The wish to hasten death: a review of clinical studies

In Defense of "Physician-Assisted Suicide": Toward (and Back to) a Transparent, Destigmatizing Debate

Many bioethicists have recently shifted from using "physician-assisted suicide" (PAS) to "medical aid-in-dying" (MAID) to refer to the act of voluntarily hastening one's death with the assistance of a medical provider. This shift was made to obscure the practice's connection to "suicide." However, as the charge of "suicide" is fundamental to arguments against the practice, "MAID" can only be used by its proponents. The result has been the fragmentation of the bioethical debate. By highlighting the role of human agency-as opposed to natural processes-in causing death, the term "PAS" makes it easier both to perceive potential risks to vulnerable populations and to affirm suicide as a potentially autonomous choice. As such, "PAS" thus more transparently expresses the arguments of both supporters and opponents of the "right to die," while avoiding the unnecessary stigmatization of suicide and suicidal people which is a result of the usage of "MAID."

The Wish to Hasten Death in Patients With Life-Limiting Conditions. A Systematic Overview

CONTEXT

A systematic review of the wish to hasten death among people with life-limiting conditions was published in 2011. Since then, other reviews and primary studies have been published that have added to knowledge regarding the conceptual definition, aetiology and assessment of the wish to hasten death.

OBJECTIVES

To provide an updated synthesis of the literature on the wish to hasten death in people with life-limiting conditions.

METHODS

An overview of systematic reviews and primary studies was conducted, using an integrative review method. PubMed, CINAHL, Scopus and Web of Science databases were searched, from their inception until 2023. We included all systematic reviews published to date and all primary studies not included in these systematic reviews.

RESULTS

Eleven systematic reviews and 35 primary studies were included. We propose that the phenomenon may usefully be considered as existing along a continuum, defined by the extent to which thoughts of dying are linked to action. A total of nine assessment tools have been described. The reported prevalence of the wish to hasten death appears to be influenced by the wording used in assessment instruments, as well as by the cut-off used when applying a particular tool. Depression, pain, functional disability, decreased sense of meaning in life, the sense of being a burden and reduced quality of life are the most widely reported related factors.

CONCLUSION

This overview underscores the need for clinical strategies that can identify different manifestations of the wish to hasten death among people with life-limiting conditions.

"So at least now I know how to deal with things myself, what I can do if it gets really bad again"-experiences with a long-term cross-sectoral advocacy care and case management for severe multiple sclerosis: a qualitative study

BACKGROUND

Persons with severe Multiple Sclerosis (PwsMS) face complex needs and daily limitations that make it challenging to receive optimal care. The implementation and coordination of health care, social services, and support in financial affairs can be particularly time consuming and burdensome for both PwsMS and caregivers. Care and case management (CCM) helps ensure optimal individual care as well as care at a higher-level. The goal of the current qualitative study was to determine the experiences of PwsMS, caregivers and health care specialists (HCSs) with the CCM.

METHODS

In the current qualitative sub study, as part of a larger trial, in-depth semi-structured interviews with PwsMS, caregivers and HCSs who had been in contact with the CCM were conducted between 02/2022 and 01/2023. Data was transcribed, pseudonymized, tested for saturation and analyzed using structuring content analysis according to Kuckartz. Sociodemographic and interview characteristics were analyzed descriptively.

RESULTS

Thirteen PwsMS, 12 caregivers and 10 HCSs completed interviews. Main categories of CCM functions were derived deductively: (1) gatekeeper function, (2) broker function, (3) advocacy function, (4) outlook on CCM in standard care. Subcategories were then derived inductively from the interview material. 852 segments were coded. Participants appreciated the CCM as a continuous and objective contact person, a person of trust (92 codes), a competent source of information and advice (on MS) (68 codes) and comprehensive cross-insurance support (128 codes), relieving and supporting PwsMS, their caregivers and HCSs (67 codes).

CONCLUSIONS

Through the cross-sectoral continuous support in health-related, social, financial and everyday bureaucratic matters, the CCM provides comprehensive and overriding support and relief for PwsMS, caregivers and HCSs. This intervention bears the potential to be fine-tuned and applied to similar complex patient groups.

TRIAL REGISTRATION

The study was approved by the Ethics Committee of the University of Cologne (#20-1436), registered at the German Register for Clinical Studies (DRKS00022771) and in accordance with the Declaration of Helsinki.

A bioethical perspective on the meanings behind a wish to hasten death: a meta-ethnographic review

BACKGROUND

The expressions of a "wish to hasten death" or "wish to die" raise ethical concerns and challenges. These expressions are related to ethical principles intertwined within the field of medical ethics, particularly in end-of-life care. Although some reviews were conducted about this topic, none of them provides an in-depth analysis of the meanings behind the "wish to hasten death/die" based specifically on the ethical principles of autonomy, dignity, and vulnerability. The aim of this review is to understand if and how the meanings behind the "wish to hasten death/die" relate to and are interpreted in light of ethical principles in palliative care.

METHODS

We conducted a meta-ethnographic review according to the PRISMA guidelines and aligned with Noblit and Hare's framework. Searches were performed in three databases, Web of Science, PubMed, CINAHL, with no time restrictions. Original qualitative studies exploring the meanings given by patients, family caregivers and healthcare professionals in any context of palliative and end-of-life care were included. A narrative synthesis was undertaken. PROSPERO registration CRD42023360330.

RESULTS

Out of 893 retrieved articles, 26 were included in the analysis, accounting for the meanings of a total of 2,398 participants. Several factors and meanings associated with the "wish to hasten death" and/or "wish to die" were identified and are mainly of a psychosocial and spiritual nature. The ethical principles of autonomy and dignity were the ones mostly associated with the "wish to hasten death". Ethical principles were essentially inferred from the content of included articles, although not explicitly stated as bioethical principles.

CONCLUSIONS

This meta-ethnographic review shows a reduced number of qualitative studies on the "wish to hasten death" and/or "wish to die" explicitly stating ethical principles. This suggests a lack of bioethical reflection and reasoning in the empirical end-of-life literature and a lack of embedded ethics in clinical practice. There is a need for healthcare professionals to address these topics compassionately and ethically, taking into account the unique perspectives of patients and family members. More qualitative studies on the meanings behind a wish to hasten death, their ethical contours, ethical reasoning, and implications for clinical practice are needed.

Definition and validation of the nursing diagnosis label "wish to die": a research protocol

BACKGROUND

Euthanasia has been incorporated into the health services of seven countries. The legalisation of these practices has important repercussions for the competences of nurses, and it raises questions about their role. When a patient with advanced disease expresses a wish to die, what is expected of nurses? What are the needs of these patients, and what kind of care plan do they require? What level of autonomy might nurses have when caring for these patients? The degree of autonomy that nurses might or should have when it comes to addressing such a wish and caring for these patients has yet to be defined. Recognising the wish to die as a nursing diagnosis would be an important step towards ensuring that these patients receive adequate nursing care. This study-protocol aims to define and validate the nursing diagnosis wish to die in patients with advanced disease, establishing its defining characteristics and related factors; to define nursing-specific interventions for this new diagnosis.

