision to permit assisted dying? In addition, there are a few other issues with the study. Although there were 47 participants from the Compassion and Choices clients, 11 had been referred from other centres. Who were these 11 and what were their criteria for inclusion? I also find the results surprising since the subjects who ultimately got the lethal drug were not only less hopeless and had lesser desire to die than those who did not, they also had lesser suffering and better quality of life (although not significant). Although the Hopelessness Scale had been used, I believe that the Beck Suicide Intent Scale [3] would have been a better measure of their suicidal intent and therefore of their mental status. References: 1)Ganzini L, Goy ER, Dobscha SK. Prevalence of depression and anxiety in patients requesting physicians’ aid in dying: cross sectional survey.BMJ 2008;337:a1682 2)Oregon Department of Human Services. Death with Dignity Act. 2007. www.oregon.gov/DHS/ph/pas/index.shtml. 3)Beck RW, Morris JB, Beck AT.Cross-validation of the Suicidal Intent Scale.Psychol Rep. 1974 Apr;34(2):445-6. Competing interests: None declared
Euthanasia and Depression: No Surprise 21 October 2008
Tom Koch, professor University of British Columbia Send response to journal: Re: Euthanasia and Depression: No Surprise	Nobody should be surprised at the prevalence of depression and anxiety in Oregon cases of physician-assisted suicide. This was the pattern of euthanasia's expansion in Holland, a movement for relief of unbearable suffering in terminal cases became a means of termination for those whose problems were often more existential, or psychological, than physical. In Holland, the critical case--in law and ethics--was the Chabot case in which a divorced woman with clinical depression folloiwng the death of a son asked for, and received, euthanasia (1). In another case, a request for euthanasia by a young woman with anorexia later was granted. A retrospective study of deaths attributed to Dr. Jack Kevorkian found none who were in end stage disease and several for whom autopsy revealed no clear organic dysfunction (2). Again, what was publicly proclaimed as an end to suffering became a matter of termination of persons whose physical or psychological suffering was not correctly palliated or treated. Depression attends generally to cases of physical limit and chronic disease. The focus on euthanasia rather than on treatment, and state support for palliative and psychological treatment, makes premature, physician-assisted death, a default option (2). This ignores in the name of "autonomy" a wealth of evidence that argues that the majority of those with chronic limits and progressive conditions may, after an initial period of anxiety and depression, find a worthiness to life as long as physical and psychological treatment is provided (4). It similarly ignores the potential for fruitful life with both aggressive palliative care and psychological support. 1.Transcript summary of prosecution against Boudewign Chabot. Docket No. 478-1993. September 16, 1993. 2. Koch, T. 1998. On the subject(s) of Jack Kevorkian, MD: A Retrospective Analysis Cambridge Quarterly of Healthcare Ethics. 7:4, 436- 441. 3 .Koch, T. 1996. Living VS Dying ‘with Dignity’ A New Perspective on the Euthanasia Debate. Cambridge Quarterly on Healthcare Ethics. 5, 50-60. 4. Koch, T. 2000. The illusion of paradox: Commentary on Albrecht, G.L. and Develiger, P.J (1998) “The disability paradox: high quality against all odds.” Social Science & Medicine 50:6, 757-759. Competing interests: None declared
Ethical issues and accuracy in diagnosis and conclusions 26 October 2008
Adarsh Shetty, Specialist Registrar in Rehabilitation Psychiatry Westminster House, 598 The Wells Road, Nottingham NG3 3AA. Send response to journal: Re: Ethical issues and accuracy in diagnosis and conclusions	Dear Editor, Ganzini et al (1) present very interesting data on the prevalence of depression and anxiety in patients who request physicians’ aid in dying. I would like to discuss some issues that arose in my mind when reading this research article. I was pleased to see that the authors did acknowledge their low participation rate – only 28% of patients who were invited actually agreed to take part in the study. However, the authors then conclude that their study suggests that most patients requesting aid in dying do not have a depressive disorder. Is it reasonable to draw this conclusion, when 72% of those invited refused to take part? Furthermore, it is not clear what criteria were used to invite patients to take part in the study. Were they consecutive referrals, randomly selected patients, or patients who had contacted the organization within a specific time-period? This information would be helpful in assessing the generalizability of their results. Clarity on their use of the hospital anxiety and depression (HAD) scale and the SCID-1 would have helped in assessing the accuracy of their diagnosis of depression. Their method description does not make it clear whether all patients who scored for caseness on the HAD were then administered the SCID-1. They used SCID positivity or HAD greater than 11 to confirm a diagnosis of depression. This is questionable, given that the HAD is, at best, a screening instrument, not a diagnostic tool. Finally, patients who were depressed were informed of this and offered