Respecting the right to die
20 Oct, 08 | by Steven Reid
A BMJ blogger, William Lee, writes of his disquiet following a visit to a meeting held by Dr Philip Nitschke, director of EXIT International, who is in the UK promoting his new ‘guide to suicide’. He describes a strange-sounding meeting with little consideration of the relationship between suicidality and mental illness, and the issue of mental capacity warranting only a cursory mention, including the bizarre recommendation to ‘get a friend to do an MMSE test before your suicide to demonstrate possession of capacity’. Assisted suicide and the ‘right to die’ feature prominently in the news media at the moment. A 45-year-old woman, Debbie Purdey, is seeking clarification of the UK law relating to assisted suicide. She doesn’t want her husband to be prosecuted should he support her in visiting Dignitas, the Swiss organisation providing facilities for euthanasia. Police are currently investigating the case of David James, a 23-year-old left with quadriplegia after sustaining a spinal injury while playing rugby. After several previous attempts he committed suicide at a clinic in Switzerland
Another case has been less widely reported, although I consider it to be no less significant (read about it here). It’s a common scenario that will be familiar to anyone with experience of working in an emergency department – someone presenting with self-poisoning and then refusing treatment. The inquest began last week into the death of Kerrie Wooltorton, a woman with a history of borderline personality disorder, who was taken to Norfolk and Norwich University Hospital after drinking antifreeze (ethylene glycol). On arrival she stated that she did not want treatment and was ‘100 per cent aware of the consequences’. She also brought in a living will (advance directive) that she had written three days previously. The physician responsible for her care thought that she had capacity to make decisions about her treatment and reported that she was ‘calm’ and ‘not agitated’. He felt that it was his ‘duty to follow her wishes’. After consultation with the hospital’s medical director and legal adviser she was not given treatment and died the following day.
The law in the UK (recently codified in the Mental Capacity Act) is clear on the question of treatment for physical illness without consent. If the subject has capacity such treatment would constitute an assault or battery. Yet there are aspects of this case which are troubling. Ms Wootorton had attempted suicide by swallowing antifreeze on nine occasions in less than a year and had previously accepted treatment (including dialysis). She also had a number of recent psychiatric admissions and had been detained under the Mental Health Act. A psychiatrist who saw her in the months before her death said he believed she had the mental capacity to make the advance directive but how can he be certain that this was the case when she wrote it? Given the context of her recent history would there not have been reasonable grounds to doubt her capacity? It’s not uncommon for people turning up in A&E after deliberate self-harm to express ambivalence about treatment and subsequently change their mind, especially in those with borderline personality disorder where impulsivity is a prominent feature. Also, suicidality fluctuates in this group, and if her intent was so clear why come to hospital at all?
These decisions are always difficult and not really made any easier by the Mental Capacity Act. My inclination would have been to treat her on this occasion with an agreement that if she maintained her wish to decline future treatment and in the cold light of day clearly had capacity, an advance directive could be drawn up with the acknowledgment that it was valid by people involved in her care. A paternalistic abuse of a person’s autonomy? Maybe, but what do you think?
A common and difficult scenario indeed. I would do the same as you Steven. My view is that anyone who is talking to you about suicide is ambivalent - and the correct response to this is curiosity. Anyway I wonder what evidence would inform this decisiion? The number of people who insist they want to die when they present to hospital and subsequently do commit suicide? Qualitative research on the experience of this phenomena from the patients perspective?
Simon Hatcher
October 20th, 2008 at 9:16 am
I agree. The MMSE score says nothing about decision-making capacity.
With respect to the suicidality of the woman who ingested ethylene glycol, I agree vehemently that she should have been given medical treatment to save her life. Her history, as you well described, is full of psychiatric overtones, and her action (coming to the hospital)evidences ambivalence.
If she really wanted to end her life, she could always refuse food and fluid for about two weeks — a method that requires continual resolve and is rarely used for emotionally based reasons by psychiatric patients. Hence: Save now; talk later; the option to refuse food and fluid can be exercised later, and with comfort care to the mouth is quite peaceful. One must err on the side of life when the alternative is irreversible death. Yet one must also allow for well-reasoned autonomy and respect the integrity of the body (eg, no forced feeding or forced IV drips).