METHODS

A prospective three-phase study will be carried out. Phase-A) Foundational knowledge: an umbrella review of systematic reviews will be conducted; Phase-B) Definition and validation of the diagnostic nomenclature, defining characteristics and related factors by means of an expert panel, a Delphi study and application of Fehring's diagnostic content validation model; Phase-C) Definition of nursing-specific interventions for the new diagnosis. At least 200 academic and clinical nurses with expertise in the field of palliative care or primary health care will be recruited as participants across the three phases.

DISCUSSION

The definition of the wish to die as a nursing diagnosis would promote greater recognition and autonomy for nurses in the care of patients who express such a wish, providing an opportunity to alleviate underlying suffering through nursing-specific interventions and drawing attention to the needs of patients with advanced disease. The new diagnosis would be an addition to nursing science and would provide a framework for providing care to people with advanced disease who express such a wish. Nurses would gain professional autonomy about identifying, exploring and responding clinically to such a wish.

Legalisation of euthanasia and assisted suicide: advanced cancer patient opinions - cross-sectional multicentre study

OBJECTIVES

The French government voted a new law in February 2016 called the Claeys-Leonetti Law, which established the right to deep and continuous sedation, confirmed the ban on euthanasia and ruled out physician-assisted suicide. The aim of this work was to gather the opinion of patients on continuous sedation and the legalisation of medical assistance in dying and to explore determinants associated with favourable and unfavourable opinions.

METHODS

This was a French national prospective multicentre study between 2016 and 2020.

RESULTS

331 patients with incurable cancer suffering from locally advanced or metastatic cancer in 14 palliative care units were interviewed. 48.6% of participants expressed a favourable opinion about physician-assisted suicide and 27.2% an unfavourable opinion about its legalisation. Regarding euthanasia, 52% of patients were in favour of its legalisation. In univariate analysis, the only factor determining opinion was belief in God.

CONCLUSIONS

While most healthy French people are in favour of legalising euthanasia, only half of palliative care patients expressed this opinion. Medical palliative care specialists were largely opposed to euthanasia. The only determining factor identified was a cultural factor that was independent of the other studied variables. This common factor was found in other studies conducted on cohorts from other countries. This study contributes to the knowledge and thinking about the impact of patients' personal beliefs and values regarding their opinions about euthanasia and assisted suicide.

TRIAL REGISTRATION NUMBER

NCT03664856.

Desire for hastened death in advanced cancer: cross-sectional study in China

OBJECTIVE

To evaluate the incidence of desire for hastened death (DHD) among patients with advanced cancer and to identify factors associated with DHD.

METHODS

This was a cross-sectional study of 227 patients with advanced cancer in Hunan Cancer Hospital. The patients were assessed using Chinese version of the Schedule of Attitudes toward Hastened Death, Karnofsky Performance Scale, Quality of Life (QOL), MD Anderson Symptom Inventory and Patient Health Questionnaire Depression Module-9.

RESULTS

The number of patients with or without DHD were 71 (31.3%) and 156 (68.7%), respectively. Follow-up visits and average and high QOL were protective factors for DHD; severely disturbed sleep, symptoms that severely interfered with mood, and symptoms that severely interfered with relations with other people were risk factors for DHD.

CONCLUSIONS

The incidence of the DHD in patients with advanced cancer at home is high. Those who have low QOL, severely disturbed sleep, symptoms that severely interfered with mood, or symptoms that severely interfered with relations with other people should be paid attention to. These data provide a theoretical basis for the early detection and diagnosis of the desire to accelerate death of patients with advanced cancer.

Eutanasia y Psicología. Algunas claves para la intervención en Procesos Adelantados de Muerte

Los países que han optado por regular los Procesos Adelantados de Muerte (PAM) van en aumento en los últimos años. Este tipo de legislaciones implican directamente a los equipos sanitarios.Los psicólogos incluidos en estos equipos están en contacto con estos procesos, por lo que se torna imprescindible dilucidar, mediante la escasa literatura existente, si los PAM presentan variables diferenciales con otros procesos de muerte, que sean necesarias tener en cuenta durante la asistencia psicológica. Esta recopilación de literatura pretende plantear las diferencias que en la actualidad están contrastadas y plantear qué opciones de intervención psicológica están a nuestra disposición para realizar el acompañamiento a estas personas, sus cuidadores y los equipos sanitarios que los asisten.

Evaluating requests for physician-assisted suicide. A survey among German oncologists

BACKGROUND

Cancer patients form a notable proportion of requestors for physician-assisted suicide (PAS). This manuscript provides data on German oncologists' views concerning due criteria for the assessment of requests for PAS and quality assurance.

METHODS

The German Society of Haematology and Medical Oncology (DGHO) has conducted a survey among its members to elicit data about practices and views on regulating PAS in March 2021. Descriptive analysis and bivariate logistic regression of quantitative data on socio-demographic and other determinants possibly associated with respondents' views on PAS as well as content analysis of qualitative data were performed.

RESULTS

About 57.1% (n = 425) of respondents (n = 745) indicated that they had been asked for information about PAS by patients. Information about palliative (92.7%; n = 651) and psychological care options (85.6%; n = 598) was deemed most important in cases of requests for PAS. More than half of the respondents (57.6%; n = 429) were in favour of a formal expert assessment of decisional capacity and about 33.4% (n = 249) favoured a time span of 14 days between the counselling and prescription of a lethal drug. There was no association between participants who received more requests and a preference for disclosing publicly their willingness to assist with suicide. A majority of respondents requested measures of quality assurance (71.3%; n = 531).

CONCLUSION

According to respondents' views, the regulation of PAS will require diligent procedures regarding the assessment of decisional capacity and counselling. The findings suggest that the development of adequate and feasible criteria to assess the quality of practices is an important task.

"It's a Living Experience": Bereavement by Suicide in Later Life

Bereavement by suicide for people in later life is significantly under-researched. Research on ageing and suicide has yet to address the experiences of those bereaved by suicide and how such a devastating loss affects the ageing experience. Objectives: We explored the substantive issues involved in bereavement by suicide and its impact on later life. Methods: This was a co-produced qualitative study. Peer researchers with lived experience conducted in-depth interviews with twenty-four people aged 60-92 years. A phenomenological approach informed the data analysis. Main Findings: Themes described included (1) moral injury and trauma; (2) the rippling effect on wider family and networks; (3) transitions and adaptations of bereaved people and how their 'living experience' impacted on ageing. Conclusions: It is important to understand how individual experiences of suicide intersect with ageing and the significance of targeted assessment and intervention for those bereaved by suicide in ageing policies and support.