appropriate help – this is reassuring. However, I wonder if there are more difficult ethical issues here, given that at least one patient who was depressed (as per SCID) then received physician aid in dying. Is there a responsibility on researchers in this situation to alert prescribing physicians that the patient requesting aid in dying is definitely depressed? On balance, I think the answer to this is, “Probably not.” Surely it would be the physicians’ responsibility to satisfy themselves that the patients were capacitous before they wrote them a lethal prescription. It would indeed be interesting to see if, in the case of patient B, the physician sought a psychiatrist’s opinion before helping this patient to die. References 1. Ganzini L, Goy ER, Dobscha SK. Prevalence of depression and anxiety in patients requesting physicians’ aid in dying: cross sectional survey. BMJ 2008; 337:a1682 Competing interests: None declared
Depression in terminal illness 28 October 2008
Lesley A M Evans, Retired Consultant Geriatrician Porlock, Somerset, TA24 8HD Send response to journal: Re: Depression in terminal illness	The article from Oregon is interesting and raises questions about the relevance of depression in those who are dying. It is perhaps not surprising that anyone facing death might be depressed. One might almost say it is normal. But depression is not a psychotic disorder, and there is no reason to assume that a depressed person is not rational and therefore perfectly capable of making an informed decision about assisted suicide. Those who are so anxious to identify depression will presumably also wish to treat it. This raises questions of patient autonomy, since the patient has probably not complained of depression, and may therefore not wish to be treated. In any case, treatment takes time, and may produce side effects, if drugs are used. Is this really appropriate in a dying patient, who does not have much time? And what exactly is the point of treatment? Is it to make sure that the patient is happy about his or her impending death? Is that a realistic or desirable therapeutic approach? Doesn't it rather impose further medication and expectations on a patient who is already suffering greatly? Why do people find it so difficult to accept that some people may actually wish to end their suffering, and may require assistance to do so, and that this is their inalienable right? Oregon has done excellent pioneering work which needs to be followed by similar legislation else where. It has been shown that if the option of Physician assisted suicide is available, very few people will actually take it, and some will be so reassured by the fact that it is an option that they will never request it. To offer it is the only humane approach to intolerable suffering, if we really do claim to have a civilised society. Yours sincerely, Lesley A M Evans Competing interests: None declared
Mandatory psychiatric review in physician assisted death legislation: following the Australian example 29 October 2008
Christopher J Ryan, Psychiatrist and Senior Clinical Lecturer University of Sydney, Sydney, Australia, 2006, Tarra Shaw Send response to journal: Re: Mandatory psychiatric review in physician assisted death legislation: following the Australian example	Ganzini’s finding that 3 of 18 Oregonians who received a prescription for a lethal drug met caseness criteria for depression, raises significant concerns about that State’s Death with Dignity Act, which demands a psychiatric review only if “concern exists that the patient has a psychiatric disorder” (1). We know that depression is common in the terminally ill and that depression may successfully treated in this population. We know that depression may impair a person’s capacity when requesting physician assisted suicide and we know that non-psychiatrically trained physicians are poor at detecting depression. We also know that these four facts are also true for delirium among the terminally ill. There is a strong argument for the inclusion of a mandatory psychiatric review in any legislation that enables physician assisted death, to detect and protect those who would not have requested assistance to die had they not been depressed or delirious (2). This safeguard was included in the Australian Northern Territory’s Rights of the Terminally Ill Act and has been included in recent attempts at legislative reform in Australia (3,4). Oregon law should be amended to include this safeguard and all future physician assisted death legislation should provide mandatory psychiatric review. References (1) Ganzini L, Goy ER, Dobscha SK. Prevalence of depression and anxiety in patients requesting physicians' aid in dying: cross sectional survey. British Medical Journal 337, 1682-1686. 2008. (2) Ryan CJ. Velcro on the slippery slope: the role of psychiatry in active voluntary euthanasia. Australian and New Zealand Journal of Psychiatry 29, 580-585. 1995. (3) Northern Territory Rights of the Terminally Ill Act, 1995. (4) Victorian Medical Treatment (Physician Assisted Dying) Bill, 2008. Competing interests: None declared
What about patients who don’t take part in research? 31 October 2008
