Psychiatric evaluation of death-hastening requests - Lessons from dialysisdiscontinuation

The authors aim to facilitate the psychiatric evaluation of death-hastening decisions, such as cessation of life-support treatment or physician-assist ed suicide, by deriving principles for evaluating patients from a literatur e review and a recently completed prospective study on dialysis discontinua tion conducted by consultation psychiatrists. Factors are delineated and su ggestions are provided for the evaluation of requests to accelerate dying. Included are the authors' method for determining major depression in the co ntext of terminal illness and their "vector analysis " in assessing patient requests to stop dialysis. As our society heatedly examines the care provi ded to the terminally ill, psychiatry also needs to reconsider whether acti ons that foreshorten life can be normative and permissible. Familiarity wit h competency, psychiatric diagnosis, and ease in communication and negotiat ion between patient, family, and staff are resources that psychiatrists can bring to these complicated assessments. Challenging areas include diagnosi ng depression, establishing the adequacy of palliative care, and appreciati ng issues related to personality features, family dynamics, and ethnic diff erences.