A scoping review exploring the ‘grey area’ of suicide-related expression in later life: Developing a conceptual framework for professional engagement

As the body of research on suicide in later life has developed, so has its vocabulary. This has generated a high level of overlap in concepts and terminology used to articulate suicide and how it might present, as well as ‘grey area’ behavioural terms that are both specific to older adults and less well-defined (e.g. ‘hastening of death’ or ‘completed life’). A better understanding of individual experiences and pathways to suicide can help to inform assessment and interventions, and increase the potential to relate any theoretical concepts to the implementation of such. Here, we adopted a scoping review to search systematically literature on specific presentation, features, circumstances and outcomes of these grey areas of suicide in later life. Fifty-three articles (quantitative, qualitative and theoretical) were reviewed. A narrative approach was used to merge and translate this body of knowledge into a new conceptual framework based on four key themes: (a) a sense of completed life or existential loneliness; (b) death thoughts, wishes and ideation; (c) death-hastening behaviour and advanced directives; and (d) self-destructive or self-injurious behaviour. We discuss the importance of integrating this understanding into current knowledge and suicide prevention strategies for older adults. Recommendations are made for unifying research with policy themes on healthy ageing, person-centredness within service provision and citizen participation.

Assessing suicide ideation among older adults: a systematic review of screening and measurement tools

OBJECTIVES

Rates of suicide in older adults may be higher than reported due to poor understandings of presentation of suicide ideation in this group. The objectives of this paper were to (i) review current measurement tools designed for older adults to detect suicide ideation and (ii) assess their psychometric properties.

DESIGN

We used a systematic review approach to identify measurement tools developed specifically for older adults without cognitive decline or impairment.

RESULTS

Ten articles that reported on a total of seven different measurement tools were identified. These included tools that focused on resiliency to suicide and those that measured risk of suicide behavior. There was wide variation across the articles: some were adaptations of existing scales to suit older populations, others were developed by authors; they varied in length from four to 69 items; a range of settings was used, and there was a mix of self-report and clinician-administered measures. Most displayed good psychometric properties, with both approaches showing similar quality. Limitations in terms of samples, settings, and measurement design are discussed.

CONCLUSION

The case for specific measures for older adults is clear from this review. There appear to be unique factors that should be considered in understanding suicide ideation and behavior among older adults that may not be directly assessed in non-specific measurements. However, there is a need to expand the diversity of individuals included in measurement development to ensure they are appropriate across gender, culture and minority status, and for the views of professionals to be considered.

Palliative care provider attitudes toward existential distress and treatment with psychedelic-assisted therapies

BACKGROUND

Existential distress is a significant source of suffering for patients facing life-threatening illness. Psychedelic-Assisted Therapies (PAT) are novel treatments that have shown promise in treating existential distress, but openness to providing PAT may be limited by stigma surrounding psychedelics and the paucity of education regarding their medical use. How PAT might be integrated into existing treatments for existential distress within palliative care remains underexplored.

METHODS

The present study aimed to elucidate the attitudes of palliative care clinicians regarding treatments for existential distress, including PAT. We recruited palliative care physicians, advanced practice nurses, and spiritual and psychological care providers from multiple US sites using purposive and snowball sampling methods. Attitudes toward PAT were unknown prior to study involvement. Semi-structured interviews targeted at current approaches to existential distress and attitudes toward PAT were analyzed for thematic content.

RESULTS

Nineteen respondents (seven physicians, four advanced practice nurses, four chaplains, three social workers, and one psychologist) were interviewed. Identified themes were 1) Existential distress is a common experience that is frequently insufficiently treated within the current treatment framework; 2) Palliative care providers ultimately see existential distress as a psychosocial-spiritual problem that evades medicalized approaches; 3) Palliative care providers believe PAT hold promise for treating existential distress but that a stronger evidence base is needed; 4) Because PAT do not currently fit existing models of existential distress treatment, barriers remain.

CONCLUSIONS

PAT is seen as a potentially powerful tool to treat refractory existential distress. Larger clinical trials and educational outreach are needed to clarify treatment targets and address safety concerns. Further work to adapt PAT to palliative care settings should emphasize collaboration with spiritual care as well as mental health providers and seek to address unresolved concerns about equitable access.

Autonomy and control in the wish to die in terminally ill patients: A systematic integrative review

BACKGROUND/OBJECTIVE

Personal autonomy and control are major concepts for people with life-limiting conditions. Patients who express a wish to die (WTD) are often thought of wanting it because of loss of autonomy or control. The research conducted so far has not focused on personal beliefs and perspectives; and little is known about patients' understanding of autonomy and control in this context. The aim of this review was to analyze what role autonomy and control may play in relation to the WTD expressed by people with life-limiting conditions.

METHODS

A systematic integrative review was conducted. The search strategy used MeSH terms in combination with free-text searching of the EBSCO Discovery Service (which provides access to multiple academic library literature databases, including PubMed and CINAHL), as well as the large PsycINFO, Scopus, and Web of Science library literature databases from their inception until February 2019. The search was updated to January 2021.

RESULTS

After the screening process, 85 full texts were included for the final analysis. Twenty-seven studies, recording the experiences of 1,824 participants, were identified. The studies were conducted in Australia (n = 5), Canada (n = 5), USA (n = 5), The Netherlands (n = 3), Spain (n = 2), Sweden (n = 2), Switzerland (n = 2), Finland (n = 1), Germany (n = 1), and the UK (n = 1). Three themes were identified: (1) the presence of autonomy for the WTD, (2) the different ways in which autonomy is conceptualized, and (3) the socio-cultural context of research participants.

SIGNIFICANCE OF RESULTS

Despite the importance given to the concept of autonomy in the WTD discourse, only a few empirical studies have focused on personal interests. Comprehending the context is crucial because personal understandings of autonomy are shaped by socio-cultural-ethical backgrounds and these impact personal WTD attitudes.

Wish to die and hasten death in palliative care: a cross-sectional study factor analysis

OBJECTIVES

The wish to die (WTD) is a complex experience sometimes accompanied by intention to hasten death. The aim of this study is to identify the predictive factors for WTD and hastening death intention (HDI) in Spanish patients with advanced illness.

METHODS

This is a subanalysis of a larger cross-sectional study conducted on patients experiencing advanced illness (N=201). Sociodemographic data and data related to symptom burden (Edmonton Symptom Assessment System-Revised), depressive and anxious symptoms (Hospital Anxiety and Depression Scale), demoralisation (Spanish version of the Demoralisation Scale), perceived loss of dignity (Patient Dignity Inventory) and WTD (Assessing Frequency and Extent of Desire to Die) were collected. The analysis used univariate and multivariate logistic regression.

RESULTS

The prevalence of WTD in the sample was 18%, with 8 out of 36 patients reporting HDI. The independent factors predictive of WTD were (1) knowledge of approximate prognosis (OR=4.78; 95% CI 1.20 to 10.8; p=0.001); (2) symptom burden (OR=1.05; 95% CI 1.00 to 1.09; p=0.038); and (3) the Demoralisation Scale subsection 'lack of meaning and purpose in life' (OR=1.61; 95% CI 1.30 to 1.99; p=0.000). An independent predictive factor for HDI was the Demoralisation Scale subsection 'patients' distress and coping abilities' (OR=1.47; 95% CI 1.04 to 2.08; p=0.028), while having religious beliefs was a protective factor (OR=0.13; 95% CI0.17 to 0.97; p=0.047).

