Physicians' experiences with the Oregon Death with Dignity Act

Preferences regarding end-of-life cancer care and associations with good-death concepts: a population-based survey in Japan

BACKGROUND

The aims of this study were to clarify end-of-life cancer care preferences and associations with good-death concepts.

METHODS

The general population was sampled using a stratified random sampling method (N = 2548; response rate = 51%) and bereaved families from 12 certified palliative care units ('PCU-bereaved families') were surveyed (N = 513; response rate = 70%). The respondents reported their end-of-life care preferences and good-death concepts.

RESULTS

Regarding place of end-of-life care, approximately 50% of the general population preferred 'Home', while 73% of PCU-bereaved families preferred 'PCU'. The concepts of 'Maintaining hope and pleasure' and 'Dying in a favorite place' were associated with the preference for 'Home'. Regarding prognostic disclosure, approximately 50% of the participants preferred some level of negotiation with the physician. The concept of 'Control over the future' was associated with this preference. Regarding treatment of severe refractory physical distress, 75% of the general population and 85% of the PCU-bereaved families preferred palliative sedation therapy. The concepts of 'Physical and psychological comfort' and 'Unawareness of death' were associated with this preference.

CONCLUSIONS

End-of-life care preferences were associated with good-death concepts. It would be useful for health-care workers to discuss patients' good-death concepts to support subsequent treatment decisions.

Mental health and other clinical correlates of euthanasia attitudes in an Australian outpatient cancer population

A majority of patients with cancer have been reported to endorse euthanasia and physician assisted suicide (PAS) in general and a substantial proportion endorse these for themselves. However, the potential influence of mental health and other clinical variables on these decisions is not well understood. This study of 228 outpatients attending an oncology clinic in Newcastle, Australia used a cross-sectional design and logistic regression modelling to examine the relationship of demographic, disease status, mental health and quality of life variables to attitudes toward euthanasia and PAS. The majority reported support for euthanasia (79%, n=179), for PAS (69%, n=158) and personal support for euthanasia/PAS (68%, n=156). However, few reported having asked their doctor for euthanasia (2%, n=5) or PAS (2%, n=5). Three outcomes were modelled: support for euthanasia was associated with active religious belief (adjusted odds ratio (AOR) 0.21, 95% CI: 0.10-0.46); support for PAS was associated with active religious belief (AOR 0.35, 95% CI: 18-0.70) and recent pain (AOR 0.87, 95% CI: 0.0.76-0.99); and personal support for euthanasia/PAS was associated with active religious belief (AOR 0.26, 95% CI: 0.14-0.48). Depression, anxiety, recent suicidal ideation, and lifetime suicide attempt were not independently associated with any of the three outcomes modelled.

Physician discussions with terminally ill patients: a cross-national comparison

A major issue in the care of terminally ill patients is communication and information provision. This paper reports the extent to which physicians in Australia, Belgium, Denmark, Italy, the Netherlands, Sweden and Switzerland discuss topics relevant to end of life care with terminally ill patients and their relatives (without first informing the patient), and possible associations between physician-specific characteristics and such discussions. Response rates to the postal survey ranged from 39% to 68% (n =10139). Physicians in most of the countries except Italy ;in principle, always' discuss issues related to terminal illness with their patients but not with patients' relatives without first informing the patient, unless the relatives ask. Cross-national differences remained strong after controlling for physician characteristics. The majority of physicians appeared to support the principle of patient-centred care to terminally ill patients, consistent with palliative care philosophy and with the law and/or professional guidelines in most of the countries studied.

End-of-life practices in the Netherlands under the Euthanasia Act

BACKGROUND

In 2002, an act regulating the ending of life by a physician at the request of a patient with unbearable suffering came into effect in the Netherlands. In 2005, we performed a follow-up study of euthanasia, physician-assisted suicide, and other end-of-life practices.

METHODS

We mailed questionnaires to physicians attending 6860 deaths that were identified from death certificates. The response rate was 77.8%.

RESULTS

In 2005, of all deaths in the Netherlands, 1.7% were the result of euthanasia and 0.1% were the result of physician-assisted suicide. These percentages were significantly lower than those in 2001, when 2.6% of all deaths resulted from euthanasia and 0.2% from assisted suicide. Of all deaths, 0.4% were the result of the ending of life without an explicit request by the patient. Continuous deep sedation was used in conjunction with possible hastening of death in 7.1% of all deaths in 2005, significantly increased from 5.6% in 2001. In 73.9% of all cases of euthanasia or assisted suicide in 2005, life was ended with the use of neuromuscular relaxants or barbiturates; opioids were used in 16.2% of cases. In 2005, 80.2% of all cases of euthanasia or assisted suicide were reported. Physicians were most likely to report their end-of-life practices if they considered them to be an act of euthanasia or assisted suicide, which was rarely true when opioids were used.

CONCLUSIONS

The Dutch Euthanasia Act was followed by a modest decrease in the rates of euthanasia and physician-assisted suicide. The decrease may have resulted from the increased application of other end-of-life care interventions, such as palliative sedation.

Critical events in the dying process: the potential for physical and psychosocial suffering

BACKGROUND

Understanding what aspects of the dying process motivate terminally ill individuals to consider hastening their death, can lead to improving end-of-life care.

