Patient experiences with requests for medical assistance in dying: Perspectives of those with complex chronic conditions.

OBJECTIVE: To explore experiences of patients who have complex chronic conditions (CCCs), such as fibromyalgia and chronic fatigue syndrome, when they request medical assistance in dying (MAID) in Canada. DESIGN: Qualitative study using semistructured interviews. SETTING: Canada. PARTICIPANTS: Individuals with CCCs who had contacted any 1 of 4 advocacy organizations between January 21, 2021, and December 20, 2022, about requesting MAID for suffering related to CCCs or who had applied and been assessed for MAID. METHODS: Interviews were conducted virtually (by video or audio) and recordings were transcribed. Thematic analysis was conducted in an iterative manner with abductive analysis. As interviews were completed, transcripts were reviewed and emerging themes were discussed at regular intervals. MAIN FINDINGS: Sixteen individuals were interviewed. All spoke of long-lasting suffering that was unresponsive to an array of medical treatments. Although some participants had hoped to receive MAID immediately following the 90-day assessment period, many mentioned that approval would provide or had provided validation of their illness and a sense of control, especially should their illness become unbearable. Participants sharply distinguished between MAID and suicide, saying they preferred MAID because it offered greater certainty and caused less emotional pain to others. Many said that participating in this research was beneficial because they believed the interviewers truly listened to them. CONCLUSION: Participants described experiences with CCCs and requests for MAID. This information may provide family doctors with new insight to inform interactions with patients with CCCs.

E-Survey of Stressors and Protective Factors in Practicing Medical Assistance in Dying.

Objective: To better identify, quantify, and understand the current stressors and protective factors reported by Canadian medical assistance in dying (MAiD) assessors and providers to inform policy, education, and supports. Methods: E-survey of MAiD stressors (n = 33) and protective factors (n = 27); resilience measurement and comments relating to practice involving physicians and nurse practitioners who provide MAiD services and belong to the Canadian Association of MAiD Assessors and Providers or a francophone equivalent. The survey was conducted, while Parliament was considering changes to MAiD eligibility criteria, which occurred during COVID-19 pandemic restrictions. Results: In total, there were 131 respondents (response rate 35.8%). Two possible changes to future eligibility (mental disorders as the sole reason for MAiD and mature minors) were highly scored as were extra clinical load and patients' family conflict over MAiD. Twenty percent of respondents considered stopping MAiD work. The CD Resilience Scale-2 mean score was 6.90. Highly scored protective factors included compassionate care, relief of suffering, patient autonomy, patient gratitude, feelings of honor, privilege, and professionally satisfying work. Discussion: The identified stressors and reasons for considering stopping MAiD work indicate needs for policy, education, and supports to be optimized or developed. Respondents showed high resilience and highly scored protective factors, which should be optimized. This survey should be repeated in countries where MAiD is legal to determine stressors and protective factors in MAiD practice, stressors addressed, and protective factors enhanced where feasible in the local context for optimal care.

The influence of cognitive distortions on decision-making capacity for physician aid in dying.

As international laws on physician aid in dying (PAD) evolve, the question of permitting PAD in non-terminal illness, and in sole psychiatric illness, is under intense debate. In jurisdictions where PAD is permissible, certain safeguards and eligibility requirements must be met for all patients making a PAD request, and one of these requirements is that the patient have sound decision-making capacity with respect to the request. Legal criteria already exist for the determination of capacity, and they are quite similar between different jurisdictions. In current debates about the question of psychiatric PAD, one concern that has been raised is that cognitive distortions in mental disorders may affect a patient's decision-making capacity. At the same time, it has been established that all persons, with or without a mental disorder, experience cognitive distortions. If cognitive distortions are ubiquitous, it is likely that the severity and frequency of cognitive distortions is dimensional rather than categorical, between samples with and without mental illness. Furthermore, currently, there is no requirement for a formalized evaluation of cognitive distortions as part of capacity assessment for any type of medical decision, including PAD decisions. The current paper examines the literature related to cognitive distortions in mental disorders and in healthy populations. It proposes that the existence of cognitive distortions, alone, cannot be used as an argument for a blanket exclusion of psychiatric PAD. It therefore concludes that further research and ethical analysis should be undertaken to examine the impact of cognitive distortions on decision-making for consequential medical decisions, including PAD, in patients with and without mental disorders.

"For Their Own Good": A Response to Popular Arguments Against Permitting Medical Assistance in Dying (MAID) where Mental Illness Is the Sole Underlying Condition.

Canada is approaching its federal government's review of whether patients should be eligible for medical assistance in dying (MAID) where mental illness is the sole underlying medical condition, and when "natural death" is not "reasonably foreseeable". For those opposed, arguments involve the following themes: capacity, value of life, vulnerability, stigma, irremediability, and the role of physicians. It has also been suggested that those who are able-bodied should have to kill themselves, even though suicide may be painful, lonely, and violent. Opponents of MAID for severe, refractory suffering due to mental illness imply that it is acceptable to remove agency from such patients on paternalistic grounds. After years of efforts to destigmatise mental illness, these kinds of arguments effectively declare all patients with mental illness, regardless of capacity, unable to make considered choices for themselves. The current paper argues that decisions about capacity must be made on an individual-patient basis. Given the rightful importance granted to respect for patient autonomy in liberal democracies, the wholesale removal of agency advocated by opponents of a permissive MAID regime is difficult to reconcile with Canadian constitutional values.

"The ickiness factor:" case study of an unconventional psychotherapeutic approach to pediatric OCD.

Obsessive-compulsive disorder (OCD) is a complex condition with biological, genetic, and psychosocial causes. Traditional evidence-based treatments include cognitive-behavioural therapy, either alone or in combination with serotonin-specific reuptake inhibitors (SSRI's), other serotonergic agents, or atypical antipsychotics. These treatments, however, often do not lead to remission, and therefore, it is crucial to explore other less conventional therapeutic approaches. This paper describes a case study in which psychodynamic, narrative, existential, and metaphor therapy in combination with more conventional treatments led to a dramatic remission of severe OCD in a 12 year old hospitalized on a psychiatric inpatient unit. The paper, which is written partly in the form of a story to demonstrate on a meta-level the power of narrative, is also intended to illustrate the challenges of countertransference in the treatment of patients with severe OCD, and the ways in which a reparative therapeutic alliance can lead to unexpected and vital change.

The ethics of providing hope in psychotherapy.

The instillation of hope is a common factor in most psychotherapies. A considerable literature exists on the ethics of providing false or positively biased hope in non-psychiatric medical settings, and ethicists have generally concluded that this practice is unethical. However, the literature on the ethics of encouraging hope in psychotherapy, especially in the case of treatment-resistant mental illness, is sparse. The author explores two clinical cases with the intention of examining the nature of hope, false hope, positive illusions, and denial, as they relate to our definitions of mental health and psychotherapy. The cases highlight the ethics of balancing an acknowledgment of likely treatment futility with a desire to hope. Clinical psychological studies on depressive realism and optimistic bias indicate that some degree of positive bias, referred to by some authors as "the optimal margin of illusion," is in fact necessary to promote what we define as "good mental health;" conversely, stark realism is correlated with mild to moderate depression. An examination of the existential literature, including Ernest Becker's work, The Denial of Death, indicates that without the defense mechanism of denial, human beings tend to experience paralytic despair as a result of being fallible, mortal creatures in a frightening world. The combination of these diverse bodies of literature, along with the surprising outcomes of our case examples, leads to an unexpected conclusion: it may occasionally be ethical to encourage some degree of optimistic bias, and perhaps even positive illusion, when treating patients in psychotherapy.