Suicide prevention in the context of ineligibility for voluntary assisted dying: emerging insights

While there has been necessary focus on careful assessments of requests for voluntary assisted dying (VAD), there has been less attention paid to the potential clinical implications of VAD ineligibility. While emergent suicidal ideation and behaviour have been described following determination of VAD ineligibility, there are no clinical guidelines for addressing this potential risk. This narrative review aimed to examine reports of suicidal behaviours following VAD ineligibility to guide potential suicide prevention strategies. The literature search and selection process followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The electronic databases of CINAHL, PubMed, PsycINFO, Embase, and Scopus were searched using broad search terms to maximise identification of relevant literature. Studies were included if they were in English and reported empirical data on suicidal behaviours or adverse psychological responses following determination of VAD ineligibility. Two authors conducted a narrative synthesis of included articles. Fourteen studies of varying study designs were included: case report/series (n = 7), cross-sectional stakeholder surveys (n = 3), death registry data (n = 1), qualitative methodology (n = 2) and systematic review (n = 1). Psychological responses included emotional distress and frustration, suicidal ideation (including the wish to die) and behaviour, commonly voluntary stopping eating and drinking (VSED), and completed suicide. Data were insufficient to determine factors associated with suicidal behaviours in this context, however VSED appeared more common in the oldest-old. Although recommendations have been made to mitigate suicide risk such as pre-VAD assessment preparation for ineligibility, and follow-up of those deemed ineligible, none of these strategies were empirically tested. A range of suicidal behaviours has been reported following determinations of VAD ineligibility, although this data is not systematically collected precluding understanding of this potentially at-risk clinical population. While guidance is lacking regarding the best way to mitigate suicide risk in this group, insights may be gleaned from the literature on suicidal behaviours in older adults. In addition to preparing applicants for their VAD assessment and possible outcomes, VAD assessors would benefit from receiving training in suicide prevention and identifying people needing further support. Follow-up should be arranged for those deemed ineligible, to explore and respond to feelings, discuss alternatives, and address unmet needs/reversible factors driving an ongoing wish to die, and training for physicians to manage these situations, including VSED if needed. Not applicable.