Journal of Forensic Psychology

Mandatory Mental Capacity Evaluations for Patients Requesting Medical Aid in Dying: Are they Necessary?

Brian Goodyear^* Independent Researcher, Clinical Psychology, Honolulu, Hawai, USA
^*Correspondence: Brian Goodyear, Independent Researcher, Clinical Psychology, Honolulu, Hawai, USA, Email:

Received: 26-Dec-2023, Manuscript No. JFPY-23-24520; Editor assigned: 28-Dec-2023, Pre QC No. JFPY-23-24520 (PQ); Reviewed: 11-Jan-2024, QC No. JFPY-23-24520; Revised: 18-Jan-2024, Manuscript No. JFPY-23-24520 (R); Published: 25-Jan-2024, DOI: 10.35248/2475-319X.23.9.318

Description

A total of 11 jurisdictions within the United States of America currently allow medical aid in dying. Eligibility in all jurisdictions requires a patient to be a terminally ill adult with a prognosis of six months or less (hospice eligible), and to have the mental capacity to make an informed medical decision.

In April 2018, the State of Hawaii became the eighth jurisdiction in the USA to legalize medical aid in dying. In addition to evaluation by an attending and consulting provider, every patient requesting medical aid in dying in Hawaii must undergo a mental capacity evaluation performed by a licensed psychiatrist, psychologist, or clinical social worker.

The State of Hawaii is currently the only jurisdiction in which a mental capacity evaluation is mandatory. In all other jurisdictions, referrals for capacity evaluations are made at the discretion of the attending provider. Such referrals are rarely found to be necessary. Only 5.6% of 991 patients in Oregon who ingested legally prescribed lethal medication were sent for psychiatric evaluation to assess competence [1]. Similarly, a review of trends in Oregon and Washington found that only 4% of 3,368 patients were referred for mental health consultation [2]. And in a sample of patients in Washington and Oregon with ALS, only 2.7% required psychiatric consultation [3].

Other studies have not found significant relationships between the presence of mental health symptoms and end-of life medical decisions [4-7].

The largest body of research on patients who participate in medical aid in dying has been done by Dr. Linda Ganzini of Oregon Health and Science University and her associates. Their research indicates that mental disorders are not present in the majority of patients who request medical aid in dying [8,9]. Based on her experiences in Oregon, Ganzini has concluded that while all patients requesting medical aid in dying should be carefully screened for depression, requiring a psychiatric consultation in every case is burdensome, unnecessary and possibly unworkable [10].

Overall, the research findings seem consistent with the legal principles described by Grisso and Appelbaum, who emphasized that courts across the USA have made it consistently clear that the presence of mental illness, mental retardation, or dementia alone does not render a person incompetent, and that a patient may be psychotic, seriously depressed, or in a moderately advanced stage of dementia, yet still be found competent to make some or all decisions [11].

Between January 2019 and December 2023, the author conducted a total of 161 mental capacity evaluations for terminally ill patients who had requested medical aid in dying in the State of Hawaii. Evaluations consisted of a review of relevant medical records, a mental status examination, and a detailed clinical interview, which included a screening for symptoms of major depressive disorder and an assessment of decisional capacity based on the principles outlined by Grisso and Appelbaum [11], and subsequently incorporated into handbooks developed jointly by the American Bar Association and the American Psychological Association [12,13]. The principles involve the assessment of four functional abilities: The ability to understand information relevant to the decision; the ability to appreciate the significance of the information and the probable consequences of the available options; the ability to use reasoning to weigh the potential risks and benefits of the options; and the ability to communicate a voluntary decision. A checklist was developed to assist in the assessment of these abilities in medical aid in dying patients.

Consistent with the findings of the patients’ attending provider’s, the author found that the vast majority of patients clearly had the mental capacity to request medical aid in dying. Only four of the 161 patients (2.48%) lacked the necessary decisional capacity, all because of rapid deterioration in cognitive functioning subsequent to the attending provider’s initial visit. A total of 15 of the 161 patients (9.32%) were found to have a mental disorder (either a depressive disorder or adjustment disorder) at the time of the evaluation. In all cases the disorder was mild, and in no case was the disorder severe enough to impair decisional capacity. Mental health treatment was recommended as deemed necessary and appropriate for these patients. Another ten patients acknowledged a remote history of mental disorder that was not evident at the time of the evaluation.