OBJECTIVE

Advance knowledge regarding critical events within the dying process that have the potential to give rise to physical and psychosocial suffering such that an elder wishes for or considers a hastened death.

DESIGN AND METHODS

Face-to-face in-depth qualitative interviews conducted with 96 terminally ill elders, 15 of whom discussed an event in their dying process that resulted in suffering so great they wished for, or considered, a hastened death. Data were content analyzed to identify and categorize the main themes and patterns involved in these elders' experiences.

SETTING

The interviews were conducted on palliative care hospital units, and in outpatient clinics, free standing hospice facilities, and home hospice.

RESULTS

Four critical events emerged: perceived insensitive and uncaring communication of a terminal diagnosis; experiencing unbearable physical pain; unacknowledged feelings regarding undergoing chemotherapy or radiation treatment; and dying in a distressing environment. Respondents discussed physical and/or psychosocial suffering that occurred at these events, and the end-of-life care practices that reduced their suffering.

CONCLUSION

Awareness of events common to the dying process, the potential physical and psychosocial suffering that may arise at these events, and the end-of-life care practices associated with reducing that suffering can lead to health care professionals being able to take a proactive rather than reactive approach to end-of-life care.

Feeling like a burden to others: a systematic review focusing on the end of life

Research into the burden of illness has focused predominantly on family caregivers, with little consideration of the other side of the caregiving relationship-care recipients' perspectives on having become a 'burden to others'. However, there is now a small but growing body of evidence to suggest that worry about creating burden to others is a common and troubling concern for people who are nearing the end of their lives. This concern is referred to as 'self-perceived burden'. The present study provides a systematic review of the literature, addressing self-perceived burden at the end of life. Using standard methods, literature was searched for relevant studies in palliative care and related fields. The review revealed that self-perceived burden is reported as a significant problem by 19- 65% of terminally ill patients. It is correlated with loss of dignity, suffering, and a 'bad death'. Self-perceived burden has also been identified as a relevant factor in death-hastening acts among patients with life-threatening illness, as well as in clinical decisions, such as the choice of place of care at the end of life, advance directives, and acceptance of treatment. Given the unique challenges faced by patients with advanced disease and their families, there is a need for further investigation into this under-researched area.

Physician assisted suicide: a new look at the arguments

In this paper, I examine the argumens agains physician assisted suicide (PAS). Many of these arguments are consequentialist. Consequentialist arguments rely on empirical claims about the future and thus their strength depends on how likely it is that the predictions will be realized. I discuss these predictions against the backdrop of Oregon's Death with Dignity Act and the practice of PAS in the Netherlands. I then turn to a specific consequentialist argument against PAS - Susan M. Wolfs feminist critique of the practice. Finally, I examine the two most prominent deontological arguments against PAS. Ultimately, I conclude that no anti-PAS argument has merit. Although I do not provide positive arguments for PAS, if none of the arguments against it are strong, we have no reason not to legalize it.

Physicians' opinions on palliative care and euthanasia in the Netherlands

BACKGROUND

In recent decades significant developments in end-of-life care have taken place in The Netherlands. There has been more attention for palliative care and alongside the practice of euthanasia has been regulated.

OBJECTIVE

The aim of this paper is to describe the opinions of physicians with regard to the relationship between palliative care and euthanasia, and determinants of these opinions.

DESIGN

Cross-sectional.

SETTING/SUBJECTS

Representative samples of physicians (n = 410), relatives of patients who died after euthanasia and physician-assisted suicide (EAS; n = 87), and members of the Euthanasia Review Committees (ERCs; n = 35).

MEASUREMENTS

Structured interviews with physicians and relatives of patients, and a written questionnaire for the members of the ERCs.

RESULTS

Approximately half of the physicians disagreed and one third agreed with statements describing the quality of palliative care in The Netherlands as suboptimal and describing the expertise of physicians with regard to palliative care as insufficient. Almost two thirds of the physicians disagreed with the suggestion that adequate treatment of pain and terminal care make euthanasia redundant. Having a religious belief, being a nursing home physician or a clinical specialist, never having performed euthanasia, and not wanting to perform euthanasia were related to the belief that adequate treatment of pain and terminal care could make euthanasia redundant.

CONCLUSION

The study results indicate that most physicians in The Netherlands are not convinced that palliative care can always alleviate all suffering at the end of life and believe that euthanasia could be appropriate in some cases.

Würde in der Begleitung schwer kranker und sterbender Patienten

Most patients, family members, health care professional as well as volunteers would agree that dignified care and being allowed to die with dignity are superior and unquestionable goals of palliative care. Although the majority of people have a more or less vague concept of dignity and despite its significance for palliative care, only a few empirical approaches to describe the sense of dignity from patients' and health care professionals' perspectives have been undertaken. However, individual descriptions of the dignity concept and definitions can serve as an impetus to improve the current palliative care practice by the development and evaluation of psychotherapeutic interventions for patients near the end of life and the allocation of resources. This article considers an internationally developed empirical-based model of dignity in severe and terminal ill patients by Chochinov et al. Furthermore, it illustrates the understanding of dignity as well as self-perceived exertions of influence on a patient's dignity from the perspective of health care professionals and volunteers. Psychotherapeutic interventions and strategies are introduced that can help conserve the sense of dignity of patients during palliative care.

