Mandating psychiatric evaluation for patients who request physician‐assisted suicide may not offer the clearcut protection from possible coercion or other abuse that proponents assert. Competence itself is a complex concept and determinations of decisionmaking capacity are not straightforward, nor is the relationship between mental illness and decisionmaking capacity in dying patients clearly understood. And casting psychiatrists as gatekeepers in end‐of‐life decisions poses risks to the profession itself.

Death in the Clinic fills a gap in contemporary medical education by explicitly addressing the concrete clinical realities about death with which practitioners, patients, and their families continue to wrestle. Visit our website for sample chapters!

In 1998 I was hired by a local health care system to evaluate the mental health of enrolled patients who requested lethal prescriptions under Oregon's newly implemented Death with Dignity Act. I drove to the trailer home of my first patient, a man in his sixties tethered to an oxygen tank for his chronic pulmonary disease who was recently diagnosed with advanced lung cancer. He told me about his abusive, alcoholic stepfather and how he left his family and church at (...) age sixteen, determined never again to be subjugated in any relationship. But in a life marked by an avoidance of intimate relationships, he corresponded regularly with his nephew and was proud to leave him a small inheritance. He shared with me his .. (shrink)

Since 1991, the Patient Self-Determination Act (PSDA) has required all health care institutions that receive Federal funds to inform patients upon admission of their rights to make decisions about medical care and to execute advance directives. Implementation of the PSDA presents a special challenge for state mental hospitals. The relevance and possible negative therapeutic impact of discussing end of life decisions at the time of an acute psychiatric admission has recently been raised in the literature. Other ethical dilemmas arising from (...) the interplay between mental illness and informed consent for medical treatment, particularly for older patients committed to state mental hospitals, have been highlighted by the PSDA. In this article we discuss some of the issues raised by implementation of the PSDA in this setting. (shrink)