Shifting attitudes on pre-planned death raises new questions for clinicians

Amid changing attitudes toward death and dying, some people with serious physical and/or mental illnesses are claiming a right to choose the time, place, and manner of their death. Discussions about "pre-planned death" pose new challenges for psychiatrists and other healthcare professionals to consider, according to an article in the September Journal of Psychiatric Practice.

As the concepts of assisted suicide and the 'right to die' become more accepted in society, "There's a growing likelihood that clinicians will encounter situations involving "pre-planned death by decisionally competent individuals," writes guest columnist Joel Yager, MD, of University of Colorado School of Medicine, Denver. His article seeks "to question conventional attitudes and assumptions, push readers' thoughts beyond typical comfort zones, and consider alternative modes of responding to challenges posed by pre-planned death."

Pre-Planned Death Raises Complex Personal and Professional Issues

Prompted by personal experiences and the recent passage of Colorado's "death with dignity" law, Dr. Yager reviews the shifting landscape related to pre-planned death—defined as "any death in which a decisionally capable individual takes actions to assure the end of life at a specified time, under specified circumstances, and via a specified mode of death."

Dr. Yager notes that the term pre-planned death is "neutral" as to whether the person has a "terminal, static, or progressive" medical or psychiatric illness, or whether the lethal act is administered by themselves or someone else. His discussion is limited to "decisionally capable" individuals—specifically excluding those whose wish to die results from symptoms of a treatable psychiatric illness.

Most people agree as to what constitutes a "good death," but don't get to choose the way they die. By a large majority, doctors say they would not want drastic measures to prolong life. When patients voice concerns about prolonged suffering at the end of life, Dr. Yager asks, "Shouldn't they be accorded the same dignities and care that physicians would want for themselves?"

He outlines the complex issues and terminology surrounding pre-planned death. In "physician-assisted" suicide, doctors may administer or supply to means to cause death. In pre-planned death, they may simply acknowledge the patient's intentions without interfering. "Theoretically, clinicians can accompany, witness, and be with patients as they go through actions that will lead to death," Dr. Yager writes.

He invites clinicians to think about a range of scenarios in which patients with serious medical and/or psychiatric illnesses may make a considered decision to plan their own deaths. Five states and the District of Columbia now have some type of "death with dignity" law, as do Canada and many European countries. While most discussions of these laws have focused on physician-assisted deaths, similar concerns might apply to "patient-initiated, self-conducted" deaths.

Although psychiatrists support medically assisted death in general, "they do not support such programs for psychiatric patients," according to Dr. Yager. He notes that the American Psychiatric Association has issued an opinion that psychiatrists "should not prescribe or administer any intervention to a non-terminally ill person for the purpose of causing death."

"But ambiguity remains," Dr. Yager writes. "Does providing moral support for a patient or family under such circumstances constitute an intervention contributing to 'the purpose of death?'" Meanwhile, people suffering from physical or mental illnesses can find several movements and organizations providing information and assistance to people considering pre-planned death.

"Considerations regarding pre-planned deaths merit greater professional and public discussion," Dr. Yager concludes. "Many options exist for improving how professionals address the quality of human experiences surrounding death."