CONCLUSIONS

Demoralisation was found to be the only common triggering factor for WTD and HDI, although experiences share certain features. Identification of the predictive factors for WTD and HDI may contribute to their prevention and management.

The wish to die and hastening death in amyotrophic lateral sclerosis: A scoping review

BACKGROUND

Amyotrophic lateral sclerosis (ALS) develops into a life-threatening condition 2 to 4 years after the onset of symptoms. Although many people with the disease decide in favour of life-sustaining measures, thoughts about hastening death are not uncommon.

OBJECTIVES

Our aim was to examine the scope of literature on the wish to die in ALS and provide an insight into determinants and motives for different end-of-life options.

METHODS

We searched eight databases for English and German publications on death wishes in ALS for the period from 2008 to 2018 and updated the search up to May 2020. After the screening process, 213 full texts were included for the final analysis. We analysed the texts in MAXQDA, using deductively and inductively generated codes.

RESULTS

We identified end-of-life considerations, ranging from wishes to die without hastening death, to options with the possibility or intention of hastening death. Besides physical impairment, especially psychosocial factors, socio-demographic status and socio-cultural context have a great impact on decisions for life-shortening options. There is huge variation in the motives and determinants for end-of-life considerations between individuals, different societies, healthcare and legal systems.

CONCLUSIONS

For a variety of reasons, the information and counselling provided on different options for sustaining life or hastening death is often incomplete and insufficient. Since the motives and determinants for the wish to hasten death are extremely diverse, healthcare professionals should investigate the reasons, meaning and strength of the desire to die to detect unmet needs and examine which interventions are appropriate in each individual case.

Medical Assistance in Dying in patients with advanced cancer and their caregivers: a mixed methods longitudinal study protocol

BACKGROUND

The legal criteria for medical assistance in dying (MAiD) for adults with a grievous and irremediable medical condition were established in Canada in 2016. There has been concern that potentially reversible states of depression or demoralization may contribute to the desire for death (DD) and requests for MAiD. However, little is known about the emergence of the DD in patients, its impact on caregivers, and to what extent supportive care interventions affect the DD and requests for MAiD. The present observational study is designed to determine the prevalence, predictors, and experience of the DD, requests for MAiD and MAiD completion in patients with advanced or metastatic cancer and the impact of these outcomes on their primary caregivers.

METHODS

A cohort of patients with advanced or metastatic solid tumour cancers and their primary caregivers will be recruited from a large tertiary cancer centre in Toronto, Ontario, Canada, to a longitudinal, mixed methods study. Participants will be assessed at baseline for diagnostic information, sociodemographic characteristics, medical history, quality of life, physical and psychological distress, attitudes about the DD and MAiD, communication with physicians, advance care planning, and use of psychosocial and palliative care interventions. Measures will subsequently be completed every six months and at the time of MAiD requests. Quantitative assessments will be supplemented by qualitative interviews in a subset of participants, selected using quota sampling methods.

DISCUSSION

This study has the potential to add importantly to our understanding of the prevalence and determinants of the DD, MAiD requests and completions in patients with advanced or metastatic cancer and of the experience of both patients and caregivers in this circumstance. The findings from this study may also assist healthcare providers in their conversations about MAiD and the DD with patients and caregivers, inform healthcare providers to ensure appropriate access to MAiD, and guide modifications being considered to broaden MAiD legislation and policy.

[The wish to hasten death: Definition, determinants, issues and perspectives]

In palliative care, it is not uncommon for people with serious illnesses to wish to hasten their death. These wishes present considerable challenges for health care professionals. The purpose of this review is to support healthcare professionals in their understanding and apprehension of patients' wishes to hasten their death. In order to do so, we will present the definition of this wish, and then we will study it, based on three main components, which are intentions, motivations and interactions. The common thread of this review lies in the following question: how to best support the human who faces death?

What defines the comprehensive assessment of needs in palliative care? An integrative systematic review

BACKGROUND

The comprehensive assessment of needs in palliative care identifies where patients most want attention to guide clinical decisions that tailor care provision from their first encounters.

AIM

To define how and what needs are identified by the comprehensive assessment of needs in the original peer-reviewed articles in the field of palliative care.

DESIGN

An integrative systematic review as outlined by Whittemore and Knafl. Quality appraisal performed using the Mixed Methods Appraisal Tool.

DATA SOURCES

PubMed, CINAHL, PsycINFO, Web of Science databases searched through May 2019 and updated in July 2020.

RESULTS

Forty-nine articles met inclusion criteria for original articles in English or Spanish reporting comprehensive assessment of needs of adult patients receiving palliative care. The majority (41/49) of studies were moderate to high quality. Two themes were identified: (1) How a comprehensive assessment of needs should be carried out in palliative care, which reflected a preference to develop structured tools for assessment; (2) What needs of patients should be assessed in the comprehensive assessment of needs in palliative care, which conveyed a trend to assess beyond core domains - physical, psychological, social, spiritual - with information and practical most prevalent, but with substantial variation in specifying and classifying needs into domains.

CONCLUSIONS

The assessment of needs in palliative care is comprehensive but lacks consensus on the needs and domains that should be assessed by the palliative care team. Future studies should better define what needs can be standardized into the assessment to improve process of care and patient satisfaction.

[Practice of euthanasia among physicians and nurses in German hospitals]

Hintergrund  Aktive Sterbehilfe und ärztlich assistierter Suizid werden in Deutschland kontrovers diskutiert. Empirische Studien fehlen, um ihr jeweiliges Vorkommen, einschließlich dem von passiver und indirekter Sterbehilfe, in deutschen Krankenhäusern einschätzen zu können. Ärztinnen und Ärzte sowie Pflegerinnen und Pfleger in deutschen Krankhäusern wurden zu ihrer Anwendung von Sterbehilfe befragt und mögliche Einflussfaktoren erhoben.

Methode  Angaben zu Sterbehilfe wurden mit deskriptiven Begriffen und zugeordneten Definitionen in einer anonymen Online-Befragung erhoben. Die objektive und subjektive Arbeitssituation der Befragten und ihre Befürwortung von aktiver Sterbehilfe wurden erfasst. Die finale ärztliche Stichprobe umfasste n = 2507, die pflegerische Stichprobe umfasste n = 2683 Personen.

Ergebnis  Die Anwendung von passiver und indirekter Sterbehilfe innerhalb von 24 Monaten wurde von einem großen Anteil der ärztlichen und pflegerischen Befragten angegeben, aktive Sterbehilfe und assistierter Suizid von deutlich weniger Befragten. Die Varianz in der Anwendung von aktiver Sterbehilfe wurde u. a. durch mehrere arbeitsbezogene Faktoren und die jeweilige Befürwortung von aktiver Sterbehilfe beeinflusst, nicht aber durch subjektive Belastungsfaktoren.

Schlussfolgerung  Sterbehilfe wird durch ärztliche und pflegerische Mitarbeiterinnen und Mitarbeiter in deutschen Krankenhäusern praktiziert. Das Vorkommen unterschiedlicher Formen von Sterbehilfe und relevante Einflussfaktoren werden vor dem Hintergrund methodischer Limitationen diskutiert.