Several conclusions can be drawn from the data reviewed above. First, a request for medical aid in dying should not be equated with the presence of a mental disorder. Second, mental disorders are found to be present in a minority of patients who request medical aid in dying. Third, even when a mental disorder is present, decisional capacity is rarely impaired. These conclusions strongly support the assertion that mental capacity evaluations are not clinically necessary for the great majority of patients who request medical aid in dying.

It thus seems reasonable to argue that mental capacity evaluations should not be legally mandated for all patients who request medical aid in dying. Referrals for such evaluations can be made at the discretion of the attending provider, consistent with the process that providers customarily follow when assessing patient’s decisional capacity for other medical procedures. Patients who request medical aid in dying should be carefully screened by their attending and consulting providers for the possible presence of any mental disorders that might affect decisional capacity. Terminally ill patients should not, however, be required to undergo a potentially costly, timeconsuming, and burdensome evaluation by a mental health specialist unless the attending or consulting provider finds that there is a clear reason to do so.

References

1. Blanke CD, LeBlanc M, Hershman DL, Ellis LM, Meyskens FL. Characterizing 18 years of the death with dignity act in oregon.  JAMA Oncol 2017;3(10):1403.

   [Crossref] [Google Scholar] [PubMed]

2. Al Rabadi L, LeBlanc M, Bucy T, Ellis LM, Hershman DL, Meyskens FL, et al. Trends in medical aid in dying in oregon and washington. JAMA Netw Open. 2019;2(8):e198648.

   [Crossref] [Google Scholar] [PubMed]

3. Wang LH, Elliott MA, Henson LJ. Death with dignity in Washington patients with amyotrophic lateral sclerosis. Neurology. 2016;87(20):2117-2122.

   [Crossref] [Google Scholar] [PubMed]

4. Bharucha AJ, Pearlman RA, Back AL, Gordon JR, Starks H, Hsu C. The pursuit of physician-assisted suicide: role of psychiatric factors. J Palliat Med. 2003;6(6):873–883.

   [Crossref] [Google Scholar] [PubMed]

5. Reinke LF, Slatore CG, Udris EM, Moss BR, Johnson EA, Au DH. The association of depression and preferences for life-sustaining treatments in veterans with chronic obstructive pulmonary disease.  J Pain Symptom Manage. 2011;41(2):402-411.

   [Crossref] [Google Scholar] [PubMed]

6. Rabkin JG, Goetz RR, Factor-Litvak P, Hupf J, McElhiney M, Singleton J, et al. Depression and wish to die in a multicenter cohort of ALS patients. Amyotroph Lateral Scler Frontotemporal Degener. 2014;16(3-4):265-273. 

   [Crossref] [Google Scholar] [PubMed]

7. Wilson KG, Dalgleish T, Chochinov HM, Chary S, Gagnon P, MacMillan K, et al. Mental disorders and the desire for death in patients receiving palliative care for cancer. BMJ Support Palliat Care. 2014;6(2):170–177. 

   [Crossref] [Google Scholar] [PubMed]

8. Ganzini L, Back A. From the USA: Understanding requests for physician-assisted death. Palliat Med. 2003;17(2):113-114.

   [Crossref] [Google Scholar]  

9. Ganzini L, Nelson HD, Schmidt TA, Kraemer DF, Delorit MA, Lee MA. Physicians’ experiences with the oregon death with dignity act. N Engl J Med. 2000;342(8):557-563.

   [Crossref] [Google Scholar] [PubMed]

10. Ganzini L. Psychiatric evaluations for individuals requesting assisted death in Washington and Oregon should not be mandatory. Gen Hos Psychiatry. 2014;36(1):10-12.

    [Crossref] [Google Scholar] [PubMed]

11. Grisso T, Appelbaum PS. Assessing competence to consent to treatment. New York: Oxford University Press. 1998.

    [Crossref] [Google Scholar] [PubMed]

12. American Bar Association and American Psychological Association Assessment of Capacity in Older Adults Project Working Group. Assessment of older adults with diminished capacity: A handbook for psychologists. Washington, DC: American Bar Association and American Psychological Association. 2008.

    [Google Scholar]  

13. American Bar Association Commission on Law and Aging and American Psychological Association. Assessment of older adults with diminished capacity, 2nd ed. Washington, DC: American Bar Association and American Psychological Association. 2021.  

    [Google Scholar]