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

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.