Die Rolle des Arztes und die Kommunikation mit Sterbenden

In palliative medicine, the doctor's role towards the patient changes from curing to looking after and depends on the different organizational forms. A key topic for the doctor remains the decision, how far medical treatment should be extended - according to patient's will. Studies for palliative medicine have also showed considerable communication deficits. This leads to the following aims of communication with the dying: Recording of somatic, psychic, social and spiritual problems of the patients, informing about illness and prognosis, responding to the patient's emotional situation and to the existential dimension of dying as well as involving relatives in communication. "Active listening" is proposed as a communication form to be learned by doctors. Training programs and possibilities of improving the emotional situation of doctors are described.

Views on physician-assisted suicide among family members of Oregon cancer patients

Ninety-eight Oregonians with advanced cancer and their family members participated in a cross-sectional survey to understand agreement in views on physician-assisted suicide (PAS), which was a legal option for these patients. Half of the family members would support the patient's request for PAS, 30% would oppose it, and 19% were undecided. Low religiousness and the family member's personal health concerns were associated with increasing support by the family member for PAS for the patient. Family members were able to predict patients' political views on legalized PAS, and there was moderately high agreement among family members on political views. Family members, however, were not knowledgeable about patients' interest in PAS for themselves, and there was low agreement among dyads on whether they had discussed this issue. Improved knowledge of patient-based barriers to discussing PAS may facilitate interventions for psychosocial distress in cancer patients.

Physician-assisted suicide: a review of the literature concerning practical and clinical implications for UK doctors

BACKGROUND

A bill to legalize physician-assisted suicide in the UK recently made significant progress in the British House of Lords and will be reintroduced in the future. Until now there has been little discussion of the clinical implications of physician-assisted suicide for the UK. This paper describes problematical issues that became apparent from a review of the medical and psychiatric literature as to the potential effects of legalized physician-assisted suicide.

DISCUSSION

Most deaths by physician-assisted suicide are likely to occur for the illness of cancer and in the elderly. GPs will deal with most requests for assisted suicide. The UK is likely to have proportionately more PAS deaths than Oregon due to the bill's wider application to individuals with more severe physical disabilities. Evidence from other countries has shown that coercion and unconscious motivations on the part of patients and doctors in the form of transference and countertransference contribute to the misapplication of physician-assisted suicide. Depression influences requests for hastened death in terminally ill patients, but is often under-recognized or dismissed by doctors, some of whom proceed with assisted death anyway. Psychiatric evaluations, though helpful, do not solve these problems. Safeguards that are incorporated into physician-assisted suicide criteria probably decrease but do not prevent its misapplication.

SUMMARY

The UK is likely to face significant clinical problems arising from physician-assisted suicide if it is legalized. Terminally ill patients with mental illness, especially depression, are particularly vulnerable to the misapplication of physician-assisted suicide despite guidelines and safeguards.

Interventions to enhance the spiritual aspects of dying

In recent years, medical and allied health publications have begun to address various topics on spirituality. Scholars have posited numerous definitions of spirituality and wrestled with the notion of spiritual pain and suffering. Researchers have examined the relationship between spirituality and health and explored, among other topics, patients' perceptions of their spiritual needs, particularly at the end of life. This paper summarizes salient evidence pertaining to spirituality, dying patients, their health care providers, and family or informal caregivers. We examine the challenging issue of how to define spirituality, and provide a brief overview of the state of evidence addressing interventions that may enhance or bolster spiritual aspects of dying. There are many pressing questions that need to be addressed within the context of spiritual issues and end-of-life care. Efforts to understand more fully the constructs of spiritual well-being, transcendence, hope, meaning, and dignity, and to correlate them with variables and outcomes such as quality of life, pain control, coping with loss, and acceptance are warranted. Researchers should also frame these issues from both faith-based and secular perspectives, differing professional viewpoints, and in diverse cultural settings. In addition, longitudinal studies will enable patients' changing experiences and needs to be assessed over time. Research addressing spiritual dimensions of personhood offers an opportunity to expand the horizons of contemporary palliative care, thereby decreasing suffering and enhancing the quality of time remaining to those who are nearing death.

Trends in acceptance of euthanasia among the general public in 12 European countries (1981–1999)

BACKGROUND

We wanted to examine how the acceptance of euthanasia among the general public in Western Europe has changed in the last decades, and we wanted to look for possible explanations.

METHODS

We analysed data from the European Values Surveys, held in 1981, 1990, and 1999-2000 in 12 West European countries. In each country, representative samples of the general public were interviewed using the same structured questionnaire in all countries. Euthanasia was explained in the questionnaires as 'terminating the life of the incurably sick'.

RESULTS

A total of 46 199 respondents participated in the surveys. A significant increase in acceptance of euthanasia could be observed in all countries except (West) Germany. While the average increase in euthanasia acceptance was 22%, the increase was particularly obvious in Belgium, Italy, Spain, and Sweden. Although changes in several characteristics of respondents, such as decrease in religious beliefs, rising belief in the right to self-determination, and (to a lesser extent) rise in levels of education, were associated with growing acceptance of euthanasia, they could only partly explain the increase of euthanasia acceptance over the years.

