Managing Requests for Medical Aid in Dying Within the Veterans Health Administration

Requests for medical aid in dying (MAID) within the Veterans Health Administration (VHA) present unique ethical, legal, and clinical challenges. MAID is a process in which a physician provides a terminally ill patient with the means to end their own life. It is expressly prohibited by federal law, including within the US Department of Veterans Affairs (VA), regardless of its legality at the state level.¹ MAID is also prohibited within community care institutions funded by the VA. The American Medical Association, American Geriatrics Society, and American Academy of Hospice and Palliative Medicine have adopted neutral positions regarding MAID due to varying opinions among their respective members.^2-4 VHA palliative care clinicians are trained to identify and honor preferences for care and alleviate physical and emotional distress, which may complicate the management of MAID requests. Veterans can request MAID due to their desire for autonomy and pain relief, but the VHA prohibits clinicians from honoring these specific preferences. The inability to help veterans achieve their care preferences conflicts with the core mission of palliative care to reduce suffering and respect end-of-life wishes.

This case report describes the management of a veteran who requested MAID while also exhibiting active suicidal ideation. The patient’s distress stemmed from fears of impending loss of autonomy and functional decline, factors frequently linked to requests for MAID in terminally ill patients.^5,6 Addressing the veteran’s request for MAID required balancing respect for patient autonomy and concerns about future suffering with the VA mission to protect veterans from self-harm and provide mental health care for suicidal ideation. This case highlights the importance of nuanced clinical approaches, ethical reflection, and interdisciplinary collaboration in navigating such complex scenarios. Informed consent was obtained from the patient’s family and health care agent (HCA) to publish this report.

Case Presentation

A 73-year-old male veteran, with Parkinson disease (PD), diagnosed at age 52 years, was referred to palliative care following diagnosis of a glioblastoma multiforme (GBM). The patient also had a history of major depressive disorder (MDD), suicidal ideation (SI), benign prostatic hypertrophy, and migraines. He was divorced, had no children, and his only sibling (sister) was deceased. His brother-in-law served as his HCA.

The patient had many close friends in the community, was an architect by training, and was active in the removal of barriers and increasing access for people with disabilities. Since 2010, about 7 years before his PD diagnosis, the patient used psychiatry and psychology resources to treat MDD, functional decline, and SI. He was hospitalized in 2016 after self-administration of heroin. During the hospitalization the patient received a high risk for suicide label. He articulated a firm and long-standing belief in his right to die and shared plans to end his life when he experienced a significant decline in his independence and quality of life (QoL).

When diagnosed with PD, the patient shared that his QoL was of utmost importance. He was aware that he would have significant physical decline as PD progressed and felt like there would be a point when his QoL would not be acceptable. When that happened, he wanted to end his life by available means. He was followed closely by his VHA care team for physical and emotional distress.

When diagnosed with a GBM in 2023, the patient declined treatment and was referred to palliative care, which had sporadically treated him for PD-related distress prior to 2023. During his previous palliative care visits, the patient had discussed a desire to engage in MAID when his functional status declined. After the GBM diagnosis, he reported no acute intent to harm himself with heroin, but planned to travel to Vermont for MAID when he felt he no longer had an adequate QoL based on functional capability.

Pharmacologic and nonpharmacologic approaches were used to treat the patient’s pain. He reported significant benefit from biofeedback therapy provided by the VA Headache Center of Excellence. This work also reconnected him to meditation, which he used daily to relieve pain and distress. The patient managed head pain with nonpharmacologic and pharmacologic interventions for 6 months and reported satisfaction with his QoL.

After 6 months, imaging showed progression of the brain tumor, which was associated with more fatigue and memory decline. At that time, the patient was enrolled in home hospice and reported continued intent to pursue MAID in Vermont but had not taken steps toward carrying it out. The patient understood the VA could not assist him in pursuing MAID; however, his care team was able to assist him in sharing his preferences for care with his loved ones and health care power of attorney.

