Palliative psychiatry and euthanasia in refractory obsessive–compulsive disorder: A case report

Abstract

Background

Spain's Organic Law 3/2021 regulates euthanasia or medical aid in dying (MAiD) for individuals with serious and incurable disease or chronic incapacitating conditions causing intolerable suffering. Psychiatric MAiD remains exceptional; decisions depend on well-documented refractoriness, preserved decision-making capacity, and intolerable mental suffering within a safeguarded legal process.

Case presentation

We report the clinical and legal course of a 24-year-old woman with childhood-onset obsessive–compulsive disorder (OCD) dominated by contamination/washing rituals, treated at a national reference center. Over several years, she completed multiple maximally dosed SSRI and clomipramine trials with antipsychotic augmentation and more than 100 therapist-guided exposure and response prevention sessions. Bilateral deep brain stimulation of the anterior limb of the internal capsule/ventral striatum was performed without durable benefit after 18 months of systematic programming. During a prolonged inpatient admission, harm-reduction and palliative psychiatry measures were implemented while 2 senior psychiatrists, independent of daily care, conducted repeated ability-based capacity evaluations confirming intact decision-making, absence of psychosis, delirium, or major depressive episode, and a consistent distinction between a sustained MAiD request and suicidality. After reiterated written requests made with full information about prognosis and alternatives, an independent psychiatric consultation, and the regional commission's ex ante authorization, MAiD was performed in hospital by the responsible psychiatrist through direct administration, without complications.

Conclusions

Even after exhaustive, guideline-concordant, and neurosurgical interventions, a small subset of patients with OCD may experience persistent, irremediable suffering. Transparent documentation of refractoriness, longitudinal capacity assessment, and proportional palliative psychiatry care are essential to ethically and legally sound MAiD practice in Spain.

Introduction

Obsessive–compulsive disorder (OCD) is a highly disabling condition with a chronic course and substantial functional impact; global burden estimates place OCD among the leading causes of disability in young adults.¹ Guideline-concordant care, consisting of high-dose serotonin reuptake inhibitors or clomipramine combined with therapist-guided exposure and response prevention (ERP), benefits many patients, yet a clinically relevant subgroup remains markedly symptomatic after adequate trials.²

For severe, treatment-refractory presentations, deep brain stimulation (DBS) has been incorporated within specialized programs. Evidence from a meta-analysis,³ a prospective international multicenter cohort,⁴ a 20-year worldwide systematic review,⁵ and long-term comparative effectiveness data⁶ supports clinically meaningful average improvements while recognizing a nonresponder subgroup. Contemporary series indicate that when benefit occurs, it typically emerges within the first 12–14 months after implantation and systematic programming; additional gains beyond that window are uncommon, informing timelines for judging lack of response.^5,6

In Spain, Organic Law 3/2021 regulates euthanasia/medical aid in dying (MAiD) for individuals with serious and incurable disease or serious, chronic, and incapacitating conditions causing constant, intolerable physical and/or mental suffering. The statute mandates reiterated written requests, independent medical consultation, and ex ante review by a regional commission.⁷ International experience indicates that psychiatric MAiD is infrequent and that determinations center on decision-making capacity and judgments of irremediability.^8–10 There is no validated questionnaire to establish irremediability in psychiatry; ethical analysis therefore calls for transparent, auditable criteria grounded in documented treatment adequacy and longitudinal evaluation.^11,12

We report a case of euthanasia after failed DBS in extreme, treatment-refractory OCD within the Spanish National Health System, showing how refractoriness can be specified with objective evidence, how capacity can be assessed longitudinally, and how palliative-oriented care can be maintained while following the statutory pathway.

Materials and methods

Design and data sources

We conducted a retrospective chart review from the OCD Unit, Bellvitge University Hospital (Barcelona, Spain), covering psychiatry and psychology notes, ERP records, medication logs, capacity assessments, and legal documents per Organic Law 3/2021.⁷

Operational refractoriness (prespecified)

Refractoriness was adjudicated in the context of severe to extreme OCD by Yale-Brown Obsessive–Compulsive Scale (Y-BOCS; range, 0–40; categories: 0–7 subclinical, 8–15 mild, 16–23 moderate, 24–31 severe, 32–40 extreme).¹³ All of the following were verified:

• 1.

  Pharmacotherapy: at least 2 high-dose SSRI trials (each lasting at least 12 weeks at the guideline upper range or maximally tolerated dose) and 1 clomipramine trial (lasting at least 12 weeks up to approximately 300 mg/day or maximally tolerated dose), plus at least 1 antipsychotic augmentation trial (e.g., aripiprazole or risperidone/paliperidone) lasting at least 8–12 weeks.

• 2.

  ERP-CBT: at least 60 therapist-guided ERP sessions with documented tasks and homework, with persistent severe rituals/avoidance.

• 3.

  Function: sustained dependence for basic self-care/supervision attributable to OCD.

• 4.