CONCLUSIONS

An increase of euthanasia acceptance among the general public took place over the last two decades in almost all West European countries, possibly indicating a growing support for personal autonomy regarding medical end-of-life decisions. If this trend continues, it is likely to increase the public and political debate about the (legal) regulation of euthanasia under certain conditions of careful medical practice in several West European countries.

Oregon Hospice Chaplains' Experiences with Patients Requesting Physician-Assisted Suicide

BACKGROUND

Oregon's Death with Dignity Act (ODDA), which legalized physician-assisted suicide (PAS) for terminally ill individuals, was enacted in 1997. Eighty-six percent of the 171 patients who have died by PAS were enrolled in hospice.

OBJECTIVE

To survey hospice chaplains regarding their views on the ODDA and experiences working with patients who request PAS.

DESIGN

Single, anonymous, mailed survey.

SUBJECTS

All chaplains affiliated with one of Oregon's 50 hospices.

RESULTS

Fifty of 77 hospice chaplains whom we identified (65%) returned the survey. Forty-two percent of respondents opposed the ODDA and 40% supported it. Over half of respondents had, in the previous 3 years, worked with a patient who had made an explicit request for assisted suicide. Conversation with patients around PAS focused on the role of faith and spirituality in this decision, reasons for wanting hastened death, and family concerns or reactions to PAS. Chaplains did not feel that they had a strong influence on the patient's decisions about PAS (mean score of 4 on a 0-10 scale), though three chaplains reported a patient who withdrew their request for PAS because of the chaplain's involvement. Chaplains reported provision of a nonjudgmental presence helped the relationship with the patient.

CONCLUSION

Oregon hospice chaplains are divided in their views on legalized PAS, but primarily see their role to deliver support to patients no matter what the patient's final decision regarding PAS.

End-of-Life Care: Lessons from Other Nations

Palliative care and hospice services have evolved across the globe in different contexts and in different ways, although many of the challenges faced are similar. Comparison between countries helps to identify the best solutions for individual patients and their families, who have complex needs and problems. This paper describes the globally shared challenges and beginnings in hospice and palliative care. It reviews evolution of services and approaches. It compares the models of hospice and palliative care in the United States and the United Kingdom, where pioneer hospices were developed through the work of Dame Cicely Saunders, and then seeks to highlight ways to learn from the different approaches to address common questions. Several research recommendations result from this review. In many countries the research agenda in palliative and end-of-life care must move from describing need (where there are ample studies) to understanding how and determining whether services and interventions work, for whom, and when. Studies should consider the whole trajectory of illness, particularly in slowly progressive or relapsing conditions (including neurological conditions). Future studies should work toward the use of a similar set of core outcome measures, as well as take advantage of the opportunity to undertake "natural experiments" by comparing and contrasting care systems developed in different contexts around the world.

Legalised euthanasia will violate the rights of vulnerable patients

Doctors in the United Kingdom can accompany their patients every step of the way, up until the last. The law stops them helping their patients take the final step, even if that is the patient's fervent wish. Next month's debate in the House of Lords could begin the process of changing the law. To help doctors decide where they stand we publish a range of opinions

Why now? Timing and circumstances of hastened deaths

We interviewed 35 families to understand the timing and circumstances of hastened deaths. We estimated life expectancy for the 26 patients who hastened their deaths and used content analysis to identify patterns in their decisions. On average, patients had lived with their illness for 2.5 years and had actively planned their deaths for 3 months. Those with less than a week to live (n = 10) were 'dying and done,' having experienced a final functional loss that signaled the end. Those with <1 month (n = 8) were 'dying, but not fast enough.' Those with 1-6 months (n = 5) saw a 'looming crisis' on their horizon that would prohibit following through with their plans. The 3 patients with >6 months were 'not recognized by others as dying, but suffering just the same.' Clinicians should regularly assess where patients perceive they are in the dying process and ask about their comfort with the pace of dying to identify opportunities for intervention.

The House of Lords Select Committee on the Assisted Dying for the Terminally III Bill: implications for specialist palliative care

The Assisted Dying for the Terminally III Bill proposed to legalise both euthanasia and physician-assisted suicide for those with a terminal illness in the UK. A House of Lords Select Committee was convened to scrutinise this Bill and has recently published its report, which will be debated in Parliament on October 10th 2005. The written and oral evidence submitted to the Select Committee represented a wide range of views on 'assisted dying'. Much of the evidence from those countries which have legalised euthanasia/physician-assisted suicide (The Netherlands, Belgium, Switzerland and Oregon, USA) dealt with the practicalities of ending life, and the legal procedures and safeguards instigated in these countries. All the written and oral evidence in the public domain was scrutinised by the authors whilst the Select Committee was sitting. We have extracted those themes relevant to specialist palliative care practice and present them in this paper. We hope that this will provide a useful resource to inform the forthcoming public debate on assisted dying. The evidence of harms inherent in making such a change in the law, as presented to the Select Committee, has moved all three authors to oppose a change in the law.