He experienced rapid functional and cognitive decline due to progression of the GBM and was admitted to the VA Connecticut Healthcare System (VACHS) acute care unit where he exhibited confusion and screened positive for delirium using the Confusion Assessment Method.⁷ His physical and cognitive deterioration was likely due to the progressive brain tumor, and the patient lacked the capacity to make complex medical decisions. Formal consent was obtained from his HCA to transfer him to inpatient hospice. Psychiatry followed the patient throughout.

After 4 weeks of hospice care, the patient had a witnessed suicide attempt while the nurse was assisting him in the bathroom. The patient attempted to use hospital pajamas to hang himself when he wrapped a hospital gown around his neck and stated he was trying to tie a knot. Due to his confusion and delirium, the patient was unable to express his reasoning for the suicide attempt. He was seen by the Psychiatry service, which determined that his suicide risk was low to intermediate. The Psychiatry service did not recommend a 1:1 safety sitter, but suggested medication changes. Levetiracetam was discontinued, and valproate 500 mg orally twice daily was initiated for seizure prevention.

The hospice team was informed of the suicide attempt and psychiatry recommendations. The suicide prevention team was also updated following this event and agreed with psychiatry recommendations. The patient continued to decline, was no longer able to get out of bed, and had minimal speech. The patient received comfort medications, including intravenous morphine 2 mg and lorazepam 0.5 mg as needed ≤ 4 times daily. He died 8 days later.

Discussion

Chronic medical illness has been associated with increased suicide risk.^8-10 The increased risk of suicide in chronically ill patients has been described as having as a bidirectional relationship with MDD, with depression not only increasing the risk of chronic medical illness but new-onset chronic medical illness being associated with new onset depression.^11,12 Chronic medical conditions are associated with numerous psychiatric disorders, and the presence of a comorbid psychiatric illness is associated with higher rates of hospitalization, emergency department visits, and increased health care costs.¹³ Research has found that the association between suicide risk and chronic medical illness remains even after accounting for comorbid mental health disorders.¹⁴ This has been postulated to be due to a multitude of interpersonal, behavioral, cognitive, and affective factors (eg, perceived burdensomeness, loneliness, stress, pain catastrophizing, self-criticism).¹⁵ Additionally, some researchers have questioned whether suicidality constitutes a distinct mental disorder.¹⁶

Patients with cancer are at increased risk for suicidal ideation (including passive death wishes) and suicide attempts.^17,18 Recent data indicate that compared with the general population, there is an 85% increased risk of suicide mortality in patients with cancer.¹⁹ Studies show the incidence of suicide is greater for individuals with cancer compared with the general population, with standardized mortality ratios ranging from 1.4 to 5.7.^20-22

Among patients with cancer, suicide risk is associated with several factors: worse prognosis, older age, male sex, living in a socioeconomically vulnerable environment, and increased communication about suicidal intent prior to death.^23-25 Just as the prevalence of suicidal ideation in people with cancer varies widely, reported rates of suicidality in caregivers of patients with cancer range from 2.7% to 71%.^17,26 A survey of health care workers indicated the following reasons patients with cancer may die by suicide or seek aid in assisted suicide: social isolation, pain, physical impairment, loss of autonomy and meaning, terminal illness, and psychic distress and desperation.²⁷

As with cancer, patients with PD exhibit increased suicidal ideation compared with the general population.^28,29 Two studies found the suicide rate in individuals with PD is about twice as high as it is in the general population.^30,31 Among people with PD, male sex, younger age, initial onset of motor symptoms in the upper or both upper and lower extremities, history of depression or any psychiatric diagnosis, delusions, higher levodopa dosing, and urban residence have been clinically correlated with suicide. Jumping has been a frequent method of suicide.^30,31

Some research has evaluated the perspectives of loved ones after a patient chooses MAID. A study in the Netherlands found that 92% of relatives surveyed believed that access to MAID improved QoL and reduced pain at the end of life.³² In another, family members of individuals who used MAID reported higher quality on items related to physical symptom control and preparedness for death, compared with individuals who did not pursue MAID or who requested but did not receive it. There were no differences on items assessing connectedness to their loved one, being unafraid of death, level of consciousness, or global quality of death items.³³ Another study found no significant differences in depression rates, grief, or use of mental health services among Oregon families whose loved ones died using MAID compared with those who did not.³⁴

