Case Presentation:☆

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The patient was a married woman, living in rural Australia. She had coped with a tough nomadic life, rearing three children in a caravan. At the age of 40, she developed an indolent rash, which was eventually diagnosed as mycosis fungoides. It was treated with psoralen and ultraviolet A, later topical nitrogen mustard, and then total body electron beam with good effect. At 52, she developed lymphadenopathy and nodular skin lesions, signifying she had entered the systemic phase of illness. She was treated with oral chlorambucil without improvement, then four cycles of intensive chemotherapy, with reduction in mass disease. However, she complained of fatigue and her pruritus persisted, causing her to be reluctant to continue. Her oncologist advised her that the disease was associated with a median survival of 9 months. He indicated he had little else to offer. She declared she wanted euthanasia.

Symptomatically, pain was well controlled. Her dominant problem was pruritus, which resulted in skin trauma, infection, eyelid edema with closure, and persistent aural discharge. Her dermatologist reassured her that a variety of medications remained to assist her pruritus, including haloperidol, pimozide, fluoxetine, and naloxone. An otolaryngologist offered guidance about aural discharge.

In view of her request for euthanasia, psychiatric assessment was sought. She said, “It's bad news, because I scratch day and night. My hands and feet blister. Yes, I want to go. I know it's the right time. I can't take anymore. It's so hopeless. You want to get something to help, but you can't.” Her husband added that each morning she asked him to help her to suicide; he too felt helpless and overwhelmed. She described insomnia, poor concentration, loss of interest in her hobbies, and tended to just lie in bed. Her recent medication included doxepin 50 mg three times daily, lorazepam 1 mg three times daily, and flunitrazepam 2 mg at night. The psychiatrist noted reduced reactivity to her surroundings, lowered mood, hopelessness, resignation about her future, and a desire to die. He wrote that her depression was “consistent with her medical condition,” adding that side effects from her general practitioner's treatment for depression, doxepin, may limit further increase in dose.

She traveled to Darwin where the Rights of the Terminally Ill Act 1995 (ROTI)¹ permitted legal euthanasia. She brought the psychiatrist's opinion with her to a doctor known to be willing to perform euthanasia. The Regulations² governing the Act required the further opinion of a specialist, resident in the Northern Territory and with expertise in the illness, to certify that the patient was terminally ill. Two surgeons agreed to see her and then withdrew; one physician assessed her and declined to certify that she was terminal. She made an appeal on national television (placing her case on the public record) following which an orthopedic surgeon saw her and certified that the provisions of the Act had been complied with. She received euthanasia in January 1997.

Did she make an informed decision to end her life? Was a single assessment from the psychiatrist sufficient to meet a duty to care? How should a society deal with a difference of medical opinion about the terminality of illness? Did the Regulations of the ROTI Act² succeed in providing safeguards to protect patients from inappropriate use of the Act?

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References 

1. Rights of the Terminally Ill Act 1995 . Northern Territory of Australia. Darwin: Government Printer; 1995;
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2. Rights of the Terminally Ill Regulations 1996 . Northern Territory of Australia. Darwin: Government Printer; 1996;
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