Résumés
Résumé
Contexte : En psychiatrie, la question d’offrir des soins palliatifs et de fin de vie pour ce qui serait une « condition psychiatrique terminale » ou, plus globalement, de considérer adopter une approche palliative pour des problèmes de santé mentale sévères et persistants constitue encore un tabou. Méthodologie : Cette question est abordée par l’analyse d’un cas effectuée lors d’une consultation en éthique clinique à l’aide de la méthode des scénarios d’Hubert Doucet. Il s’agit de madame Sanchez, une patiente âgée de plus de 90 ans, présentant des troubles psychiatriques, exprimant le désir de mourir par des gestes suicidaires, refusant les traitements proposés, ainsi que refusant de boire et manger. Son histoire clinique est racontée par le filtre de l’accompagnement réflexif offert en éthique clinique aux diverses parties prenantes. Résultats : L’analyse de cas, loin de répondre aux défis posés par le concept des soins palliatifs et de fin de vie en contexte psychiatrique, présente néanmoins une occasion d’en nommer les enjeux éthiques principaux : la souffrance psychique, le refus de manger et de boire ainsi que le refus de traitement, la sédation palliative et l’aide médicale à mourir, les volontés et directives médicales anticipées, ainsi que les défis clinico-organisationnels suscités par la clientèle gérontopsychiatrique. Conclusion : Les défis cliniques et éthiques demeurent nombreux pour les professionnels et les décideurs afin de répondre aux besoins de la clientèle de santé mentale très âgée. Nous appelons à un plus grand développement des connaissances sur ce thème précis.
Mots-clés :
- psychiatrie,
- soins palliatifs et de fin de vie,
- refus de boire et de manger,
- refus de traitement,
- éthique,
- idéation suicidaire,
- désir de mourir,
- personnes âgées
Abstract
Background: In psychiatry, the issue of providing palliative and end-of-life care for what would be a “terminal psychiatric condition” or considering a palliative approach to severe and persistent mental health problems is still a taboo. Methodology: This question is addressed through an analysis of a case arising during a clinical ethics consultation, using Hubert Doucet’s scenario method. It is about Mrs. Sanchez, a patient over 90 years of age with a psychiatric profile, expressing the desire to die by suicidal gestures, refusing the proposed treatments, and refusing as well to drink and eat. Her clinical history is told through the filter of reflexive support offered in clinical ethics to the various stakeholders. Results: The case analysis, far from responding to the challenges posed by the concept of palliative and end-of-life care in a psychiatric context, nevertheless presents an opportunity to name its main ethical issues: psychic suffering, refusal to eat and drinking as well as refusal of treatment, palliative sedation and medical assistance in dying, wishes and advanced medical directives and clinical-organizational challenges for geriatric psychiatry clients. Conclusion: There are still many challenges for professionals and decision-makers to meet the needs of older mental health clients. We call for further development of knowledge on this specific topic.
Keywords:
- psychiatry,
- palliative and end-of-life care,
- refusal to drink and eat,
- treatment refusal,
- ethics,
- suicidal ideation,
- wish to die,
- elderly
Parties annexes
Bibliographie
- 1. Woods A, Willison K, Kington C, Gavin A. Palliative care for people with severe persistent mental illness: a review of the literature. Can J Psychiatry. 2008;53(11):725-736.
- 2. Ruggeri M, Leese M, Thornicroft G, Bisoffi G, Tansella M. Definition and prevalence of severe and persistent mental illness. Br J Psychiatry. 2000;177(2):149-155.
- 3. Loi concernant les soins de fin de vie. L.R.Q., chapitre S-32.0001., c. 2, a. 3.; 2014.
- 4. Crump C, Winkleby MA, Sundquist K, Sundquist J. Comorbidities and mortality in persons with schizophrenia: a Swedish national cohort study. Am J Psychiatry. 2013;170(3): 324-333.
- 5. Thornicroft G. Physical health disparities and mental illness: the scandal of premature mortality. Br J Psychiatry. 2011;199(6):441-442.
- 6. Nordentoft M, Wahlbeck K, Hällgren J et al. Excess mortality, causes of death and life expectancy in 270,770 patients with recent onset of mental disorders in Denmark, Finland and Sweden. PLoS ONE. 2013;8(1):e55176.
- 7. Lawrence D, Kisely S, Pais J. The epidemiology of excess mortality in people with mental illness. Can J Psychiatry. 2010;55(12):752-60.
- 8. Laursen TM. Life expectancy among persons with schizophrenia or bipolar affective disorder. Schizophr Res. 2011;131(1-3):101-104.
- 9. Trachsel M, Irwin SA, Biller-Andorno N, Hoff P, Riese F. Palliative psychiatry for severe and persistent mental illness. Lancet Psychiatry. 2016;3(3):200.
- 10. Swiss Academy of Medical Sciences (SAMS). Medical-ethical guidelines and recommendations on palliative care. Basel, Switzerland; 2006.