The desire for death in Portuguese home-care palliative patients: Retrospective analysis of the prevalence and associated factors

OBJECTIVE

Desire for death (DfD) is a complex and multifactorial dimension of end-of-life experience. We aimed to evaluate the prevalence of DfD and its associations, arising within the setting of a tertiary home-based palliative care (PC) unit.

METHOD

Retrospective analysis of all DfD entries registered in our anonymized database from October 2018 to April 2020.

RESULTS

Of the 163 patients anonymously registered in our database, 122 met entry criteria; 52% were male, the average age was 69 years old; 85% had malignancies, with a mean performance status (PPS) of 56%. The prevalence of DfD was 20%. No statistical differences were observed between patients with and without DfD regarding sex, age, marital status, religion, social support, prior PC or psychological follow-up, type of diagnosis, presence of advanced directives/living will, time since diagnosis and PC team's follow-up time. Statistically significant associations were found between higher PPS scores and DfD (OR = 0.96; 95% confidence interval (CI) [0.93-0.99]); Edmonton Symptom Assessment Scale scores for drowsiness (OR = 4.05; 95% CI [1.42-11.57]), shortness of breath (OR = 3.35; 95% CI [1.09-10.31]), well-being (OR = 7.64; 95% CI [1.63-35.81]). DfD was associated with being depressed (OR = 19.24; 95% CI [3.09-+inf]); feeling anxious (OR = 11.11; 95% CI [2.51-49.29]); HADS anxiety subscale ≥11 (OR = 25.0; 95% CI [2.10-298.29]); will-to-live (OR = 39.53; 95% CI [4.85-321.96]). Patients feeling a burden were more likely to desire death (OR = 14.67; 95% CI [1.85-116.17]), as well as those who were not adapted to the disease (OR = 4.08; 95% CI [1.30-12.84]). In multivariate regression analyses predicting DfD, three independent factors emerged: higher PPS scores were associated with no DfD (aOR = 0.95; 95% CI [0.91-0.99]), while the sense of being a burden (aOR = 12.82; 95% CI [1.31-125.16]) and worse well-being (aOR = 7.72; 95% CI [1.26-47.38]) predicted DfD.

SIGNIFICANCE OF RESULTS

Prevalence of DfD was 20% and consistent with previous Portuguese evidence on DfD in PC inpatients. Both physical and psychosocial factors contribute to a stronger DfD.

Screening for the Desire to Die in the First Palliative Care Encounter: A Proof-of-Concept Study

Context: There is a lack of consensus about the appropriate moment to assess a potential wish to hasten death (WTHD) in patients with life-threatening illness, despite evidence of its positive appraisal among patients. Objectives: To evaluate the practical potential and acceptability of questions about the WTHD in the first palliative care (PC) clinical encounter. Design: A proof-of-concept single-arm unmasked trial. Subjects: We enrolled 30 advanced cancer patients, 16 inpatients and 14 outpatients in their first PC clinical encounter. Measurements: We assessed the WTHD using a semistructured interview guide, the Assessment of the Frequency and Extent of the Desire to Die (AFEDD) embedded in a multidimensional needs assessment carried out during the first PC encounter. Information about practical potential [patients consider the assessment (a) important and (b) helpful] and acceptability [patients (a) understand and (b) are not bothered by the questions] was obtained. Results: Thirty-two patients were approached and 30 (94%) agreed to participate. The WTHD was present in two outpatients and eight inpatients. The question to assess WTHD were well understood by 94% of patients and was considered not bothersome by 87% and quite or very helpful by 80%, regardless of whether they had WTHD. Conclusions: The results support that clinicians can integrate screening for the WTHD in usual clinical practice within a multidimensional needs assessment. Patient acceptability suggests that this as a part of patient-centered care including in the first PC clinical encounter. Further studies are needed to confirm efficacy and safety in larger and different populations.

Life worth living: cross-sectional study on the prevalence and determinants of the wish to die in elderly patients hospitalized in an internal medicine ward

BACKGROUND

Elderly people frequently express the wish to die: this ranges from a simple wish for a natural death to a more explicit request for death. The frequency of the wish to die and its associated factors have not been assessed in acute hospitalization settings. This study aimed to investigate the prevalence and determinants of the wish to die in elderly (≥65 years) patients hospitalized in an internal medicine ward.

METHODS

This cross-sectional study was conducted between 1 May, 2018, and 30 April, 2019, in an acute care internal medicine ward in a Swiss university hospital. Participants were a consecutive sample of 232 patients (44.8% women, 79.3 ± 8.1 years) with no cognitive impairment. Wish to die was assessed using the Schedule of Attitudes toward Hastened Death-senior and the Categories of Attitudes toward Death Occurrence scales.

RESULTS

Prevalence of the wish to die was 8.6% (95% confidence interval [CI]: 5.3-13.0). Bivariate analysis showed that patients expressing the wish to die were older (P = .014), had a lower quality of life (P < .001), and showed more depressive symptoms (P = .044). Multivariable analysis showed that increased age was positively (odds ratio [OR] for a 5-year increase: 1.43, 95% CI 0.99-2.04, P = .048) and quality of life negatively (OR: 0.54, 95% CI 0.39-0.75, P < 0.001) associated with the likelihood of wishing to die. Participants did not experience stress during the interview.

CONCLUSIONS

Prevalence of the wish to die among elderly patients admitted to an acute hospital setting is low, but highly relevant for clinical practice. Older age increases and better quality of life decreases the likelihood of wishing to die. Discussion of death appears to be well tolerated by patients.

Cross-sectional survey of the wish to die among palliative patients in Spain: one phenomenon, different experiences

Objective

Cultural backgrounds and values have a decisive impact on the phenomenon of the wish to die (WTD), and examination of this in Mediterranean countries is in its early stages. The objectives of this study were to establish the prevalence of WTD and to characterise this phenomenon in our cultural context.

Methods

A cross-sectional study with consecutive advanced inpatients was conducted. Data about WTD (Assessing Frequency & Extent of Desire to Die (AFFED) interview) and anxiety and depression (Edmonton Symptom Assessment System-revised (ESAS-r)) were collected through two face-to-face clinical encounters. Data were analysed with descriptive statistics, χ² and analysis of variance.

Results

201 patients participated and 165 (82%) completed both interviews. Prevalence of WTD was 18% (36/201) in the first interview and 16% (26/165) in the second interview (p=0.25). After the first interview, no changes in depression (p=0.60) or anxiety (p=0.90) were detected. The AFFED shows different experiences within WTD: 11% of patients reported a sporadic experience, while 7% described a persistent experience. Thinking about hastening death (HD) appeared in 8 (22%) out of 36 patients with WTD: 5 (14%) out of 36 patients considered this hypothetically but would never take action, while 3 (8%) out of 36 patients had a more structured idea about HD. In this study, no relation was detected between HD and frequency of the appearance of WTD (p=0.12).

Conclusions

One in five patients had WTD. Our findings suggest the existence of different experiences within the same phenomenon, defined according to frequency of appearance and intention to hasten death. A linguistically grounded model is proposed, differentiating the experiences of the ‘wish’ or ‘desire’ to die, with or without HD ideation.