Stanley A. Terman, PhD, MD
Board Certified in Psychiatry
Medical and Executive Director, Caring Advocates
http://www.CaringAdvocates.org
2730 Argonauta St.; Carlsbad, CA 92009
800 647 3223 or 760 431 2233 or SKYPE: stan_terman
Author of “The BEST WAY to Say Goodbye: A Legal Peaceful Choice at the End of Life” and “Lethal Choice,”
and co-developer of the combined document, the “Physician’s Orders to Permit Natural Dying/Advance Directive to Permit Natural Dying”
Coming soon: “Peaceful Transitions: How to Die When and How YOU Want”
Stanley A Terman
October 21st, 2008 at 3:56 am
At what point do the impulses of someone with borderline personality disorder become wrong rather than acceptable? Is it when they are considered harmful to themselves or others? I’m just thinking that decisions to commit suicide could be just as valid despite the varying dominance of the personality disorder over the person. Even if she lacked capacity when she wrote the advance directive she was judged to understand what she had written when she came into hospital. And as she had attempted (and been treated) 9 times previously then she would have been aware of the treatment and had decided against it while she had the capacity to do so. Some people (choose to) end their lives in hospital, others in hospices and still others at home; why should the fact that she actively brought forward her time of death mean that coming to hospital to die was a sign of ambivalence? But after all that, I’m glad I wasn’t the one having to decide whether to treat her, especially in light of the potential for litigation for assault.
Julie Solomon
October 28th, 2008 at 4:23 pm
This is a really sad case. I have BPD and its a really difficult condition to live with (despite the article stating it is not treatable it is with alot of work). People with BPD are very emotional and senstive and unable to regulate their emotions. The condition brings on great psychic distress. She was distressed at not being able to have children.
BPD is a personality disorder (in that the behaviours are deeply routed in ones personality) and not a mental illness such as depression, yet brings about the same suffering.
I think she did have capacity to make a rational decision (she was not mentally ill but personality disordered). I don’t think it was impulsive as she wrote out her living will 3 days before she attempted suicide. Although she had been previously treated 9 times for an attempted suicide and consented to treatment, I think this time she said enough was enough and decided to end it all (much like when a person who has chemo and then the cancer comes back and they have chemo again and then the thrid time,if it does come back, they might not want to fight it anymore and would rather just receive pallitative care). I think it was the same for her, her emotional pain kept coming back and it was too profound.
She made it clear to the ambulance that she did not call them for them to save her life. She just wanted pallitative care and to make her comfortable. Some people don’t want to die alone in the house where there body is discovered 2 months later and she wanted to die in the hospital.
Despite saying all this, I think it is very sad. She was very brave and only 26.
Sarah
November 1st, 2008 at 1:25 am
I mentioned the above situation to a group of residents in psychiatry working in Spain (Las Palmas). It is interesting to mention that it was the first time that I obtained a reaction from them (I had been posting psychiatric articles and comments to them with little success); the responses were, in general, balanced and sensible. All of them reacted in a conservative way (i.e.: using the Spanish Mental Healh Legislation to keep the patient in hospital and to treat her regardless of her Life Testament). The reasoning to get there differed, some were spot on, concerning capacity,etc, some placed the emphasis on saving a life and dealing with legal issues later.
Having worked in the UK - and being Section 12 approved under the MHA (1983, though, not the new one), I am appalled that they allowed this patient to die. I am also surprised to see that there was no psychiatric intervention (?) Where was the consultant psychiatrist on call for that day? Where was the Crisis Resolution Team? When I worked in London, I had to deal with similar cases, and we always had the support of a team to deal with these patients.
Exemplary case to use as a teaching tool… Great blog…
C Cabrera-Abreu
November 2nd, 2008 at 12:02 pm
C Cabrera, she was let down by the mental health team as many people with borderline personality disorder are. It seems that everytime she presented with an OD (9 times within a year) she was treated and discharged home with probably a little bit of follow up. This is quite astounding and I can’t help but think (cynically) that they just wanted to get rid of her once and for all. Patients who present with deliberate self harm are often treated with disdain rather than as people who need help. What she need was involuntary hospitalization. Alot of pyschiatrists think that if you have a personality disorder than you cannot have a comorbid depressive disorder either.
“Apparently” a psychiatrist reviewed her months before her death. If you ask me, peoples mental states can deteriorate in a few months, esp without adequate support. I think deep down she was really crying out for help.
I understand that she felt lonely and wanted to die when she learnt she was infertile and couldn’t have children. She also had a fight with her partner. They are all emotional reasons to end your life and are not rational decisions.
In my opinion, the only people should be able to make a rational choice about dying are people with terminal cancers that have absolutely no prospect of recovery. They should be allowed to die with dignity. This case is a far cry from terminally ill patients wanting to die with dignity. This case shows a blatent disregard to mentally ill people and a gross breach of the doctors duty of care to keep her alive.
The sad thing is that a week or even a year later she would have changed her mind and wanted to live…but we will never know.
Sarah
November 9th, 2008 at 9:34 am
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