  Last-line failure: documented nonresponse to prior neuromodulation (DBS), noted as historical evidence of refractoriness.

Decision-making capacity. Capacity was assessed longitudinally by 2 senior psychiatrists independent of day-to-day decisions, using a 4-abilities model (understanding, appreciation, reasoning, and stable choice), with documentation of the absence of psychosis, delirium, or major depressive episode and differentiation of a sustained MAiD request from acute suicidality.

Legal pathway (verification). Safeguards under Organic Law 3/2021 were confirmed: after being informed about the course of her illness and all reasonable therapeutic alternatives, the patient submitted 2 written requests separated by a minimum 15-day reflection period; an independent psychiatric consultation by a specialist not involved in day-to-day care was obtained; ex ante authorization was granted by the regional Comisión de Garantía y Evaluación; and the procedure was performed by the attending team. The complete legal timeline, from first request to procedure, spanned approximately 45–50 days, in accordance with statutory timeframes (Table 1). Throughout the process, institutional protocols ensured verification of eligibility, capacity, and voluntariness, as well as documentation for ex post commission review.

Table 1.

Spain's MAiD pathway (Organic Law 3/2021): procedural steps and roles.

Step	Requirement/Content	Statutory timing	Responsible party	Documentation/Output
1. Information and deliberation	Patient is informed about illness trajectory, realistic alternatives, and palliative-oriented options; multidisciplinary discussion; capacity screening	Ongoing; precedes any request	Responsible physician and care team	Clinical notes; records of family meetings; information materials
2. First written request	Signed request submitted after full information; voluntariness documented	Start of formal process	Patient; responsible physician receives and files	Signed request; initial report
3. Reflection interval	Legally mandated interval between requests (may be shortened in exceptional circumstances)	Statutory interval	Patient and responsible physician	Record of interval and counseling
4. Second written request	Patient reaffirms request in writing; voluntariness reconfirmed	After the reflection interval	Patient and responsible physician	Second signed request; updated report
5. Independent consultation	Independent psychiatrist not previously involved assesses refractoriness, capacity, and safeguards	After second request	Independent consultant	Written opinion (consultant's report)
6. Submission to the Commission	Reports from the responsible and independent psychiatrists submitted to the regional Comisión de Garantía y Evaluación for ex ante review	Immediately after consultation	Responsible physician	Complete dossier submitted to the Commission
7. Commission review	Commission evaluates eligibility and safeguards and may request clarifications	Within statutory timelines	Regional Commission	Authorization or denial with justification; right to appeal
8. Final confirmation	Capacity and consent reconfirmed; patient may revoke at any time	Same day as the procedure	Responsible physician	Final consent and capacity note
9. Provision modality	Direct administration by the responsible physician or prescription for self-administration; conscientious objection managed through official registry	According to authorization	Responsible physician	Procedure record; medication administration documentation

Statutory process for euthanasia and medical aid in dying (MAiD) in Spain, outlining key responsibilities and documentation requirements.

Ethics. The institutional committee indicated that formal approval was not required for an anonymized single case. Written informed consent for publication was obtained from the patient.

Results

A 24-year-old woman with childhood-onset obsessive–compulsive disorder (OCD), dominated by contamination obsessions and prolonged washing/cleaning rituals, remained severely disabled despite guideline-concordant treatment. Over 7 years, she received multiple adequate pharmacological trials at maximally tolerated doses, including selective serotonin reuptake inhibitors and clomipramine up to 300 mg/day, with antipsychotic augmentation. Across these trials, the Y-BOCS score did not fall below 32 (severe-extreme range). A transient reduction to 29 was achieved for approximately 1 year with fluvoxamine potentiation and intensive therapist-guided ERP; this benefit subsequently dissipated, with Y-BOCS scores returning to 32–35, and functional dependence persisted. In total, she completed more than 100 ERP sessions delivered across inpatient, day-hospital, and outpatient settings, with documented homework and good engagement.

Years before the MAiD process, she underwent bilateral deep brain stimulation targeting the anterior limb of the internal capsule/ventral striatum. Despite 18 months of systematic programming, nonresponse was concluded, with the Y-BOCS score remaining at 35, without durable symptom reduction or functional gains. Lesional surgery and retargeting to the subthalamic nucleus were proposed and declined.

She was subsequently admitted to the tertiary OCD unit for stabilization and care planning. Goals focused on harm reduction and comfort while continuing reasonable measures, including simplified routines, occupational interventions, symptom relief for anxiety/insomnia, and structured family work. She consistently stated that her suffering was constant and intolerable and that all reasonable treatments had been exhausted. Two senior psychiatrists independent of day-to-day decisions conducted repeated capacity assessments using an abilities-based framework. She was oriented and free of psychosis, delirium, or major depressive episode; evaluators distinguished a sustained MAiD request from acute suicidality. She demonstrated realistic understanding of prognosis, limited likelihood of improvement, and alternatives including palliative care and long-term institutional care, and she understood her right to revoke the request.