Perceived Burdensomeness and the Wish for Hastened Death in Persons With Severe and Persistent Mental Illness

Background: In several European countries, medical assistance in dying (MAID) is no longer confined to persons with a terminal prognosis but is also available to those suffering from persistent and unbearable mental illness. To date, scholarly discourse on MAID in this population has been dominated by issues such as decision-making capacity, uncertainty as to when a disease is incurable, stigmatization, isolation, and loneliness. However, the issue of perceived burdensomeness has received little attention. Objective: The study explores the possible impact of perceived burdensomeness on requests for MAID among persons with severe and persistent mental illness (SPMI). Method: Using the method of ethical argumentation, we discuss the issue of access to MAID for persons with SPMI and perceived burdensomeness. Conclusion: Perceived burdensomeness may be a contributing factor in the wish for hastened death among persons with SPMI. MAID is ethically unsupportable if SPMI causes the individual to make an unrealistic assessment of burdensomeness, indicating a lack of decision-making capacity in the context of that request. However, the possibility that some individuals with SPMI may perceive burdensomeness does not mean that they should be routinely excluded from MAID. For SPMI patients with intact decision-making capacity who feel their life is not worth living, perceived burdensomeness as a component of this intolerable suffering is not a sufficient reason to deny access to MAID.

When is hastened death considered suicide? A systematically conducted literature review about palliative care professionals' experiences where assisted dying is legal

Background

Laws allowing assisted suicide and euthanasia have been implemented in many locations around the world but some individuals suffering with terminal illness receiving palliative care services are hastening death or die by suicide without assistance. This systematic review aims to summarise evidence of palliative care professionals’ experiences of patients who died by suicide or hastened death in areas where assisted dying is legal and to understand when hastened death is considered to be a suicide.

Methods

AMED, CINAHL Complete, PsycINFO, PubMED, and Academic Search Ultimate were searched for articles from inception through June 2018. Quality assessment used the Hawker framework.

Results

A total of 1518 titles were screened resulting in thirty studies meeting eligibility criteria for this review. Published studies about professionals’ experiences from areas with legalised assisted dying includes limited information about patients who hasten death outside legal guidelines, die by suicide without assistance, or if the law impacts suicide among palliative care patients.

Conclusion

There are a range of experiences and emotions professionals’ experience with patients who die by euthanasia, assisted suicide, or hasten death without assistance. The included literature suggests improved communication among professionals is needed but does not explicitly identify when a hastened death is deemed a suicide in areas where assisted dying is practiced. More research is needed to help clarify what hastened death means in a palliative care context and identify how and if assisted dying impacts issues of suicide in palliative care settings.

Electronic supplementary material

The online version of this article (10.1186/s12904-019-0451-4) contains supplementary material, which is available to authorized users.

The clinical evaluation of the wish to hasten death is not upsetting for advanced cancer patients: A cross-sectional study

BACKGROUND

An important concern of healthcare professionals when exploring the wish to hasten death with patients is the risk of causing them some type of distress.

AIM

To assess the opinion of hospitalized patients with advanced cancer about the proactive assessment of the wish to hasten death.

DESIGN

Descriptive, cross-sectional study.

SETTING/PARTICIPANTS

We assessed 193 advanced cancer patients admitted to an oncology ward for the wish to hasten death using a semi-structured clinical interview. After the assessment the participants were surveyed to determine whether they found the interview upsetting and, if so to what extent, and also their opinion regarding the assessment's importance.

RESULTS

The wish to hasten death was reported by 46 (23.8%) patients. The majority of patients (94.8%) did not find talking about the wish to hasten death to be upsetting, regardless of whether they presented it or not. The majority of patients (79.3%) considered that it was either quite or extremely important for the clinician to proactively assess the wish to hasten death and discuss this topic, regardless of whether they experienced it.

CONCLUSIONS

In this study, most of the advanced cancer patients did not find the assessment of wish to hasten death to be upsetting, and a substantial proportion of patients in this study believe that it is important to routinely evaluate it in this setting. These findings suggest that healthcare professionals can explore the wish to hasten death proactively in routine clinical practice without fear of upsetting patients.

Wishes to die at the end of life and subjective experience of four different typical dying trajectories. A qualitative interview study

RESEARCH AIMS

The motivations that lead to wishes to die (WTD) in palliative care patients with cancer are relatively well studied. But little is known about WTD in other pathologies and the relation between subjective understandings of dying trajectories and a WTD. We investigated the WTD of palliative patients in four different dying trajectories: neurological diseases, organ failure, frailty due to age, and cancer.

STUDY POPULATION

62 palliative cancer (n = 30) and non-cancer (n = 32) patients (10 neurological disease; 11 organ failure; 11 frailty), their families and health professionals in different palliative care settings (248 interviews).

STUDY DESIGN AND METHODS

Qualitative semi-structured interviews. Data analysis through Interpretive Phenomenological Analysis and Grounded Theory.

RESULTS

In addition to personal motivations, we found that people dealing with similar trajectories were often confronted with similar questions and concerns due to similar challenges. For four trajectories we show typical patterns, similarities and differences that should be considered when talking with patients about their WTD. These illness-related considerations do not explain the WTD completely, but give important information on the challenges for particular patient groups that might experience a WTD. In all patient groups, there were clear moments that triggered a WTD: for neurological patients it was experiencing breathlessness, high-dependency care, or when considering tube feeding or respiratory support; for persons with organ failure it was an acute burdensome crisis; for patients with cancer after the initial diagnosis, it was the first relapse or the move into advanced palliative care; for elderly frail persons it was the move into care facilities, or the loss of important relationships or capabilities. The feeling of being a burden to others was reported in all patient groups.

INTERPRETATION

WTD can be triggered within disease trajectories by specific conditions and transitional points that affect agency and self-understanding. A better understanding of the concerns and challenges of a particular dying trajectory as well as its characteristic trigger points can facilitate early and comprehensive communication about patients' WTD, and the underlying motivations and protective factors.

Voluntary stopping of eating and drinking (VSED) as an unknown challenge in a long-term care institution: an embedded single case study

Background

Chronically ill persons experience conditions of life that can become unbearable, resulting in the wish to end their life prematurely. Relatives confronted with this wish experience ambivalence between loyalty to the person's desire to die and the fear of losing this person. Caring for a person during the premature dying process can be morally challenging for nurses. One way to end one's life prematurely is Voluntary Stopping of Eating and Drinking (VSED).

Methods

This embedded single case study explored the experiences of registered nurses (embedded units of analysis: ward manager, nursing manager, nursing expert) and relatives who accompanied a 49-year-old woman suffering from multiple sclerosis during VSED in a Swiss long-term care institution (main unit of analysis). By means of a within-analysis, we performed an in-depth analysis of every embedded unit of analysis and elaborated a central phenomenon for each unit. Afterwards, we searched for common patterns in a cross-analysis of the embedded units of analysis in order to develop a central model.

