Palliative psychiatry and assisted dying: a new review maps a contested divide

Few questions in modern mental health care are as ethically charged as what to do for people whose psychiatric suffering resists every treatment medicine can offer. A new scoping review published in eClinicalMedicine has now mapped, for the first time, how the scholarly and grey literature understands the relationship between palliative psychiatry — the application of palliative care principles to severe and persistent mental illness — and assisted dying for mental illness. The verdict is striking in its consistency: across fifty publications spanning more than a decade, the overwhelming majority of authors treat the two frameworks as fundamentally different enterprises, even as both grapple with the same agonizing problem of intolerable, seemingly irremediable psychiatric suffering.

The concept of palliative psychiatry entered the literature in 2016, when Trachsel and colleagues argued that principles long accepted in end-of-life care for cancer and organ failure — prioritizing quality of life, relieving suffering, and avoiding both therapeutic neglect and overly aggressive intervention — could and should be applied to psychiatry. The idea targets people with severe and persistent mental illness, a population in which many trials of the best available treatments fail to improve symptoms and can, in some cases, worsen suffering. Since then, discussions of palliative psychiatry have collided with a parallel and far more politically volatile development: the movement to legalize assisted dying, used here as an umbrella term covering voluntary euthanasia, assisted suicide, physician-assisted death, and medical assistance in dying, for people whose sole underlying condition is a mental disorder.

That collision is what motivated the review. Debates over assisted dying for mental illness foreground contested concepts such as the irremediability of psychiatric disorders and intolerable suffering — the very same concepts that animate palliative psychiatry. Critics have warned that expanding access could entrench structural discrimination, including ableism, racism, sexism, and classism, while proponents argue that refusing the option abandons a suffering minority. Yet no previous review had systematically examined how palliative psychiatry and assisted dying relate to one another. The research team, led by Micaela Forte and Daniel Z. Buchman and funded by the Canadian Institutes of Health Research, set out to answer a deceptively simple question: what does the literature actually say about the relationship between the two?

Methodologically, the review was exhaustive. A health sciences librarian built database-specific search strategies for MEDLINE, Embase, APA PsycInfo, CINAHL, the Philosopher’s Index, and Academic OneFile, using Boolean and adjacency operators to pair terms such as “palliative” or “non-curative” with terms for serious mental illness. Crucially, the searches captured literature on palliative psychiatry even when assisted dying terms never appeared in an article’s metadata, allowing the team to scope how assisted dying surfaces — or pointedly does not — across the field. To capture the public dimension of the debate, the researchers also searched the Global Newsstream Collection and hand-searched Psychiatric Times Online and Google. After removing 300 duplicates, they screened 647 publications by title and abstract, advanced 190 to full-text review, and retained 50 publications written between 2010 and 2025. Two authors independently screened each record, with a third resolving conflicts, and the protocol was registered on the Open Science Framework.

The analytical approach was equally careful. The team extracted one illustrative quote per publication, coded it against ten a priori categories describing possible relationships, and then used qualitative content analysis and discussion to refine the codes — recoding 25 quotes and removing codes from 14 publications before collapsing the categories into a final spectrum of six. That spectrum runs from “differentiated” at one end to “equivalent” at the other. At the most prevalent pole, twelve publications discussed assisted dying and palliative psychiatry in entirely separate sections, sometimes explicitly stating that assisted dying was outside the scope of the paper. Fifteen publications argued the two are conceptually distinct, emphasizing the contrast between life-affirming approaches and interventions that hasten or cause death. Thirteen positioned palliative psychiatry as an alternative or substitute for assisted dying. Nine said the two are related but not the same. Only two publications treated assisted dying as an example of palliative psychiatry, and only two argued that advocacy for palliative psychiatry necessarily leads to advocacy for assisted dying.

The distinctions authors drew are philosophically substantive rather than semantic. Several argued that palliative psychiatry rests on the premise that suffering can be remedied within life, directly contradicting what they described as the philosophy underlying assisted dying. Others highlighted reversibility: under a palliative psychiatry framework, individuals can change their minds and resume aggressive treatment at any time, whereas assisted death is irreversible. Some distinguished the two through the wishes of patients themselves — if a person’s goal is to maintain or enhance quality of life without pursuing symptom-free recovery, palliative psychiatry fits; those who wish to pursue assisted dying follow a different path. One recurring concern was linguistic: authors cautioned that conflating palliative psychiatry with assisted dying advocacy misrepresents palliative care’s goals, may increase barriers to its adoption, and could be misread as implying that people with mental illness are approaching end of life.

