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Table 3 Clinical and legal complexity in a request for physician-assisted suicide

From: Physician-assisted suicide: a review of the literature concerning practical and clinical implications for UK doctors

Mr. A, a 63-year-old Oregonian, called a PAS helpline to request PAS the day he received a diagnosis of terminal lung cancer. He was distraught and saw no purpose in chemotherapy, saying "I might as well end it". The worker informed him that he had actually called a group offering support and palliative care for individuals considering PAS. He ended up discussing his concerns and described having suicidal feelings that first began after his mother committed suicide when he was 21. After her death, he attempted suicide 3 times and was treated for depression in a psychiatric hospital. With the worker's support, he decided to get treatment for his depression from his GP and to start chemotherapy and radiation treatment which alleviated his physical symptoms. He disclosed his diagnosis to his daughter, who became involved.
One year later, he obtained a PAS prescription from a doctor who had actively publicized assisting the suicide of a depressed patient, and who did not consider a psychiatric consultation to be "necessary" for Mr. A. Another doctor associated with the PAS movement was in contact with Mr. A to discuss the PAS option. When asked if this doctor knew of his psychiatric history, Mr. A replied that they "didn't get into that. Our conversations were superficial".
Six months later, Mr. A was admitted involuntarily to a psychiatric ward for suicidal and homicidal thoughts. In addition to being diagnosed with a depressive disorder and narcissistic personality traits, he was diagnosed with intermittent delirium, probably from his numerous sedative medications. During his hospitalization, some of his doctors did not provide comprehensive psychiatric assessment or treatment, seeming to compartmentalize his suicidal symptoms under the rubric of PAS. Prior to his discharge, although firearms were removed from his house based on his risk to self and others, and guardianship was set up due to his "periods of confusion and impaired judgement", his treating doctors did not remove the assisted suicide drugs prescribed by the PAS doctor because they were unsure of their legal right to do so. Mr. A had now long outlived his original prognosis of 6 months, so a PAS doctor gave him a new prognosis of 6 months to live so that his assisted suicide would be "legal".
Mr. A's suicidal urge receded, but returned 3 weeks before his death when he experienced pain from constipation and from stopping his pain medicine in the midst of confusion and paranoia. He was desperate from the pain and on the verge of taking the overdose. His PAS doctor offered to sit with him while he took it. His GP and palliative care worker offered him reassurance, rehydration and a morphine pump. He accepted these interventions and his confusion, pain, fear and suicidality quickly cleared. He was much relieved in the remaining weeks of his life despite his physical deterioration [16].