Characteristics of persons approving of physician-assisted death

The present study describes the characteristics and attitudes of non-terminally ill persons who support physician-assisted death (PAD) along with their expectations and preferences for care in the future. Participants (N = 101) completed a survey assessing current affect and attitudes and those expected if terminally ill. Participants' responses indicated they were a well-adjusted group with little evidence of depressive symptoms or past suicidal ideation. Current attitudes were differentially related to future care preferences. Findings suggest a need for longitudinal research on the stability of current attitudes and how they relate to PAD among non-terminally ill supporters of assisted death.

A Burden to Others: A Common Source of Distress for the Terminally Ill

Recent research into the desire for death among people with terminal illness has begun to recognize the importance of "feeling oneself a burden to others" as a factor in suicidal behaviour. In this study, 69 patients with advanced cancer underwent semi-structured interviews. The sense of self-perceived burden was found to be a common experience, reported by 39.1% of participants as a minimal or mild concern and by 38% as a moderate to extreme concern. The sense of burden showed a low correlation with physical symptoms (r = 0.02-0.24) and higher correlations with psychological problems (r = 0.35-0.39) and existential issues (r = 0.45-0.49). Comparisons of participants with high or low levels of self-perceived burden showed the importance of this factor for overall quality of life. In summary, self-perceived burden is an important but underestimated dimension of social cognition in the medically ill.

Desire for hastened death, cancer pain and depression: report of a longitudinal observational study

Desire for hastened death (DHD) is reported in the literature as being common in patients with cancer pain. However, there is currently little evidence to suggest that improvement in pain results in improvement in DHD. Our objectives were to assess 1) the impact of improvements in cancer pain severity and pain's interference with daily functioning and depression on DHD, and 2) the role of factors such as social and spiritual well-being, educational level, and patient age in moderating the impact of pain and depression on DHD. This observational study included patient-rated and clinician-rated scales administered twice at 4-week intervals. We enrolled 131 newly-referred patients to the Pain and Palliative Care Service at Memorial Sloan-Kettering Cancer Center or newly-admitted patients to Calvary Hospital in New York. One hundred and sixteen patients completed the baseline measures and 64 patients completed both baseline and follow-up measures. The main outcome measures included the Brief Pain Inventory (BPI), Beck Depression Inventory (BDI), and the Desire for Hastened Death Scale (DHD). Sixty-six percent of patients had no DHD at baseline and 45% of patients had BDI scores of 14 or greater ('mild' depression). Only 40% of patients with moderate/severe depression were receiving antidepressants. BPI scores improved significantly from baseline to follow-up (6.36 vs. 4.86, P < 0.01). DHD scores increased significantly from baseline to follow-up (0.84 to 1.38, P = 0.03). All other measures including depression were stable. DHD scores were moderately correlated with depression (r = 0.43), low social support (r = 0.38), poor spiritual well-being (r = -0.38), religious well being (r = -0.25), pain interference (r = 0.27), higher educational level (F = 4.50, P = 0.02) and lower physical functioning (KPRS, r = -0.40), but were unrelated to sex, age, race, or marital status. In multivariate regression analyses, baseline DHD (beta = 0.30, P = 0.05) and change in depression (beta=0.36, P = 0.02) were predictive of follow-up DHD. Improvement in pain interference was not predictive of follow-up DHD. The results suggest that improvement in depression moderated the severity of desire for hastened death in a population of patients with cancer pain. Depression was common in this population and was often untreated. Improvements in functional impairment due to pain did not moderate the severity of DHD in a setting of aggressive pain management. Strategies to preemptively screen for depression in the routine assessment of patients with cancer pain may be important to address DHD.

Motivations for physician-assisted suicide

OBJECTIVE

To obtain detailed narrative accounts of patients' motivations for pursuing physician-assisted suicide (PAS).

DESIGN

Longitudinal case studies.

PARTICIPANTS

Sixty individuals discussed 35 cases. Participants were recruited through advocacy organizations that counsel individuals interested in PAS, as well as hospices and grief counselors.

SETTING

Participants' homes.

MEASUREMENTS AND RESULTS

We conducted a content analysis of 159 semistructured interviews with patients and their family members, and family members of deceased patients, to characterize the issues associated with pursuit of PAS. Most patients deliberated about PAS over considerable lengths of time with repeated assessments of the benefits and burdens of their current experience. Most patients were motivated to engage in PAS due to illness-related experiences (e.g., fatigue, functional losses), a loss of their sense of self, and fears about the future. None of the patients were acutely depressed when planning PAS.

CONCLUSIONS

Patients in this study engaged in PAS after a deliberative and thoughtful process. These motivating issues point to the importance of a broad approach in responding to a patient's request for PAS. The factors that motivate PAS can serve as an outline of issues to explore with patients about the far-reaching effects of illness, including the quality of the dying experience. The factors also identify challenges for quality palliative care: assessing patients holistically, conducting repeated assessments of patients' concerns over time, and tailoring care accordingly.