Results

The following central concept emerged from cross-analysis of the embedded units of analysis: As a way of ending one's life prematurely, VSED represents an unfamiliar challenge to nurses and relatives in the field of tension between one's personal attitude and the agents' concerns, fears and uncertainties. Particularly significant is the personal attitude, influenced on the one hand by one's own experiences, prior knowledge, role and faith, on the other hand by the VSED-performing person's age, disease and deliberate communication of the decision. Depending on the intention of VSED as either suicide or natural dying, an accepting or dismissing attitude evolves on an institutional and personal level.

Conclusions

To deal professionally with VSED in an institution, it is necessary to develop an attitude on the institutional and personal level. Educational measures and quality controls are required to ensure that VSED systematically becomes an option to hasten death. As VSED is a complex phenomenon, it is necessary to include palliative care in practice development early on and comprehensively. There is a high need of further research on this topic. Particularly, qualitative studies and hypothesis-testing approaches are required.

Determinants of favorable or unfavorable opinion about euthanasia in a sample of French cancer patients receiving palliative care

BACKGROUND

Opinion about euthanasia has been explored among the general population and recently in patients receiving palliative care. 96% of the French population declared themselves in favor of euthanasia while less of 50% of palliative care patients are. The aim of the present study was to explore and identify potential determinant factors associated with favorable or unfavorable opinion about euthanasia in a French population of cancer patients receiving palliative care.

METHODS

We performed a cross-sectional study among patients in two palliative care units. Eligible patients were identified by the medical staff. Face-to-face interviews were performed by two investigators. Two groups were defined as favorable or unfavorable about euthanasia according to the answer on the specific question about patient opinion on euthanasia. A multivariate analysis including age, belief in God, chemotherapy and gender was built.

RESULTS

Seventy-eight patients were interviewed. Median age was 60.5 years (range: 31-87.2). In univariate analysis, patients with a favorable opinion were most often under 60 years old (62 versus 38% unfavorable; p = 0.035), in couple (64 versus 35%; p = 0.032), didn't believe in God (72 versus 28% were non-believers; p < 0.001) and had more frequently an history of chemotherapy treatment (58 versus 42% received at least one cycle of chemotherapy; p = 0.005). In a multivariate analysis, age <  60 years, absence of belief in God and an antecedent of chemotherapy were independently associated with a favorable opinion about euthanasia (OR = 0.237 [0.076-0.746]; p = 0.014, OR = 0.143 [0.044-0.469]; p = 0.001, and OR = 10.418 [2.093-51.853]; p = 0.004, respectively).

CONCLUSION

We report here determinants of opinion about euthanasia in palliative care cancer patients. Thus, young patients who do not believe in God and have a history of chemotherapy treatment are more likely to request the discontinuation or restriction of their treatment. A better understanding of these determinants is essential for the development of information and/or interventions tailored to the palliative context.

[Voluntary stopping eating and drinking (VSED) : A position paper of the Austrian Palliative Society]

In some cases terminally ill patients fear of prolonged dying and suffering can manifest itself in the voluntary refusal of food and fluids, aiming to accelerate the dying process. This represents a considerable area of conflict, because of the ethical responsibility to not aid a person's death but also to respect a patients autonomy.There is a clear separation between an assisted suicide and following a patient's wishes. Not to accept the voluntary refusal of FVNF would have to be considered as forced treatment of patients while they are capable of self-determination.Several symptoms associated with or caused by voluntary refusal of food and fluids do require palliative care. It is important to be aware, that caring for dying patients refusing food and fluids and accepting their choice is not synonymous with assisted suicide. Rather is it part of medical and nursing care for patients during their dying-process.An interprofessional working group of the Austrian Palliative Society (OPG) intends to shed light on the legal, ethical, medical and nursing related aspects concerning this subject of growing public and professional interest.

Assumptions and moral understanding of the wish to hasten death: a philosophical review of qualitative studies

It is not uncommon for patients with advanced disease to express a wish to hasten death (WTHD). Qualitative studies of the WTHD have found that such a wish may have different meanings, none of which can be understood outside of the patient's personal and sociocultural background, or which necessarily imply taking concrete steps to ending one's life. The starting point for the present study was a previous systematic review of qualitative studies of the WTHD in advanced patients. Here we analyse in greater detail the statements made by patients included in that review in order to examine their moral understandings and representations of illness, the dying process and death. We identify and discuss four classes of assumptions: (1) assumptions related to patients' moral understandings in terms of dignity, autonomy and authenticity; (2) assumptions related to social interactions; (3) assumptions related to the value of life; and (4) assumptions related to medicalisation as an overarching context within which the WTHD is expressed. Our analysis shows how a philosophical perspective can add to an understanding of the WTHD by taking into account cultural and anthropological aspects of the phenomenon. We conclude that the knowledge gained through exploring patients' experience and moral understandings in the end-of-life context may serve as the basis for care plans and interventions that can help them experience their final days as a meaningful period of life, restoring some sense of personal dignity in those patients who feel this has been lost.

Relationship Between Spirituality, Meaning in Life, Psychological Distress, Wish for Hastened Death, and Their Influence on Quality of Life in Palliative Care Patients

CONTEXT

Spiritual, existential, and psychological issues represent central components of quality of life (QOL) in palliative care. A better understanding of the dynamic nature underlying these components is essential for the development of interventions tailored to the palliative context.

OBJECTIVES

The aims were to explore 1) the relationship between spirituality, meaning in life, wishes for hastened death and psychological distress in palliative patients and 2) the extent to which these nonphysical determinants influence QOL.

METHODS

A cross-sectional study involving face-to-face interviews with Swiss palliative patients was performed, including the Schedule for Meaning in Life Evaluation (SMILE), the Functional Assessment of Chronic Illness Therapy-Spiritual Well-Being Scale (FACIT-Sp), the Idler Index of Religiosity (IIR), the Hospital Anxiety and Depression Scale (HADS), and the Schedule of Attitudes toward Hastened Death (SAHD). QOL was measured with a single-item visual analogue scale (0-10).

RESULTS

Two hundred and six patients completed the protocol (51.5% female; mean age = 67.5 years). The results indicated a significant negative relationship between FACIT-Sp/SMILE and HADS total scores (P = 0.000). The best model for QOL explained 32.8% of the variance (P = 0.000) and included the FACIT-Sp, SMILE, and SAHD total scores, the IIR "private religiosity" score, as well as the HADS "depression" score.

CONCLUSION

Both spiritual well-being and meaning in life appear to be potential protective factors against psychological distress at the end of life. Since nonphysical determinants play a major role in shaping QOL at the end of life, there is a need for the development of meaning-oriented and spiritual care interventions tailored to the fragility of palliative patients.

Understanding patients' experiences of the wish to hasten death: an updated and expanded systematic review and meta-ethnography

OBJECTIVES

Patients with advanced disease sometimes express a wish to hasten death (WTHD). In 2012, we published a systematic review and meta-ethnography of qualitative studies examining the experience and meaning of this phenomenon. Since then, new studies eligible for inclusion have been reported, including in Europe, a region not previously featured, and specifically in countries with different legal frameworks for euthanasia and assisted suicide. The aim of the present study was to update our previous review by including new research and to conduct a new analysis of available data on this topic.

