TABLE 4.

Proposal for an extended ICD-11 classification in cases with medical aid in dying including symptom-oriented categories (Zurich, Switzerland, 2023).

For our proposal, we suggest an extension of the classification from chapter 23 (“External causes of morbidity and mortality”) with a new code that exclusively describes the phenomenon of “Medical aid in dying.”
Alternatively, “Medical aid in dying” could also be included in chapter 25 (“Codes for special purposes”).
Subheading: Medical aid in dying PM1: Assisted suicide. PM2: Voluntary active euthanasia.
Note: Medical aid in dying is considered as the circumstance in which a doctor prescribes a patient wishing to die a lethal substance or makes that substance available with the object of enabling the patient to die. In assisted suicide, the physical control of administering the drug is in the hands of the patient, i.e., the patients wishing to die must themselves carry out the last, decisive act of the procedure that will cause death. In contrast, in active euthanasia, the physician or healthcare professionals also administers the lethal drug.
The underlying disease or condition recorded with the ICD-11 coding was the main reason for the wish to die.
If the wish to die was not based on tangible illnesses leading to a natural death in the foreseeable future, but rather on other diseases or symptom-oriented complaints, additional codes (PM1.1-4; PM2.1-4) can be used.
PM1.0 / PM2.0	The underlying ICD-coded disease was the main reason for the wish to die.
	Comment: This code includes, for example, the most common group of indications for MAID today, namely cancer; e.g., the case of a woman who decides to have AS at a late stage of breast cancer will be coded PM1.0 or PM2.0 and 2C61 (Invasive carcinoma of the breast).
PM1.1 / PM2.1	Medical aid in dying due to multimorbidity.
	Comment: Multimorbidity also includes the accumulation of old age complaints. In this case, it does not matter which of the usually several existing age-related diseases and conditions is additionally coded as underlying disease.
PM1.2 / PM2.2	Medical aid in dying due to severe neurologic-related conditions.
	Comment: In this case, the underlying neurologic disease that was critical to the desire to die must be coded; e.g., for Parkinson’s disease: PM1.0 or PM2.0 and 8A00.0.
	This code includes cases in which neurodegenerative diseases (e.g., Parkinson’s disease, amyotrophic lateral sclerosis, multiple sclerosis) were the main reason for the desire for death. Cases in which dementia was the underlying condition of the desire for death are excluded (→ PM1.4 or PM2.4).
	Cases in which severe neurological limitations such as blindness and paralysis (tetraplegia) led to MAID are also included.
	Similarly, this category also includes patients for whom the consequences of a stroke were the determining factor to choose MAID. In a symptom-based system, it makes much more sense to remove these cases from the category of “cardiovascular diseases,” in which they are currently still classified. When the consequences of a stroke lead to MAID, there is virtually always a clinical picture of severe and irreversible immobility and paralysis. This clinical picture then corresponds far more to those of the other neurologically related diseases summarized in this chapter than to those of other cardiovascular diseases, e.g., heart failure.
PM1.3 / PM2.3	Medical aid in dying due to chronic pain.
PM1.4 / PM2.4	Medical aid in dying due to mental disorders or dementia.
PM1.Z / PM2.Z	Medical aid in dying, unspecified.

MAID, medical aid in dying.