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AUSTIN, Texas -- Should hospitals require a psychiatrist to certify whether a patient who requests physician aid in dying is competent to make such a request? Psychiatrists disagreed on that question during a discussion here at the American Academy of Psychiatry and the Law (AAPL) annual meeting.

"A psychiatrist can help identify potentially treatable psychiatric symptoms that may relieve elements of patient suffering, and detect family agreement versus family conflict that may require further intervention and counseling," said Anna Glezer, MD, an associate professor of psychiatry and of ob/gyn. at the University of California San Francisco (UCSF), which requires such an assessment of its patients who make that request.

"I've done a case where I didn't say 'This person meets the criteria or doesn't,' but [instead said] 'These are my concerns,'" she said. In this case, the patient had lost her husband within the past year "and I thought grief might be compounding her decision-making capacity."

But Richard Martinez, MD, professor of psychiatry and law at the University of Colorado Denver, said he opposed a mandatory capacity assessment. "I understand why UCSF went forward with such a policy, but I think it's an invasion of privacy," he said. " To mandate an interaction with a stranger is concerning to me."

In addition, the field of psychiatry "has got to look at our own narcissism. There's nothing like having a new area of activity to make a career out of -- we can probably get it board-certified eventually," he added.

A Complicated Issue

Physician aid in dying (PAD) is a complicated issue for psychiatrists, said Ariana Nesbit, MD, MBE, a psychiatrist at the San Diego Central Jail. "Our goal is often thought to be to prevent suicide, and we still conceptualize suicidal ideation as a symptom and pathological. As someone who just recently finished training in three very liberal states, I can tell you that at no point during my training was I ever taught how to figure out whether someone's suicidal ideation, or their suicide attempt, was rational, so we don't have any widely accepted method for determining this."

Unlike some other countries, PAD in the U.S. -- in those states that have legalized it -- is restricted to patients with a terminal illness, which is defined as an irreversible condition that is likely to lead to death within 6 months, Nesbit explained. "This requires two-physician determination -- an attending who makes an initial determination that this is terminal, and a consulting physician who needs to determine that." All states also require patients to have decision-making capacity, which is again a two-physician determination, she added.

But capacity is defined slightly differently in different states, said Nesbit. In Colorado, for example, capacity is defined as "the ability to make and communicate an informed decision to healthcare providers." California expands this definition a bit, saying that the patient not only has to be able to make and communicate the decision, but also "understand the nature, consequences, benefits, risks, and alternatives to those decisions."

Mental Health Provider Involvement

When are mental health providers involved? This depends on the state, Nesbit said. "In Oregon, Washington, and [the District of Columbia], a mental health provider is consulted if the patient may be suffering from a psychiatric disorder or if there's concern that depression is causing impairment. In Colorado, a mental health provider is consulted if the physician believes [the patient is] not mentally capable of making an informed decision. And in California it's a little broader -- it's really just if there are indications of a mental disorder."

Data from Oregon show that out of 1,275 patients who requested PAD from 1998 to 2017, 62 patients were referred for a psychiatric assessment. And in a , Linda Ganzini, MD, MPH, of the Oregon Health & Science University in Portland, and colleagues found that of 143 patients who requested PAD, 20% had symptoms of depression, Nesbit said.

-- this time interviewing patients and screening them for depression -- found that 26% of patients requesting PAD did meet depressive disorder criteria, and three of them were approved for PAD. "So the authors concluded that current practices may fail to protect patients who are influenced by depression," said Nesbit.

Martinez, however, didn't see that as a problem. "Depression should not be an exclusionary decision," he said.

Patient 'Bookends'

Martinez gave two examples of patients who had vastly different outcomes in terms of PAD. The first patient, Dax Cowart, suffered severe burns when trying to fix a broken-down car. "It's a phenomenal story of a man who begged to be allowed to die; he wanted treatment stopped," said Martinez. "Even though he was cognitively intact to make that statement, the judgment of [his doctor was] he did not have that capacity and people continued to treat him."

Cowart ultimately got married, became an attorney, and is still alive. "What he says to this day is that 'I'm glad I'm alive, but what they did to me morally and legally was wrong,'" said Martinez.

A contrary example is Tim Bowers, a man who endured a severe spinal cord injury after falling out of a tree while deer hunting. Bowers was taken to a hospital and put on a ventilator; his family requested that the ventilator be removed, saying that Bowers wouldn't want to live that way. Although Bowers was heavily sedated, his doctors were able to bring him to consciousness and felt that Bowers adequately communicated to them his wish not to be kept on the ventilator. He was taken off the ventilator and died shortly thereafter.

"To the bioethics community, this was an extremely concerning process," he said. "We can argue one way or the other [but] these are the two bookends ... Are we dealing with authentic choices or forced choices? Are these voluntary or involuntary decisions? I would submit they're both true; it's not an either-or. It's not fully voluntary or fully involuntary; it is a forced choice to some degree."

A Waiting Period?

In the rehab literature, "people who work with people with spinal cord injuries have argued for a waiting period, so Tim Bowers never should have happened," said Martinez. "[They say] there should have been a period to get him distant from that injury and see whether he would have wanted a ventilator withdrawn or not."

During a question-and-answer session, Annette Hanson, MD, adjunct assistant professor of psychiatry at the University of Maryland in Baltimore, questioned whether PAD was a good idea. "We're not just consulting psychiatrists -- we're members of a profession," she said. "We're shapers of healthcare policy that will affect everyone in the country ... including people who are institutionalized, including people who don't have physical illnesses."

Hanson said she was once contacted by a colleague who asked how to do these evaluations because a patient claimed to be suffering from an "irreversible neurological condition" and wanted to go to a clinic in Switzerland for PAD, but the clinic required him to get an evaluation by a U.S. doctor first. "It turned out the 'irreversible neurologic condition' was schizophrenia," she said. "So the publicity surrounding the right-to-die movement is hurting our psychiatric patients."

Hanson added that "the American Psychiatric Association also considers [PAD] to be unethical, and re-emphasized that in [amicus] briefs to the Supreme Court."

Another AAPL attendee Dileep Borra, MD, of Wausau, Wisconsin, asked the panelists about their self-care after performing these evaluations. Borra said one thing he does to protect himself after making these evaluations is "I try not to find out what happened to the patient." Nesbit said she often found out what happened to the patients she evaluated, because she would see an announcement about a memorial service, but not always. "I agree self-care is really important," she added.

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