Suicide risk unintended consequence of assisted death, study finds

A 96-year-old man asked his GP for an assisted death after his wife died – but when that was denied he attempted it himself.

He didn’t have a terminal illness that was likely to end his life within 6 months, so was deemed ineligible under the strict criteria.

So the man contacted his family to say goodbye and was found on the floor of his room in residential care after a suicide attempt.

”The management of those who are not eligible for assisted dying requires careful follow-up and treatment,” the case report by psychiatrist Dr Adam Sims and Auckland University’s Dr Gary Cheung concluded.

The report, published in the New Zealand Medical Journal, suggested a comprehensive suicide risk assessment should routinely form part of an assisted-death assessment.

The End of Life Choice Act was implemented in New Zealand in November 2021 to provide a medico-legal framework for terminally ill people experiencing unbearable suffering to access assisted dying.

In the first year there were 661 applications and 257 assisted deaths, the report said.

However, 91 people were deemed ineligible by medical practitioners and the outcomes of those cases were unknown.

The 96-year-old man’s wife died 18 months before his suicide attempt and subsequent admission to presentation to hospital. He reported feeling “lonely and desperate” after her death and consequently moved into residential care from independent living.

“He suffered from insomnia and worsening mood in the weeks leading up to his residential care placement and was prescribed melatonin and escitalopram.”

The man requested assisted dying through his GP, but was declined because he did not suffer from a terminal illness likely to end his life within 6 months.

After the suicide attempt that followed, he was transferred to hospital via ambulance for further assessment.

While in hospital, he attempted suicide again.

“His antidepressant was switched to sertraline and his mood gradually improved. He became more animated and less hopeless in his disposition,” the case report said.

He reported, upon reflection in the hospital, feeling increasingly demoralised when told he was ineligible for assisted dying and this promoted his suicidal thoughts.

He denied a past history of depression, suicide attempt or other mental health problems and said he had not contemplated suicide before being told he was ineligible for assisted dying.

The report’s authors said the man was diagnosed with depression and his wish to die could be “conceptualised” as part of his depressive syndrome.

A 95-year-old woman also tried to take her own life after being deemed ineligible for assisted death by her GP.

She did not have a terminal illness likely to end her life within 6 months.

The woman was admitted to hospital following the suicide attempt, and was confused but recovered well and was discharged a few days later.

She had been living in an independent flat with support and close oversight from family members.

She has been an active member of EXIT and a strong advocate for end-of-life choice. She had previously considered flying to Switzerland to end her life.

The woman maintained an active wish to die after discharge from hospital, the report said, but made no further plans to harm herself.

It was concluded she had chronic death wishes but no clear diagnosis of depression.

“These two cases reflect the possible unintended consequences of the Act,” the case report concluded.

It said the act was likely to result in societal change as assisted dying became “normalised”, which may have also contributed factor to the openness of the two people in expressing their death wishes to their GP and requesting an assisted death.

The report’s authors noted there was limited international literature on suicide attempt in the context of ineligibility for an assisted death.

The first reported case was of three adults in their 80s who attempted suicide after they were deemed ineligible for an assisted death in Canada in 2020.

The authors highlighted the time following an ineligible assisted-death assessment represents a “heightened at-risk period”.

The cases suggested a comprehensive suicide risk assessment should routinely form part of an assisted death assessment, the report said.

The Ministry of Health developed a care pathway for practitioners providing assisted dying services, including ensuring an ineligible person was supported to have access to primary or end-of-life care.

“However, there is no guidance on suicide risk assessment”

Sims worked as a liaison psychiatrist in the hospital and assessed both cases during the first year of assisted dying being available in New Zealand.

Where to get help

• 1737, Need to talk? Free call or text 1737 to talk to a trained counsellor.
• Anxiety New Zealand 0800 ANXIETY (0800 269 4389)
• Depression.org.nz 0800 111 757 or text 4202
• Lifeline 0800 543 354
• Mental Health Foundation 09 623 4812, click here to access its free resource and information service.
• Rural Support Trust 0800 787 254
• Samaritans 0800 726 666
• Suicide Crisis Helpline 0508 828 865 (0508 TAUTOKO)
• Yellow Brick Road 0800 732 825
• thelowdown.co.nz Web chat, email chat or free text 5626
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• Youthline 0800 376 633, free text 234, email talk@youthline.co.nz, or find online chat and other support options here.
• If it is an emergency, click here to find the number for your local crisis assessment team.
• In a life-threatening situation, call 111.