Interpersonal processes in palliative care: an attachment perspective on the patient-clinician relationship

The progression of advanced disease often brings enormous adaptational challenges related to a loss of the capacity to be self-sufficient and to a heightened need for support from others. The increasing need to rely on others at the end of life may reactivate relational problems and may trigger threatening feelings of vulnerability and dependency. Clinicians may find it difficult to identify and respond appropriately to the specific relational needs of individuals receiving end-of-life care. Attachment theory is a developmentally-based approach to understanding the formation and maintenance of relationships relevant to felt security. Although attachment theory has been widely applied to parent-child relationships and to relationships of individuals with chronic medical conditions to their medical caregivers, it has not previously been applied to the understanding of clinician-patient relationships in the palliative care setting. This paper provides an overview of this theory and demonstrates its application and relevance to palliative care.

Misrepresentations about palliative options and prognosis in motor neurone disease: some legal considerations

If euthanasia were legalized, clinicians would be under a duty to explain to patients requesting euthanasia what the prognosis and palliative options were. Anecdotal evidence suggests that some patients suffering from motor neurone disease may request euthanasia because of a fear of choking to death. The literature indicates that with competent palliative care this is unlikely to occur. It is assumed, for the purposes of argument, that responsible clinicians would accordingly reassure patients that such a fear was unwarranted, and that such a reassurance would cause patients for whom choking was the main concern either to withdraw a request for euthanasia or not to make it in the first place. The legal consequences of both negligent and deliberate failure to represent the true prognostic and palliative situation are discussed. In the case of a deliberate failure, with the intention to induce the patient to consent to euthanasia, it is suggested that a verdict of murder would be ethically right. It is argued that such a failure is best regarded as an omission. The English law currently does not countenance the possibility of murder by omission. It is suggested that the distinction between acts and omissions, while sometimes convenient, can sometimes produce injustice, and that the distinction should not be allowed to prevent conviction for murder where this is clearly appropriate.

Physician-Assisted Suicide

Tremendous debate surrounds the acceptability of physician-assisted suicide in the United States. Progress requires carefully mapping the relationship of this practice to termination of life-sustaining treatment, appropriate pain relief and palliative care, and euthanasia. Arguments that have been offered in favor of permitting physicians to aid suicide include the importance of patient autonomy, the claim that patients need this option to cope with symptoms at the end of life, and the assertion that practices already accepted involve intentionally ending life. Arguments that have been offered against include the potential for abuse, the claim that forbidding intentional killing is essential to the ethics of medicine, and the assertion that patients can be provided good and humane care at the end of life without assisting suicide. Addressing the demand for physician-assisted suicide requires improvement in end-of-life care and continued discussion attentive to emerging empirical data.

Schmerzdiagnostik und -therapie in der Geriatrie

A primary goal of pain treatment in geriatric patients consists of maintaining physical and mental function, which is a precondition of activity and participation. In patients with chronic pain, multidisciplinary treatment without excluding invasive procedures is the most effective approach. The medication ladder, suggested by the WHO initially for cancer pain, provides a guideline for pharmacological treatment. Due to age-dependent alterations in the kinetics and dynamics of pharmaceuticals, the titration of the medication follows the rule "start low and go slow." The same principle holds true for the maintenance or augmentation of physical activity in order to escape from the activity-deconditioning cycle. The training should be based on learning theories, include pain management strategies, and incorporate psychological approaches to facilitate the active participation of the patient in the treatment program. In hospitals and nursing homes, nurses play an important role in defining the need for pain treatment and in supervising the patient in the treatment process. Despite all these endeavors, a significant number of patients remains whose pain cannot be controlled sufficiently. Euthanasia on demand of the patient with untreatable pain is not admitted in Germany.

Advance directives and cancer decision making near the end of life

Seriously ill individuals, including those seriously ill with cancer, are frequently encouraged to complete instructional advance directives (i.e., living wills) to ensure that their wishes about the use of life-sustaining treatment are honored if they should lose the ability to make decisions for themselves. The authors present a social psychological analysis making explicit a series of steps that must necessarily take place if living wills are to honor the wishes of incapacitated patients. They then focus on 3 key steps in the analysis and review relevant research from the medical and psychological literatures. In each case, this research raises serious questions about the psychological assumptions underlying the effective use of living wills in end-of-life decision making. Discussion focuses on the need for policy and law guiding the use of advance directives to be informed by both basic and applied research on judgment and decision making.

A critical analysis of criticisms of the Oregon Death with Dignity Act

This article critically examines the validity of common criticisms of the Oregon Death with Dignity Act, primarily through reviewing published research and analyses. After summarizing the law and recent developments, 11 areas of concerns are examined: (a) the amount of data collected, (b) the availability of the data, (c) the reporting process, (d) protection of physicians, (e) terminal illness as a requirement, (f) the amount of data on palliative care interventions, (g) data on lethal prescriptions, (h) data on psychological/psychiatric evaluations, (i) whether the decision to request medication is informed, (j) whether the request is voluntary, and (k) financial factors. The authors examine each of these areas of concern and find criticisms to be unfounded given the research and analyses conducted to date.

Euthanasia and Physician-Assisted Suicide Policy in the Netherlands and Oregon

This article presents a comparative analysis of euthanasia and physician-assisted suicide policy in The Netherlands and the state of Oregon in the United States. The topics of euthanasia and physician-assisted suicide are discussed in the context of the historical setting of The Netherlands and the United States with special emphasis placed on public opinion, role of the courts and the legislative bodies, and opinions of physicians. Major similarities and differences in the laws of The Netherlands and Oregon are discussed. The article examines whether the passage of the law has led to a slide down the slippery slope in The Netherlands and Oregon as had been suggested by the opponents of the law. The article concludes that the empirical evidence does not support the contention of the opponents. However, the author argues that the potential for this happening is much greater in The Netherlands than in Oregon.