- 11. Lindblad A, Helgesson G, Sjöstrand M. Towards a palliative care approach in psychiatry: do we need a new definition? J Med Ethics. 2019;45(1): 26-30.
- 12. Roy-Desruisseaux J, Poulin P, Hassoun J,Tremblay A. Document de réflexion : enjeux cliniques et éthiques en soins de fin de vie. Association des médecins psychiatres du Québec; mai 2015.
- 13. Aulisio MP, Arnold RM, Youngner SJ, for the Society for Health and Human Values–Society for Bioethics Consultation Task Force on Standards for Bioethics Consultation. Health care ethics consultation: nature, goals, and competencies: a position paper from the society for health and human values–Society for Bioethics Consultation Task Force on Standards for Bioethics Consultation. Ann Intern Med. 2000 Jul 4;133(1):59-69.
- 14. Tarzian AJ, ASHB Core Competencies Update Task Force 1. Health care ethics consultation: an update on core competencies and emerging standards from the American Society for Bioethics and Humanities’ Core Competencies Update Task Force. Am J Bioeth. 2013;13(2):3-13.
- 15. Fox E, Myers S, Pearlman RA. Ethics consultation in United States hospitals: a national survey. Am J Bioeth. 2007;7(2):13-25.
- 16. Dion-Labrie M. La méthode des scénarios : Présentation d’une grille d’analyse pour la résolution de situations éthiques problématiques en réadaptation physique. Association des établissements de réadaptation en déficience physique du Québec; mars 2009.
- 17. Dees MK, Vernooij-Dassen MJ, Dekkers WJ, Vissers KC, Weel C van. ‘Unbearable suffering’: a qualitative study on the perspectives of patients who request assistance in dying. J Med Ethics. 2011;37(12):727-34.
- 18. Schuklenk U, van de Vathorst S. Treatment-resistant major depressive disorder and assisted dying. J Med Ethics. 2015;41(8):577-583.
- 19. van Tol D, Rietjens J, van der Heide A. Judgment of unbearable suffering and willingness to grant a euthanasia request by Dutch general practitioners. Health Policy. 2010;97(2-3):166-172.
- 20. Seller L, Bouthillier M-E, Fraser V. Situating requests for medical aid in dying within the broader context of end-of-life care: ethical considerations. J Med Ethics. 2019;45(2):106-111.
- 21. Downie, J. An alternative to medical assistance in dying? The legal status of voluntary stopping eating and drinking (VSED). Can J Bioeth. 2018;1(2):48-58.
- 22. Bolt EE, Snijdewind MC, Willems DL, Heide A van der, Onwuteaka-Philipsen BD. Can physicians conceive of performing euthanasia in case of psychiatric disease, dementia or being tired of living? J Med Ethics. 2015;41(8):592-8.
- 23. Linden M, Barnow S. The wish to die in very old persons near the end of life: A psychiatric problem? Results from the Berlin aging study. International Psychogeriatrics. 1997;9(3):291-307.
- 24. Jansen LA. No safe harbor: the principle of complicity and the practice of voluntary stopping of eating and drinking. J Med Philos. 2004;29(1):61-74.
- 25. Savulescu J. A simple solution to the puzzles of end of life? Voluntary palliated starvation. J Med Ethics. 2014;40(2):110-3.
- 26. Rady MY, Verheijde JL. Distress from voluntary refusal of food and fluids to hasten death: what is the role of continuous deep sedation? J Med Ethics. 2012;38(8):510-512.
- 27. Etkind SN. Terminal sedation: an emotional decision in end-of-life care. J Med Ethics. 2012;38(8):508-9.
- 28. Schwarz JK. Death by voluntary dehydration: suicide or the right to refuse a life-prolonging measure?. Widener L Rev. 2011;17(2):351-361.
- 29. Jox RJ, Black I, Borasio GD, Anneser J. Voluntary stopping of eating and drinking: is medical support ethically justified? BMC Med. 2017;15(1):186.
- 30. McGee A, Miller FG. Advice and care for patients who die by voluntarily stopping eating and drinking is not assisted suicide. BMC Med. 2017;15:222.
- 31. Pope TM. Voluntarily stopping eating and drinking (VSED) to hasten death: may clinicians legally support patients to VSED? BMC Medicine. 2017;15(1):187.
- 32. Wax JW, An AW, Kosier N, Quill TE. Voluntary stopping eating and drinking. J Am Geriatr Soc. 2018;66(3):441-5.
- 33. Quill TE, Byock IR, for the ACP-ASIM End-of-Life Care Consensus Panel. Responding to intractable terminal suffering: the role of terminal sedation and voluntary refusal of food and fluids. Annals Int Med. 2000;132(5):408-414.
- 34. Douglas C. Moral concerns with sedation at the end of life. J Med Ethics. 2014;40(4):241.
