Suicide in the medically and terminally ill: psychological and ethical considerations

Euthanasia and assisted suicide in neurological diseases: a systematic review

OBJECTIVE

To identify the neurological diseases for which euthanasia and assisted suicide are most frequently requested in the countries where these medical procedures are legal and the specific characteristics of euthanasia in some of these diseases, and to show the evolution of euthanasia figures.

METHODS

We conducted a systematic literature review.

RESULTS

Dementia, motor neuron disease, multiple sclerosis, and Parkinson's disease are the neurological diseases that most frequently motivate requests for euthanasia or assisted suicide. Requests related to dementia constitute the largest group, are growing, and raise additional ethical and legal issues due to these patients' diminished decision-making capacity. In some countries, the ratios of euthanasia requests to all cases of multiple sclerosis, motor neuron disease, or Huntington disease are higher than for any other disease.

CONCLUSIONS

After cancer, neurological diseases are the most frequent reason for requesting euthanasia or assisted suicide.

Euthanasia and assisted suicide in neurological diseases: a systematic review

OBJECTIVE

To identify the neurological diseases for which euthanasia and assisted suicide are most frequently requested in the countries where these medical procedures are legal and the specific characteristics of euthanasia in some of these diseases, and to show the evolution of euthanasia figures.

METHODS

We conducted a systematic literature review.

RESULTS

Dementia, motor neuron disease, multiple sclerosis, and Parkinson's disease are the neurological diseases that most frequently motivate requests for euthanasia or assisted suicide. Claims related to dementia constitute the largest group, are growing, and raise additional ethical and legal issues due to these patients' diminished decision-making capacity. In some countries, the ratios of euthanasia requests to all cases of multiple sclerosis, motor neuron disease, or Huntington disease are higher than for any other disease.

CONCLUSIONS

After cancer, neurological diseases are the most frequent reason for requesting euthanasia or assisted suicide.

A mixed-methods pilot study of 'LIFEView' audiovisual technology: Virtual travel to support well-being and quality of life in palliative and end-of-life care patients

BACKGROUND

There is evidence that psychosocial and spiritual interventions of short duration, such as reminiscence therapy, provide positive impacts on quality of life and emotional and existential well-being in adults receiving palliative care.

AIM

To determine (1) the feasibility of integrating 'LIFEView', a video-based software with >1600 videos of world destinations, in palliative care settings, and (2) positive, neutral or harmful effects of using 'LIFEView' videos.

DESIGN

A mixed-methods pre-post intervention pilot study was conducted to collect feasibility and preliminary data on physical and psychological symptoms, physiological indicators, spiritual well-being and aspects of quality of life.

SETTING/PARTICIPANTS

Adult patients on an inpatient palliative care unit or receiving care from a community palliative care consultation team who were capable of providing consent and completing the outcome measures were eligible participants.

RESULTS

Overall, 27/41 (66%) participants took part in the study. Feasibility criteria, including participant acceptability, low participant burden, tool completion rate and retention rate, were fulfilled, though challenges were experienced with recruitment. Modest improvements, though non-significant, were shown on preliminary data collected on physical and psychological symptoms using the Edmonton Symptom Assessment System-revised, spiritual well-being assessed by the 12-item Functional Assessment of Chronic Illness Therapy - Spiritual Well-Being scale and physiological measurements. Qualitative analysis revealed five themes: motivations for using 'LIFEView', perceptions of the technology, reminiscence, 'LIFEView' as an adaptable technology and ongoing or future use.

CONCLUSION

A future adequately powered study to investigate the impacts of 'LIFEView' on patient well-being and quality of life appears to be feasible.

Predictors of Attitudes Towards Physician-Assisted Suicide

Psychological factors may influence an individual's acceptance of euthanasia and physician-assisted suicide (PAS). The purpose of the present investigation was to evaluate predictors of attitudes towards PAS. Data were collected from 136 college students at a private Midwestern university. In addition to demographic and family history information, respondents completed measures of attitudes towards seeking mental health services, depression, hopelessness, and PAS attitudes. Respondent age, race, and hopelessness scores emerged as the only significant predictors ( R2 = .20) in a multiple regression model used to identify potential predictors of PAS attitudes. Younger, non-minority respondents, and those endorsing more hopelessness reported more accepting attitudes towards PAS. Data from a three month follow-up assessment supported the stability of this pattern. The findings highlight the important role that mental health professionals should play in PAS decision making. Implications for the evaluation of medically ill considering PAS and their caregivers are discussed.

Attitudes toward Assisted Suicide: Does Family Context Matter?

