Working with decisionally capable patients who are determined to end their own lives

Psychiatrists face complex, vexing, and often conflicting issues in assessing and managing patients with advanced medical illnesses who are determined to end their own lives. Substantial differences of opinion exist among psychiatrists regarding the roles they might take with such patients when the patients are decisionally capable and do not have clear-cut psychiatric disorders. Even those with psychiatric diagnoses often possess rational deliberative abilities and may make decisions to hasten death that are not impacted by their psychiatric disorder. How psychiatrists interact with these patients may be influenced by contradictory and even incompatible ethical, psychological, social, cultural, and professional biases. Tensions often exist between patients' autonomous preferences regarding their wish to die and psychiatrists' usual approaches to suicide prevention. To consider these issues, we review some ethical, legal, psychological, social, and clinical concerns; potential interventions; and support for psychiatrists caring for decisionally capable patients with advanced medical illness who wish to end their own lives. Although psychiatrists' work strongly focuses on suicide prevention, harms might result if suicide prevention becomes the only focus of treatment plans for these patients. We recast benefits and harms in such situations and make suggestions for assessing and managing such patients and for potentially offering assistance to families and other survivors. While psychiatrists should carefully think through each case on its own merits and seek consultation with experts, they should not act reflexively to prevent all deaths at any cost. We argue they may, in some cases, honor patients' and families' wishes and even collaborate with them around decisions to hasten death.