- 35. Raus K, Anquinet L, Rietjens J, Deliens L, Mortier F, Sterckx S. Factors that facilitate or constrain the use of continuous sedation at the end of life by physicians and nurses in Belgium: results from a focus group study. J Med Ethics.2014;40(4):230-4.
- 36. Bruinsma SM, Rietjens JAC, Swart SJ, Perez RSGM, Delden JJM van, Heide A van der. Estimating the potential life-shortening effect of continuous sedation until death: a comparison between two approaches. J Med Ethics. 2014;40(7):458-62.
- 37. Delden JJMV. Terminal sedation: different practices, different evaluations. In: Tännsjö T, ed. Terminal Sedation: Euthanasia in Disguise? Dordrecht: Springer Netherlands; 2004. p.103-13.
- 38. Rietjens JA, Voorhees JR, Heide A van der, Drickamer MA. Approaches to suffering at the end of life: the use of sedation in the USA and Netherlands. J Med Ethics. 2014;40(4):235-40.
- 39. Tännsjö T. Terminal sedation: a substitute for euthanasia? In: Tännsjö T., editor. Terminal Sedation: Euthanasia in Disguise? Dordrecht: Springer Netherlands; 2004. p.15-30.
- 40. Comité d’experts sur l’aide médicale à mourir. Aide médicale à mourir : L’état des connaissances sur l’aide médicale à mourir pour les mineurs matures, L’état des connaissances sur les demandes anticipées d’aide médicale à mourir et L’état des connaissances sur l’aide médicale à mourir lorsqu’un trouble mental est le seul problème médical invoqué. Ottawa : Conseil des académies canadiennes; 2018.
- 41. Special Theme Issue: Medical Assistance in Dying (MAID). J Ethics Mental Health; 2015-2020.
- 42. Thienpont L, Verhofstadt M, Loon TV et al. Euthanasia requests, procedures and outcomes for 100 Belgian patients suffering from psychiatric disorders: a retrospective, descriptive study. BMJ Open. 2015;5(7):e007454.
- 43. Kim SYH, De Vries R, Peteet JR. Euthanasia and assisted suicide of patients with psychiatric disorders in the Netherlands 2011–2014. JAMA Psychiatry. 2016;73(4):362-8.
- 44. Blikshavn T, Husum TL, Magelssen M. Four reasons why assisted dying should not be offered for depression. J Bioeth Inq. 2017;14(1):151-7.
- 45. Berghmans R, Widdershoven G, Widdershoven-Heerding I. Physician-assisted suicide in psychiatry and loss of hope. Int J Law Psychiatry. 2013;36(5-6):436-43.
- 46. Steinbock B. Physician‐assisted death and severe, treatment‐resistant depression. Hastings Cent Rep. 2017;47(5):30-42.
- 47. Diehl-Schmid J, Jox R, Gauthier S et al. Suicide and assisted dying in dementia: what we know and what we need to know: a narrative literature review. International Psychogeriatrics. 2017;29:8:1247-59.
- 48. Shalev D, Brewster K, Arbuckle MR, Levenson JA. A staggered edge: End-of-life care in patients with severe mental illness. Gen Hosp Psychiatry. 2017;44:1-3.
- 49. Ganzini L, Volicer L, Nelson WA, Fox E, Derse AR. Ten myths about decision-making capacity. J Am Med Dir Assoc. 2005;6(3 Suppl):S100-104.
- 50. Geppert CMA, Cohen MA, Bourgeois JA, Peterson MJ. Bioethical challenges for psychiatrists: determination of decisional capacity. Psychiatric Times. 2016;33(7) Jul 26.
- 51. Charland L. Mental competence and value: The problem of normativity in the assessment of decision‐making capacity. Psychiatry, Psychology and Law. 2001;8:135-45.
- 52. Association canadienne de protection médicale-ACPM. Ce patient est-il apte à donner son consentement? Association canadienne de protection médicale; 2011.
- 53. Hewitt J. Why are people with mental illness excluded from the rational suicide debate?. Int J Law Psychiatry. 2013;36(5):358–65.
- 54. Nowland R, Steeg S, Quinlivan L et al. Management of patients with an advance decision and suicidal behaviour: A systematic review. BMJ Open. 2019;9:e023978.
- 55. Miller DG, Dresser R, Kim SYH. Advance euthanasia directives: a controversial case and its ethical implications. J Med Ethics. 2019;45(2):84-89.
- 56. Fairman N, Irwin SA. Palliative care psychiatry: update on an emerging dimension of psychiatric practice. Curr Psychiatry Rep. 2013;15(7):374.
- 57. Meier DE, Beresford L. Growing the interface between palliative medicine and psychiatry. J Palliat Med. 2010;13(7):803-6.
- 58. Balon R, Bankovska Motlova L, Beresin EV et al. A case for increased medical student and psychiatric resident education in palliative care. Acad Psychiatry. 2015;40:203-206.