SETTING

Eligible studies originated from Australia, Canada, China, Germany, The Netherlands, Switzerland, Thailand and USA.

PARTICIPANTS

Studies of patients with life-threatening conditions that had expressed the WTHD.

DESIGN

The search strategy combined subject terms with free-text searching of PubMed MEDLINE, Web of Science, CINAHL and PsycInfo. The qualitative synthesis followed the methodology described by Noblit and Hare, using the 'adding to and revising the original' model for updating a meta-ethnography, proposed by France et al. Quality assessment was done using the Critical Appraisal Skills Programme checklist.

RESULTS

14 studies involving 255 participants with life-threatening illnesses were identified. Five themes emerged from the analysis: suffering (overarching theme), reasons for and meanings and functions of the WTHD and the experience of a timeline towards dying and death. In the context of advanced disease, the WTHD emerges as a reaction to physical, psychological, social and existential suffering, all of which impacts on the patient's sense of self, of dignity and meaning in life.

CONCLUSIONS

The WTHD can hold different meanings for each individual-serving functions other than to communicate a genuine wish to die. Understanding the reasons for, and meanings and functions of, the WTHD is crucial for drawing up and implementing care plans to meet the needs of individual patients.

The Patient Dignity Inventory: Just another evaluation tool? Experiences with advanced cancer patients

OBJECTIVE

The Patient Dignity Inventory (PDI) evaluates sources of distress related to the feeling of loss of dignity and was designed for patients at the end of life. The aim of the present work was to generate a better understanding of the experiences of healthcare staff when using the PDI.

METHOD

An exploratory qualitative study is presented about the experience of 4 professionals who applied the PDI to 124 advanced-cancer patients. Our study consisted of an analysis of their experiences, taken from information generated in a focus group. A thematic analysis was performed on the information generated at that meeting by two researchers working independently.

RESULTS

The initial experiences with the PDI on the part of the professionals led them to systematically administer the questionnaire as part of an interview instead of having patients fill it out themselves in written form. What started out as an evaluation very often led to a profound conversation on the meaning of life, dignity, and other sensitive, key issues related to the process of the illness.

SIGNIFICANCE OF RESULTS

The PDI has intrinsic therapeutic value and is useful in clinical practice, and it is also a way of examining issues related to dignity and the meaning of life within the context of advanced-stage illness. There is a need for studies that examine patient experiences through a PDI-based interview.

Assessment of the wish to hasten death in patients with advanced disease: A systematic review of measurement instruments

BACKGROUND

Patients with advanced conditions may present a wish to hasten death. Assessing this wish is complex due to the nature of the phenomenon and the difficulty of conceptualising it.

AIM

To identify and analyse existing instruments for assessing the wish to hasten death and to rate their reported psychometric properties.

DESIGN

Systematic review based on PRISMA guidelines. The COnsensus-based Standards for the selection of health Measurement INstruments checklist was used to evaluate the methodological quality of validation studies and the measurement properties of the instrument described.

DATA SOURCES

The CINAHL, PsycINFO, Pubmed and Web of Science databases were searched from inception to November 2015.

RESULTS

A total of 50 articles involving assessment of the wish to hasten death were included. Eight concerned instrument validation and were evaluated using COnsensus-based Standards for the selection of health Measurement INstruments criteria. They reported data for between two and seven measurement properties, with ratings between fair and excellent. Of the seven instruments identified, the Desire for Death Rating Scale or the Schedule of Attitudes toward Hastened Death feature in 48 of the 50 articles. The Schedule of Attitudes toward Hastened Death is the most widely used and is the instrument whose psychometric properties have been most often analysed. Versions of the Schedule of Attitudes toward Hastened Death are available in five languages other than the original English.

CONCLUSION

This systematic review has analysed existing instruments for assessing the wish to hasten death. It has also explored the methodological quality of studies that have examined the measurement properties of these instruments and offers ratings of the reported properties. These results will be useful to clinicians and researchers with an interest in a phenomenon of considerable relevance to advanced patients.

Risk Factors for Suicidal Ideation in Patients Feeling Severely Affected by Multiple Sclerosis

BACKGROUND

Being severely affected by multiple sclerosis (MS) brings substantial physical and psychological challenges. Contrary to common thinking that MS is not lethal, there is a higher mortality risk in patients also reflected in alarming rates of assisted suicide, and - where possible - euthanasia.

OBJECTIVE

Analyzing independent variables promoting suicidal ideation in severely affected MS patients.

DESIGN

A self-report questionnaire with 25 needs categories including one self-assessment item "prone to suicidal ideation" was applied.

SETTING/SUBJECTS

Included were patients reporting feeling subjectively severely affected by MS. Of 867 patients addressed, 573 (66.1%) completed the questionnaires.

MEASUREMENTS

32 items being potential risk factors for suicidal ideation were tested for statistical significance using a multivariate logistic regression model with stepwise, backward elimination procedure.

RESULTS

22.1% of 573 patients (median age 51, range 20-83) had suicidal ideation. 48.4% suffered from secondary progressive, 24.7% from relapsing-remitting and 21.9% from primary progressive MS. A set of six statistically significant criteria for suicidal ideation were found. Three items were risk factors for suicidal ideation: the extent to which MS affects leisure time (p < 0.001), depression (p < 0.000), and feeling socially excluded (p < 0.002). Three items reduced the odds of suicidal ideation: having a purpose in life (p < 0.000), being productive (p < 0.000), and having comfort in faith and spiritual beliefs (p < 0.024).

CONCLUSION

This study identified potentially modifiable factors that may help preventing suicide in people with MS. Integrating palliative care (PC) with its multidisciplinary approach could be beneficial to reduce patient's burden.

An International Consensus Definition of the Wish to Hasten Death and Its Related Factors

BACKGROUND

The desire for hastened death or wish to hasten death (WTHD) that is experienced by some patients with advanced illness is a complex phenomenon for which no widely accepted definition exists. This lack of a common conceptualization hinders understanding and cooperation between clinicians and researchers. The aim of this study was to develop an internationally agreed definition of the WTHD.

METHODS

Following an exhaustive literature review, a modified nominal group process and an international, modified Delphi process were carried out. The nominal group served to produce a preliminary definition that was then subjected to a Delphi process in which 24 experts from 19 institutions from Europe, Canada and the USA participated. Delphi responses and comments were analysed using a pre-established strategy.

FINDINGS

All 24 experts completed the three rounds of the Delphi process, and all the proposed statements achieved at least 79% agreement. Key concepts in the final definition include the WTHD as a reaction to suffering, the fact that such a wish is not always expressed spontaneously, and the need to distinguish the WTHD from the acceptance of impending death or from a wish to die naturally, although preferably soon. The proposed definition also makes reference to possible factors related to the WTHD.

CONCLUSIONS

This international consensus definition of the WTHD should make it easier for clinicians and researchers to share their knowledge. This would foster an improved understanding of the phenomenon and help in developing strategies for early therapeutic intervention.