Little is known about how family-related contextual variables impact attitudes toward assisted suicide. A probability sample (N = 272) responded to a multiple-segment factorial vignette designed to examine the effects of 6 variables-patient sex, age, type of illness, relationship status, parenthood status, and family support-on attitudes toward physician- and family-assisted suicide. Respondents were more likely to support physician-assisted suicide if they heard about an older patient or a patient experiencing physical pain than a younger patient or one suffering from depression, respectively. For family-assisted suicide, respondent support was higher when the patient had physical pain than depression, and when the patient's spouse or friend was supportive of the wish to die than unsupportive. Attitudes about physician and family obligation to inform others were affected by type of illness, relationship status, family support, and respondent education and religiosity. The experience of pain, motivations for family involvement, confidentiality issues, and physicians' biases concerning assisted suicide are discussed.

Accounts of suicidality in the Huntington disease community

Health professionals, researchers, and philosophers have debated extensively about suicide. Some believe suicides result from mental pathology, whereas others argue that individuals are capable of rational suicide. This debate is particularly poignant within illness communities, where individuals may be suffering from chronic and incurable conditions. This article engages with these issues by presenting the accounts of 20 individuals with Huntington disease (HD), a fatal degenerative condition, and 10 informal caregivers (e.g., spouses). Suicide is a leading cause of death amongst people with HD, with an incidence rate many times higher than the general population. In contrast to the majority of the academic literature on HD suicidality, study participants did not connect suicide with mental pathology. Instead, they perceived suicide as a response to the realities of living with HD, such as prolonged physiological degeneration and the need for long-term intensive health care. These findings are subsequently discussed in relation to the rational-pathological suicide binary.

Educational preferences and outcomes from suicide prevention training in the Veterans Health Administration: one-year follow-up with healthcare employees in Upstate New York

This study identifies training outcomes and educational preferences of employees who work within the Veterans Health Administration (VHA). Using a longitudinal pre- postsurvey design, 71 employees from one geographic region of VHA healthcare facilities participated in an evaluation of a brief standardized gatekeeper program and a needs assessment on training preferences for suicide and suicide prevention. Results indicate significant differences in knowledge and self-efficacy from pre to post (p < 0.001), although only self-efficacy remained significant at 1 year follow-up, (M = 3.01; SD = 0.87) as compared to pretraining (M = 2.50, SD = 1.05) (t = -5.64, p < 0.001). At post-training, 90% of the participants were willing to learn more about suicide, with 88% willing to spend more than 1 hour in future training activities on more advanced topics. This training program can increase the knowledge and abilities of VHA staff to engage, identify, and refer veterans at risk for suicide to appropriate care.

Suicide in older people without psychiatric disorder

OBJECTIVE

To determine the psychological characteristics and nature of life problems, including physical illness, in people 60 years and over dying through suicide in the absence of psychiatric disorder.

METHODS

Psychological autopsy interviews with relatives and friends for 23 people aged 60 years or over who had died through suicide and did not have a psychiatric disorder at the time of death.

RESULTS

Three (13%) of the sample had significant psychiatric symptoms, one had a diagnosis of personality disorder, and ten (43.5%) had significantly abnormal personality traits. Physical illness and recent bereavement were the commonest life problems associated with suicide. Five (21.7%) of the sample were suffering from severe physical illness at the time of death.

CONCLUSION

Sub-syndromal psychiatric disorder may be less important than personality factors, physical illness, and recent bereavement as important contributory factors to suicide in older people not suffering from psychiatric illness at the time of death.

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.

Effect of spiritual well-being on end-of-life despair in terminally-ill cancer patients

BACKGROUND

The importance of spirituality in coping with a terminal illness is becoming increasingly recognised. We aimed to assess the relation between spiritual well-being, depression, and end-of-life despair in terminally-ill cancer patients.

METHODS

160 patients in a palliative care hospital with a life expectancy of less than 3 months were interviewed with a series of standardised instruments, including the functional assessment of chronic illness therapy-spiritual well-being scale, the Hamilton depression rating scale, the Beck hopelessness scale, and the schedule of attitudes toward hastened death. Suicidal ideation was based on responses to the Hamilton depression rating scale.

FINDINGS

Significant correlations were seen between spiritual well-being and desire for hastened death (r=-0.51), hopelessness (r=-0.68), and suicidal ideation (r=-0.41). Results of multiple regression analyses showed that spiritual well-being was the strongest predictor of each outcome variable and provided a unique significant contribution beyond that of depression and relevant covariates. Additionally, depression was highly correlated with desire for hastened death in participants low in spiritual well-being (r=0.40, p<0.0001) but not in those high in spiritual well-being (r=0.20, p=0.06).

INTERPRETATION

Spiritual well-being offers some protection against end-of-life despair in those for whom death is imminent. Our findings have important implications for palliative care practice. Controlled research assessing the effect of spirituality-based interventions is needed to establish what methods can help engender a sense of peace and meaning.