Catherine Leask, SpR Palliaitve Medicine University Hospitals Bristol NHS Trust, BS2 8EU, Jane Gibbins, Gaye Senior-Smith, Charlie Beard, Jennet Williams, Sophy Gretton, Dida Cornish, Tina Quinn, Jo Chambers Send response to journal: Re: What about patients who don’t take part in research?	We read with interest the recent article by Ganzini et al (1) which attempts to calculate the prevalence of depression and anxiety in those patients who request patient assisted suicide. Whilst we acknowledge this is an important but difficult study to design and carry out, only 28% of patients invited to take part in the study were enrolled. The authors conclude that ‘the study suggests that most patients who request aid in dying do not have a depressive disorder.’ Although there is no evidence to suggest which patients with incurable illnesses are more or less likely to take part in research, this study is only able to tell us the prevalence of depression in those patients who were willing to take part in research. Thus, the results may be very different for the majority of patients (72%) who were unable, or who did not want to take part in the study. 1. Ganzini L, Goy ER, Dobscha SK. Prevalence of depression and anxiety in patients requesting physicians’ aid in dying: cross sectional study. BMJ 2008;337:a1682 Competing interests: None declared
BMJ: Tacit Credence to Access 6 November 2008
David Todd, Sports Physician Student Bath BA2 4NR Send response to journal: Re: BMJ: Tacit Credence to Access	Dear Sir/Madam, The mere publication of articles such as "Prevalence of depression and anxiety in patients requesting physicians' aid in dying: cross sectional survey" is either interesting or concerning. But the publication assumes that the study has legitimatised the access of patients to doctors for such advice. (Only then can the patients be consented for study of their anxiety/depression). In my opinion, publication bias can "creep" in many and subtle ways, and (also only my opinion) I do not think physicians, beyond those trained in specialist palliative care, have any role here. Mcluhan said something I'd like to say much more adroitly, but media must be careful about leading the message and the messenger. Especially when that message could be a subtly malign one. Dr David Todd (Bath, Somerset) Competing interests: None declared
Discrimination against terminally ill patients 6 November 2008
Anne M Doherty, Registrar in Child Psychiatry, Ballyfermot Child and Family Centre, Ballyfermot Road, Dublin 10. Send response to journal: Re: Discrimination against terminally ill patients	The recent study by Ganzini et al on depression in terminally ill patients who requested aid in dying[1] raises a number of very interesting questions about how we, as a profession and as a society, regard two particularly vulnerable sub-groups of patients: those with terminal illness and those with mental illness. This study showed that 1 in 6 patients who requested their physician’s assistance in dying had a depressive illness. A previous study[2] indicated that depressive symptoms are increased 7-fold among terminally ill patients who wished to die relative to those who did not. Do we consider that a patient should be deprived of a soi-disant treatment or intervention on the basis of a diagnosis of a mental illness? Could this be construed as a form of discrimination against those persons who may have a mental illness? Conversely, if a person is depressed, it is not uncommon for them to have suicidal ideation, regardless of any medical co-morbidities. If they do not have any medical co-morbidities, if they do not have a terminal illness, we regard their suicidal ideation as being pathological. We do not agree with them that their life is not worth living, that the best thing to do is to die. Instead we ensure that they are reviewed by a psychiatrist, we treat their depression, and in so doing we treat their suicidal ideation. Should patients who have terminal illnesses be afforded the same treatment? To withhold it on the basis of their physical status is discriminatory, if not unethical. More ethical guidance, particularly in those jurisdictions where physician’s aid in dying is legal, is surely indicated in the light of this evidence. Perhaps the state of Oregon should consider mandatory psychiatric reviews for those patients who have such a wish to die. References: 1. Ganzini L, Goy ER, Dobscha SK. Prevalence of depression and anxiety in patients requesting physicians’ aid in dying: cross sectional survey. BMJ 2008; 337: a1682. 2. Chochinov HM, Wilson KG, Enns M, Mowchun N, Lander S, Levitt M, et al. Desire for death in the terminally ill. Am J Psychiatry 1995; 152: 1185-91. Competing interests: None declared
Compelling reasons to require psychiatric evaluations before aid in dying 14 November 2008