The higher suicide rate among terminally ill patients highlights the complex issue of MAID and the right to die. It is important to differentiate between euthanasia and medically-assisted dying. Euthanasia is an act whereby a person other than the patient acts to cause death. In MAID, the patient is provided with a medication that they self-administer. Recent Gallup polls found that > 70% of Americans believe physicians should be “allowed by law to end the patient’s life by some painless means if the patient and his or her family request it.”³⁵

It is important to acknowledge MAID in the context of chronic suicidality, like in the case described in this article. It is imperative not to dismiss reports of suicidality in this population. Ignoring reports of suicidal ideation may lead to decreased access to pharmacologic and nonpharmacologic interventions. It is also important to maintain a timeline of symptom occurrence and to differentiate between chronic suicidality and the desire to die associated with having a terminal illness. A thorough assessment is necessary to assess whether the patient’s decision stems from a calculated decision with preserved capacity or from underlying mental health conditions. Other factors that may lead the patient to a hastened death (ie, pain, poor psychosocial support, delirium, cognitive impairment, incomplete understanding of treatment/prognosis) need to be addressed prior to finalizing choices. In this case, an assessment was performed by psychiatry, psychology, social work, and chaplains to ensure comprehensive evaluation.

The VHA offers resources to assist individuals experiencing suicidal ideation, including suicide prevention coordinators who work directly with veterans and offer consultation to teams working with veterans at risk for suicide. Support for VHA clinicians who treat veterans considering MAID may help address any moral distress. In this case, the care team met early for overnight sign-out, had daily core hospice team meetings, as-needed safety huddles, and weekly care plan meetings to ensure maximal physical and emotional comfort for the patient. These meetings cultivate open, honest, and transparent discussions regarding any staff concerns or personal distress around the plan of care. The VACHS chief well-being officer was also available for all staff.

A systematic review of the impact of MAID on clinicians found that MAID legislation influenced emotional responses. For countries whose MAID legislation emphasized alleviation from pain in addition to terminal illness, clinicians reported more emotional reflection. Whereas, in countries where MAID legislation is stricter and can be applied solely for terminal illness, clinicians reported a stronger and more polarizing range of emotions.³⁶ This highlights the potential influence of the context in which clinicians work on their emotional experience with MAID. Given that MAID is not permitted in the VA, staff members may experience heightened emotional responses. In a survey of US adults, there was an interest in using MAID but there were knowledge deficits regarding the process and legality.³⁷

Legal aspects come into play as well with regards to MAID. Eligibility requires the patient be aged ≥ 18 years, be terminally ill with a prognosis of ≤ 6 months, have the capacity to make their own health care decision, and be able to self-administer the medication. States also may have residency restrictions. Special care and adequate education are needed, as having anyone but the patient administer the medication may be considered criminal. Furthermore, since MAID is not allowed federally, this creates further distress in VHA clinicians entrusted to minimizing pain for patients.

Strategies to support veterans given prohibition of MAID include: conversations about the patient’s values, clarifying reasons for request, assessing all domains of distress, affirming concerns with compassion and nonjudgment, addressing any pain using pharmacologic and nonpharmacologic interventions, providing education on other permissible options for end-of-life care, and consulting other specialties.³⁸

End-of-life options permitted by the VA include withholding/ withdrawing life-sustaining treatments, palliative sedation, and voluntary stopping of eating and drinking.³⁹ Given the complexities of MAID, the VHA should initiate discussions of MAID, educate clinicians on what they can and cannot do as federal employees, and establish committees to discuss approaches that could minimize pain for patients and clinician distress.

Conclusions

Caring for veterans who request MAID requires clinicians to navigate a complex intersection of ethical obligations, legal constraints, and patient preferences. Within the VHA, where MAID is prohibited, clinicians must balance respect for patient autonomy with adherence to VA regulations. Comprehensive assessment to identify sources of distress, interdisciplinary collaboration, and recognition of permissible alternatives that align with patients’ values are essential to provide effective end-of-life care at the VHA for individuals considering MAID. As requests for MAID continue to emerge in clinical practice, the VHA has an opportunity to strengthen clinician education, clarify institutional expectations, and promote supportive structures that reduce both patient suffering and clinician moral distress.