Doctors order fewer exams of patients seeking suicide.

Byline: Tim Christie The Register-Guard

After eight years of physician-assisted suicide in Oregon, psychological exams for dying patients who request lethal prescriptions have become the exception, not the rule.

The Death With Dignity Act requires Oregon doctors to order such an exam for any patient who requests assisted suicide if they believe a patient's judgment is impaired by a psychiatric or psychological disorder.

But the percentage of patients referred for psychological exams has steadily decreased since the program began in 1998.

In the first two years, doctors referred 31 percent and 37 percent of patients for psychiatric exams, according to a review of the state's annual reports on assisted suicide. In third, fourth and fifth years, they referred 19 percent, 14 percent and 13 percent. In each of the past three years, doctors ordered psychiatric exams for just 5 percent of patients who ask for a lethal prescription.

Doctors, ethicists and advocates of assisted suicide say those numbers don't reflect the actual level of mental health screening that patients receive before getting a prescription.

An opponent of the law says the lack of psychiatric evaluation shows that doctors who support the law are not doing enough to dissuade their patients from an inherently irrational decision.

A guidebook to Oregon's law for doctors, published by the Center for Ethics in Health Care at Oregon Health & Science University in Portland, strongly recommends a mental health consultation for any patient seeking a lethal prescription, especially for those not enrolled in hospice. A psycho-social evaluation by a clinical social worker is standard practice when a patient enrolls in hospice.

For patients not in hospice, "we do recommend they get a psychiatric evaluation for the reason that depression is a common cause for people feeling suicidal, and it's treatable," said Dr. Linda Ganzini, chief of geriatric psychiatry at OHSU, who co-wrote the guidebook's chapter on mental evaluations.

Since 1998, 87 percent of patients who have died under Oregon's law were enrolled in hospice, according to state statistics.

"It appears that many more people have a psycho-social evaluation done than these figures would suggest," said Dr. Susan Tolle, director of the Center for Ethics in Health Care. "I think some sort of evaluation should be done on everyone, but I think the social worker in hospice is a reasonable screen for most people."

Getting a psychiatric evaluation can be difficult.

Ganzini's research has found that only 36 percent of psychologists in Oregon were willing to perform these evaluations.

She also reported that only 6 percent of psychiatrists and psychologists were "very confident" that they could determine whether a mental disorder was influencing the judgment of a person seeking a lethal prescription after just one visit.

Dr. Peter Rasmussen, a Salem oncologist board-certified in hospice and palliative medicine, said he used to order psychiatric exams automatically for any patient who requested suicide. He still will make such a referral if he has questions, he said, but not as a matter of routine.

"I'm more confident in my ability to detect patients who might have depression as I spend more and more time dealing with these exact patients," he said.

He said that in most cases, he didn't find the psychiatric consultation to be very helpful because most patients were not depressed. "What I did was make a lot of work for the patient and psychiatrist," he said.

When a patient makes a request, he'll explore the reasons behind the question, take a psychiatric history and find out how they've reacted emotionally to their illness.

Terminally ill patients typically are grieving the end of their lives, and losing their loved ones, "and they are sad, but none of these disqualify a patient," he said.

Patients who are truly depressed typically don't have the energy to follow-through on the rigorous process of obtaining a lethal prescription required under the law, he said.

Dr. William Toffler, national director of Physicians for Compassionate Care, a group that opposes assisted suicide, said he suspects that doctors aren't referring more patients for psychiatric evaluations because they've grown comfortable with the idea that a patient asking for suicide is making a rational choice.

"Many of my colleagues who participate in assisted suicide at whatever level, they have adopted this stance that this is reasonable," said Toffler, a professor of family medicine at OHSU. "They, in my judgment, collude with the sense of depression a patient might have if they feel their life is not worthwhile."

"You either are an advocate for the health and well-being of that depressed patient or you're not - you can't have it both ways."

Some family members and doctors, when a patient makes a request for assisted suicide, respond in a detached way - "whatever you want is OK," Toffler said.

Patients need to hear from someone who will tell them that all life has inherent dignity, he said. A person's feelings can change from day to day, week to week, and doctors can influence the decisions their patients make, he said.

"My response to people who express such wishes has a huge impact on the continued perseverance of that request," he said. "I don't believe persons are islands."