A palliative psychiatry evaluation was conducted, including symptom control (Y-BOCS score, 35–38), psychological and social assessment, exploration of values and life meaning, and facilitation of family discussions. Multiple deliberation sessions ensured that the request was informed, sustained, and aligned with her values. Palliative care recommendations were integrated into her care plan. A simplified timeline is provided in Fig. 1.

Fig. 1.

Clinical and legal timeline summarizing the patient's treatment course and the procedural milestones of medical aid in dying (MAiD) under Spain's Organic Law 3/2021. The figure illustrates key interventions across pharmacotherapy, cognitive-behavioral therapy, and neurosurgical and palliative psychiatry care, followed by sequential steps of the statutory MAiD process (information and deliberation, written requests, independent consultation, ex ante commission review, and direct administration).

Discussion

This case documents euthanasia under Spain's Organic Law 3/2021 in a woman with extreme, treatment-refractory obsessive–compulsive disorder after exhaustive, guideline-concordant care. It highlights the need to develop structured palliative frameworks in psychiatry for patients with severe, enduring mental disorders whose suffering remains intolerable despite all reasonable treatments. Within such frameworks, euthanasia may be considered a complementary option under strict safeguards and ethical oversight.

The determination of refractoriness rested on contemporaneous, auditable elements: documented adequacy of pharmacological and psychological trials, persistent functional dependence, and historical DBS nonresponse confirmed 18 months after implantation.

Assessment of decision-making capacity and intolerable suffering required particular rigor. There is no validated questionnaire to establish irremediability or quantify intolerable mental suffering in psychiatry; transparent standards and longitudinal evaluation are therefore essential.^11,12 Repeated abilities-based assessments by 2 senior psychiatrists, independent of day-to-day decisions, consistently demonstrated intact understanding, appreciation, and reasoning, with a stable choice, distinguishing a sustained MAiD request from acute suicidality. The statutory safeguards, including reiterated written requests, independent psychiatric consultation, and ex ante authorization by the regional commission, added external scrutiny and provided procedural reassurance for the team and family.⁷

Autonomy was central to the evaluation. The patient articulated a sustained wish to end unbearable suffering, stating that “living this way was not dignified for her.” Capacity assessments confirmed intact decision-making, understanding of prognosis and alternatives, absence of coercion, and a consistent voluntary request over time. After exhausting all evidence-based therapeutic options, including pharmacotherapy, intensive ERP, and DBS, compelling her to continue living in a state she described as intolerable, with persistent extreme OCD symptoms (Y-BOCS score, 35–38), total functional dependence, and no prospect of improvement, would itself constitute harm to both her and her family.

Alongside legal deliberations, care adopted a palliative orientation: harm-reduction strategies, symptom relief, realistic goal setting, and structured family work were maintained throughout.¹² Although psychiatry regularly encounters severely disabling conditions associated with marked and persistent suffering, palliative approaches remain underused in mental health settings.¹⁴ Such measures aim to reduce suffering without prejudging eligibility for MAiD and help ensure that requests do not arise from remediable distress; they should be standard practice in treatment-refractory presentations.¹⁵

Participation in MAiD assessments can entail emotional strain for clinicians. Programs should offer debriefing and psychological support, alongside clear pathways for conscientious objection.¹⁵

As a single case, generalizability is limited. Nevertheless, contemporaneous documentation, independent capacity assessments, and meticulous adherence to legal safeguards delineate how MAiD may be considered in exceptional psychiatric circumstances when refractoriness is specified with objective evidence, capacity is demonstrated longitudinally, and proportional palliative care is maintained.

Conclusions

After comprehensive guideline-concordant pharmacotherapy, intensive ERP, and DBS, a minority of patients with OCD may experience intolerable and likely irremediable suffering and request euthanasia under Spain's MAiD law. This case demonstrates how refractoriness can be specified with auditable evidence, how capacity can be assessed longitudinally by independent senior clinicians, and how proportional palliative care can be maintained throughout the statutory pathway. Transparent presentation of cases can help consolidate standards for psychiatric MAiD as a complementary approach to palliative care in patients with mental disorders.

Ethics approval

The institutional committee indicated that formal approval was not required for an anonymized single case. Written informed consent for publication was obtained.

Funding

This study was supported by Instituto de Salud Carlos III (PI22/00752 and PI25/01407) and Fundació La Marató de TV3 (grant 202201), co-funded by FEDER funds (“A way to build Europe”). We also acknowledge institutional support from the CERCA Programme/Generalitat de Catalunya. SB received a Río Hortega grant (CM21/00278).

Conflicts of interest

None declared.

Data availability

All relevant case information is contained in the article; additional de-identified notes can be provided to editors on reasonable request.

Acknowledgments

We thank the patient and family for their generosity and courage in permitting publication of anonymized details. We would like to thank the hospital euthanasia committee and all healthcare professionals involved in the patient's care (including medical staff, nursing staff, and healthcare assistants) for their contribution and support.