Request for medical assistance in dying after a suicide attempt in a 75-year-old man with pancreatic adenocarcinoma

• Assessment of a patient’s wish to hasten death requires careful exploration of physical, emotional, spiritual and existential suffering.

• Suffering goes beyond the mere presence of symptoms in any one of these domains; it occurs in the context of how a patient interprets their symptoms and situation.

• In patients with a concurrent psychiatric syndrome such as depression, one of the clinician’s roles is to determine whether this syndrome affects capacity to make decisions with regard to medical assistance in dying.

• A patient’s illness experience often changes over time, requiring serial assessments from a multidisciplinary team, especially in complex cases.

A 75-year-old man was brought to the emergency department by his wife after he ingested an overdose of hydromorphone with the intent of ending his life. One month earlier, he had received a diagnosis of metastatic pancreatic adenocarcinoma. He had chosen not to receive chemotherapy or other cancer-directed treatments, in favour of palliative care through his family physician. Two weeks previously, he had inquired with his family physician about medical assistance in dying (MAiD), who had agreed to look into the process.

In the emergency department, the patient was drowsy and had a depressed respiratory rate. Naloxone was administered with effect. He was assessed by the hospital’s psychiatry and palliative care services, to whom he confirmed his desire to end his life. He cited progressive abdominal pain and dyspnea, as well as a fear of future disability from his malignant disease. He identified a preference for MAiD over suicide, stating that he wished to take the “proper” legal route. His prognosis was estimated to be in the range of weeks, given the extent of his disease. He had no previous psychiatric comorbidities and was not thought to be clinically depressed. After much discussion, the patient was admitted voluntarily to hospital, for management of his symptoms, evaluation of his eligibility for MAiD and continuous assessment for suicide risk.

Over the next week, the patient’s pain and dyspnea improved with titration of his opioids and drainage of large, malignant pleural effusions. He expressed frustration with the loss of autonomy that came with his illness, which was partially addressed by starting an ambulatory infusion pump for patient-controlled analgesia. He was offered the option of initiating a request and undergoing assessments for MAiD on multiple occasions, but he opted to defer this in light of overall improving physical symptoms. He cited unfinished financial affairs and meaningful activities at home that made life worth living, for the moment. However, he indicated that if his symptoms were not controlled or his autonomy were substantially compromised, he would wish to pursue MAiD.

After 11 days in hospital, the patient was discharged home with the infusion pump, an outpatient appointment for consideration of a celiac plexus block, an indwelling pleural catheter, home care services and in-home palliative care provided jointly through his family physician and a palliative care physician.

One week later, the patient returned to hospital after holding a knife to his throat in an apparent suicidal gesture. He described intolerable ongoing symptoms and spoke about wanting “the final needle.” He was delirious upon assessment, rendering him incapable of making a request for MAiD, but he assented to a voluntary admission to hospital. His delirium persisted, with no clear reversible cause identified. By the fourth day of his admission, he was agitated, with a fluctuating level of consciousness. Patient and family were given the option of continuous palliative sedation, which they agreed to pursue. However, within the hour, before a sedative infusion could be initiated, the patient died in hospital with his wife by his side.