Responding to persistent requests for assistance in dying: a phenomenological inquiry

Little is known about how American nurses understand and respond to requests made by decisionally capable patients for assistance in dying. This article is based on a broader qualitative study first reported elsewhere (Schwarz, 2003). The study used phenomenological interpretation and analysis of stories told by 10 nurses who worked in home hospice, critical care, and HIV/AIDS care settings. Persistent requests for assistance in dying were relatively uncommon, but when heard, participants provided the following responses: refusing assistance, administering palliative drugs that might secondarily hasten dying, tacitly permitting and not interfering with patient or family plans to hasten death, and actively providing direct assistance in dying. Nurses' responses were context-driven; they did not seek guidance from professional codes of ethics or colleagues. Secrecy and collusion were routinely practised. Few participants unequivocally agreed or refused to help patients die; most struggled to find morally and legally acceptable ways to help patients die well. Regardless of how they responded, nurses who believed they had hastened death described feelings of guilt and moral distress. Healthcare professionals who provide care for symptomatic dying patients need opportunities to meet with supportive colleagues, to share the experience of troubling cases and of moral conflict, and to be supported and heard in a 'safe' environment.

Association Between Clinician Factors and a Patient’s Wish to Hasten Death: Terminally Ill Cancer Patients and Their Doctors

This study investigated the clinical factors associated with a wish to hasten death among patients with advanced cancer receiving palliative care, with a focus on the role of clinician-related factors. Patients were grouped into high- and low-scoring groups on the basis of their wish to hasten death; doctor-patient pairs were formed. Questionnaire data collected from patients and their treating doctors were subjected to multivariate analysis. Significant predictors of a high wish to hasten death in terminally ill patients from among treating clinicians included the clinician's perception of the patient's lower optimism and greater emotional suffering, the patient indicating a wish to hasten death, the doctor willing to assist the patient in hastening death (if requested and legal), and the doctor reporting less training in psychotherapy. When these variables were combined with patient factors identified in a previous study, the model significantly predicted a wish to hasten death with the following variables-patient factors: a higher perceived burden on others, higher depressive symptom scores, and lower family cohesion; physician factors: the doctor willing to assist the patient in hastening death (if requested and legal), the doctor's perception of lower levels of optimism and greater emotional distress in the patient, and the doctor having less training in psychotherapy; and the setting of care: recent admission to a hospice. The findings support the multifactorial influences on the wish to hasten death and suggest that the role of the clinician is a vital context within which the wish to hasten death should be considered.

Oregon Physicians' Responses to Requests for Assisted Suicide: A Qualitative Study

In 1997, the Oregon Death with Dignity Act was enacted, allowing physicians to prescribe lethal dosages of medication to competent, terminally ill patients who request them. To improve our understanding of physicians' reactions to requests for assisted suicide, we performed semistructured interviews of 35 Oregon physicians who had received requests from patients. Interviews were completed in 2000, and audiotaped, transcribed, and analyzed using qualitative techniques. Requests for assisted suicide had a powerful impact on physicians and their practices. Physicians often felt unprepared, and experienced apprehension and discomfort before and after receiving requests. Prominent sources of discomfort included concerns about adequately managing symptoms and suffering, not wanting to abandon patients, and incomplete understanding of patients' preferences, especially when physicians did not know patients well. Participation in assisted suicide required a large investment of time and was emotionally intense. Regardless of whether they prescribed or not, physicians did not express major regrets about their decisions. Requests often facilitated discussion of important issues, and many physicians felt that the process increased their confidence and assertiveness in discussing end-of-life issues with other patients. Physicians rarely sought support from colleagues; instead, they tended to discuss emotional aspects of their experiences with their spouses.

Ethical challenges in the care of patients with serious illness

The approach to management of patients with advanced disease and serious illness has been strongly influenced by advances in science and technology, the increasing role of ethics in clinical practice, and the recognition of new rights and social changes. At the present time, decision making is modulated by ethical and legal considerations. One of the challenges of clinical practice is to maintain the delicate balance between the technical aspects and the humanistic aspects of care. For the resolution of this challenge, this article proposes an ethical and legal framework that considers the goals of care and respects the basic values of autonomy, beneficence, and justice. Ethical and legal principles complement sound medical practice but should never replace it. At all times, clarification of the medical situation, good communication, and information about state of the art treatment proposals are essential. In the context of advanced illness, the most prominent issues relate to decision making, justice, and research.

Voluntary refusal of food and fluids: attitudes of Oregon hospice nurses and social workers

As the ethical debate about euthanasia and physician-assisted suicide (PAS) continues, one alternative that has been suggested is for the patient to voluntarily refuse all food and fluids (VRFF). The article describes the results of a study of hospice nurses' and social workers' attitudes towards VRFF and compares them with their attitudes towards PAS. In 2001, a questionnaire was posted to nurses and social workers who care for Oregon residents enrolled in hospice programmes to determine their attitudes towards PAS and VRFF. In general, hospice workers expressed support for patients who choose to hasten their death by VRFF; they were less supportive of PAS. The results from this study suggest that perceptions regarding VRFF are significantly different from those regarding PAS. These results may have important clinical implications for nurses and social workers involved in end-of-life care who encounter patients who wish to hasten their deaths.