Stanley A Terman, Medical & Executive Director, Caring Advocates Carlsbad, CA 92009 Send response to journal: Re: Compelling reasons to require psychiatric evaluations before aid in dying	Ganzini and colleagues’ survey of depression and anxiety in patients requesting physicians’ aid in dying [1] led to their statement, “Our study suggests that in some cases depression is missed or overlooked." Yet they still concluded that “most” were not depressed based on, “One in four [of the total of 58 patients] having clinical depression.” Of three specifically identified depressed patients who received lethal medication who died within two months, none had been evaluated by a mental health professional before the survey and only one received treatment for depression—after the survey. The last patient "reported that depression somewhat influenced her decision to purse aid in dying.” Morally, Ganzini et al.'s conclusion about “most” is not quite good enough. It is similar to saying that of those people sentenced to death for Capital Punishment, “most” were not innocent. [2] What about the sanctity of lives of those “few” depressed patients, and those few innocent accused (at least 130, and counting) whose lives were shortened? Furthermore, Ganzini et al.'s conclusion of “most” was based on data that did not include 72% of those who were requested to participate in the study but did not accept. Not only is this a low response rate in general; but under the specific clinical circumstances, the usual statement that there is no reason to believe that the population not sampled is any different from those sampled does not apply: Depressed people are less responsive to life, including and perhaps especially to surveys about depression and hopelessness, given their likely ambivalence about possessing a lethal dose of medication that literally puts them in control of ending their lives. Hence, it is arguably likely that a higher percentage of patients were depressed in the group that did not respond. The above considerations make it compelling to require routine evaluation for psychiatric disorders for patients who request aid in dying. The same safeguard should apply to patients who have a discussion with a “healthcare provider” in preparation for a physician signing off on a Physician’s Order for Life-Sustaining Treatment for “Comfort Care Only” – a form that another Oregon group is actively promoting nationwide, which at present also includes no safeguard by requiring a psychiatric evaluation. [3] 1. Ganzini L, Goy ER, Dobscha SK. Prevalence of depression and anxiety in patients requesting physicians’ aid in dying: cross sectional survey. BMJ 2008; 337: a1682. 2. http://www.law.northwestern.edu/wrongfulconvictions/issues/deathpenalty/executinginnocent/ and http://www.deathpenaltyinfo.org/innocence-and-death-penalty 3. Schmidt TA, Hickman SE, Tolle SW, Brooks HS. (2004). The Physician Orders for Life-Sustaining Treatment (POLST) Program: Oregon Emergency Medical Technicians’ Practical Experiences and Attitudes. J. Am Ger Soc 52, 1430- 1434, and www.polst.org Competing interests: I am the co-developer of a form that could be seen as an alternative to the POLST, the Physician's Orders to Permit Natural Dying
Fear of living 17 November 2008
Rosemarie Anthony-Pillai, Locum Consultant in Palliative Medicine Peace Hospice, Watford WD17 3PH Send response to journal: Re: Fear of living	The recent debate triggered by the publication of Ganzini and colleagues' findings of the prevalence of depression in patients requesting physician-assisted euthanasia in Oregon has been very thought- provoking. 1 I agree with Ryan and Shaw that there is a very strong argument for mandatory psychiatric review as part of any legislation allowing physician-assisted death.2 It may even be that any legislation should also require mandatory optimal palliation of symptoms such as pain, since these can also affect someone's decision-making abilities, and yet, this often remains a service that should merely be offered to those requesting an assisted death. However there is another area of concern; clients may well pass every element for assessing capacity (namely being able to understand, retain or weigh up information and communicate their wishes) but, as the judgement in the case of MB suggests, this in itself may not be sufficient to show capacity. MB required a Caesarean section but withdrew consent because of her needle phobia. The judge's view, upheld by the Court of Appeal, was that MB's capacity was impaired by her fear and panic arising from her needle phobia.3 One could argue that any bid to take this gravest of decisions (to end one's life) should be made in the absence of fear, be it fear of pain, suffering, being a burden or even an existential fear of living. To abide by any request for assisted death that is motivated by fear may be to abide by the request of someone incapable of making that decision. 1. Ganzani L, Goy ER, Dobscha SK. Prevalence of depression and anxiety in patients requesting physicians' aid in dying: cross sectional survey. BMJ 2008;337:a1682. 2. Ryan C, Shaw T, Psychiatric review is mandatory in Australia. BMJ 2008;337:a2478 3. Re MB (Adult, medical treatment) [1997] 38 BMLR 175 CA Competing interests: None declared
Capacity of the participants 12 July 2009
saurabh saxena, CT year 1, Old age Psychiatry St Georges hospital, Morpeth, NE61 2NU Send response to journal: Re: Capacity of the participants	Thanks authors, This is an informative article and gives an insight into the issues sorrounding physicians assisted suicide. I am concerned that though the MacArthur competence tool and cognitive impairment were assessed, no patients were excluded because of cognitive impairment or lack of capacity to consent to research. I am also inerested in knowing the results of the capacity assessment and cognitive assessment results of the participants. Also i feel its important to know whether the participants were able to fill the rating scales independently or required help of relatives/friends, when the results may not reflect the accurate account. thanks again Dr Saurabh Saxena Competing interests: None declared