The “alternative” category may prove the most clinically consequential. Thirteen publications proposed palliative psychiatry as a middle path for people with treatment-resistant illness who might otherwise face a stark and inadequate choice between coercive suicide prevention and assisted dying. Some argued it should outright replace assisted dying in severely treatment-resistant cases; others envisioned a two-track model in which life-oriented palliative interventions and discussions of assisted dying eligibility proceed in parallel. Several authors insisted that palliative psychiatry must never be understood as justifying a lower threshold for assisted dying, and warned that requests for death should stem from unalleviated suffering despite comprehensive care — not from inadequate or inaccessible care. Some suggested that expanding palliative psychiatry could reduce the number of people with severe mental illness who request assisted dying at all, by addressing the disparities that leave them feeling death is their only option.

Context matters enormously to these positions. The reviewed publications came overwhelmingly from high-income countries: eleven from Canada, where assisted dying is legal but not for mental illness as a sole condition; ten from the United States, where it is illegal in most states; and large clusters from Switzerland, Belgium, and the Netherlands, which have long-standing legalized practices. The authors suggest that jurisdictions where psychiatric assisted dying is legal may conceptualize the relationship as a spectrum of treatment options, while jurisdictions where it is prohibited may frame the two as standalone alternatives or as opposing sides of a legalization debate. Most publications focused on severe and persistent mental illness generally, but seventeen gave extended attention to severe and enduring anorexia nervosa, with schizophrenia, major depressive disorder, and bipolar disorder also appearing. Most were commentaries, case studies, or conceptual papers rather than empirical research, and most were written by psychiatrists and other clinicians reflecting on their own practice — a pattern the review authors note leaves the conversation grounded more in clinical experience than in theoretical or empirical frameworks.

The review’s limitations are candidly acknowledged. Seven publications in French, Dutch, Spanish, and German were translated with a free machine-translation tool, raising the possibility of subtle mistranslation, and the analysis relied on one quote per publication, contextualized against the full texts. The authors also disclose that some team members have themselves published on palliative psychiatry and received federal funding to study it, making author overlap with the included literature unavoidable; they mitigated this through independent dual review and explicit reflexivity about their roles as scholars, clinicians, and people with lived experience of mental illness.

What emerges is a field in broad, if not unanimous, agreement: seventy-eight percent of the sources assert that palliative psychiatry and assisted dying are different, and almost none treat them as interchangeable. Palliative psychiatry, in most tellings, rejects the dichotomy of inadequate care-as-usual versus a hastened death, proposing instead a third, life-affirming pathway that limits coercive interventions and prioritizes quality of life. Whether conversations about death wishes and assisted dying requests belong inside that pathway remains genuinely unresolved — nine publications raised the question without answering it. As more jurisdictions weigh legalizing assisted dying for mental illness, the review’s central message is that the scholarly landscape is heterogeneous, the conceptual boundaries are real but imperfectly drawn, and both clinicians and policymakers will need far more empirical research before these frameworks can reliably guide decisions for people enduring the most severe psychiatric suffering medicine cannot yet relieve.

Subject of Research: The relationship between palliative psychiatry and assisted dying for severe and persistent mental illness

Article Title: The relationship between palliative psychiatry and assisted dying: a scoping review

Article References: Forte, M., Panko, L., Tsiandoulas, K., Rodak, T., Costa, L., Levitt, S., & Buchman, D. Z. (2026). The relationship between palliative psychiatry and assisted dying: a scoping review. eClinicalMedicine, 100, Article 104200. https://doi.org/10.1016/j.eclinm.2026.104200

Image Credits: AI Generated

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Keywords: palliative psychiatry, assisted dying, severe and persistent mental illness, medical assistance in dying, euthanasia, scoping review, medical ethics, end-of-life care, treatment-resistant mental illness, anorexia nervosa, mental health policy, eClinicalMedicine