Oregon versus Ashcroft: pain relief, physician-assisted suicide, and the Controlled Substances Act

OBJECTIVE

Late in 2001, the State of Oregon filed suit against Attorney General John Ashcroft, seeking to halt his recent directive that physicians who comply with the Oregon Death with Dignity Act by writing a lethal prescription for a controlled substance should be prosecuted for violating the federal Controlled Substances Act (CSA). This special article reviews the history of the series of challenges to the Oregon Act since its initial adoption in 1994, with particular consideration of the arguments on both sides of Oregon v. Ashcroft and the disposition of the case by the district court.

DESIGN

The article utilizes an historical review of the Oregon Act, including legal and political challenges to it, as well as discussion of the 3 years of data on the experience with legalized physician-assisted suicide in Oregon, and analysis of the legal issues in the current litigation.

CONCLUSIONS

The federal district court concluded that the Attorney General's interpretation of certain provisions of the CSA so as to preclude the writing of a lethal prescription where otherwise permitted by state law as a legitimate medical practice was inconsistent with the CSA and, therefore, beyond the scope of his authority. The Oregon Act will continue in force while the Attorney General's appeal of the district court ruling is considered by the Ninth Circuit Court of Appeals.

End-of-life care in geriatric psychiatry

Depression, anxiety and delirium are relatively common during the final stages of terminal disease, and each can profoundly impact the quality of those last days for both patient and involved family. In this article the authors review the assessment and treatment of each syndrome in the context of palliative care for older adults. Treatment of mental disorders at the end of life warrants special consideration due to the need to balance the benefits of treatment against the potential burden of the intervention, especially those that might worsen quality of life. Dementia and the complications of depression and behavioral disturbance within dementia are also discussed. Finally, caregivers of dying patients are vulnerable to stress, depression, grief, and complicated bereavement. Interventions for caregivers who are debilitated by these states are briefly summarized.

The quality of medical care at the end-of-life in the USA: existing barriers and examples of process and outcome measures

CONTEXT

Cancer is a leading cause of morbidity and mortality in the USA and despite many recent advances in detection and treatment, over half a million cancer patients in this country will die from their disease each year.

OBJECTIVE

Using cancer as a prototype, we provide a conceptual framework to identify and review barriers to optimal end-of-life care and propose examples of linked process and outcome measures that could be used to evaluate whether standards of optimal end-of-life care are being achieved.

METHODS

We propose a conceptual model of end-of-life care and use this model to review the published literature to identify the key goals of optimal end-of-life care and summarize existing barriers to optimal end-of-life care. We then provide examples of process and outcome measures linked to the goals of optimal end-of-life care and domains within the conceptual framework.

RESULTS

Within all components of care at the end-of-life--societal attitudes, health care system(s), providers, and patients and their families--there are significant barriers to the quality of care. Some of the most critical barriers to optimal care at the end-of-life in the USA are limited availability, and coverage of, co-ordinated service delivery; poor provider communication and diagnostic skills; limited opportunities for training in palliative care; patient fears and attitudes towards the sick role, and a lack of, or inadequate health insurance. Proposed patient, provider, and system level measures of the quality of care were guided by goals of optimal end-of-life care, and focus on communication about prognosis and risks and benefits of treatment, development of clear and informed treatment goals, delivery of services consistent with treatment goals, and promotion of quality of life.

CONCLUSIONS

At present, there are substantial societal, health care system, provider, and patient barriers to obtaining optimal cancer care at the end-of-life. Ongoing discussions about appropriate measures of the quality of end-of-life care are gaining momentum, however. The proposed process and outcome measures for assessing optimal end-of-life care use cancer as a prototype, but are broadly applicable to other patient populations with life-threatening disease.

Should a suicidal patient with Huntington's disease be hospitalized against her will? Attitudes among future physicians and lawyers and discussion of ethical issues

The issue of rational suicide of a competent patient suffering from a hopeless but not terminal disease is controversial. Little is known about how psychiatrists, other physicians or judges make decisions about involuntary hospitalization of such patients, or about their ethical reasoning. The objective of this study was to identify future physicians' and lawyers' views on involuntary hospitalization of a suicidal Huntington's disease (HD) patient and to evaluate whether they are ethically defendable. Five-hundred and ninety-nine law students and advanced medical students reported whether they agree or not to involuntary hospitalize a suicidal HD patient (audio/video recording). No significant differences were found between medical and law students. Forty-four percent of students agreed to hospitalization, 49.3% disagreed. The comments indicate that medical and law students had pessimistic views about the quality of life of an HD patient. Medical students referred more often than law students to patients' autonomy rights and less often to benefits to relatives. Involuntary hospitalization of a suicidal but not terminal HD patient is controversial among future physicians and lawyers. Students underestimated the need for careful evaluation. More open discussion and more ethical teaching on the subject of acceptance of rational suicide for hopelessly, but not yet terminally ill patients are needed.