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

Older adults' attitudes toward using Euthanasia at the end-of life: cancer vs. Parkinson's disease

Background

There is a paucity of studies that compare older adults' attitudes toward Euthanasia in two different terminal illnesses. Moreover, these studies did not relate to potentially influencing psycho-social factors. The current study aimed to examine the impact of a diverse range of variables on attitudes among older adults toward Euthanasia in two medical conditions: cancer and Parkinson's disease.

Methods

A total of 501 individuals aged 75 and above participated in the study. Attitudes toward Euthanasia were measured using vignettes which described two conditions: an 80-year-old man with metastatic cancer and another man in an advanced stage of Parkinson's disease. The questionnaire included measures of relevant experience (with a close family member or a friend dying from a terminal illness), self-efficacy, will to live, satisfaction with life, will to prolong life, fear of death and dying, social support, and psycho-social characteristics. The data were analyzed using hierarchical linear regression models.

Results

A more positive attitude toward Euthanasia was found in the case of cancer compared to Parkinson's disease. Being a woman, having more years of education, lower level of religiosity, greater fear of death and dying and higher self-efficacy contributes to more favorable attitudes toward Euthanasia in both end-of life conditions.

Conclusions

The finding that attitudes toward Euthanasia are statistically significantly more positive in the case of cancer compared to Parkinson's disease can be attributed to the greater prevalence of cancer in the population, and to the public's awareness of the suffering associated with each of these medical conditions. Beyond the important role of the socio-demographic characteristics of gender, education, and religiosity, it appears that fear of death and dying and self-efficacy are important psychological factors in explaining attitudes toward Euthanasia in both illnesses among older people. These findings shed light on older adults' attitudes toward Euthanasia in debilitating illnesses.

The association between social connectedness and euthanasia and assisted suicide and related constructs: systematic review

BACKGROUND

Euthanasia and assisted suicide (EAS) requests are common in countries where they are legal. Loneliness and social isolation are modifiable risk factors for mental illness and suicidal behaviour and are common in terminal illness. Our objective was to summarise available literature to clarify whether these and related measures of social connectedness might contribute to requests for EAS.

METHODS

We conducted a pre-registered (PROSPERO CRD42019160508) systematic review and narrative synthesis of quantitative literature investigating associations between social connectedness and a) requested/actual EAS, b) attitudes towards EAS, and c) a desire for hastened death (DHD) by searching six databases (PsycINFO, MEDLINE, EMBASE, Scopus, Web of Science, Google Scholar) from inception to November 2022, rating eligible peer-reviewed, empirical studies using the QATSO quality assessment tool.

RESULTS

We identified 37 eligible studies that investigated associations with a) requested/actual EAS (n = 9), b) attitudes to EAS (n = 16), and c) DHD (n = 14), with limited overlap, including 17,359 participants. The majority (62%) were rated at medium/high risk of bias. Focussing our narrative synthesis on the more methodologically sound studies, we found no evidence to support an association between different constructs of social connectedness and requested or actual EAS, and very little evidence to support an association with attitudes to EAS or an association with DHD.

CONCLUSIONS

Our findings for all age groups are consistent with a those of a previous systematic review focussed on older adults and suggest that poor social connectedness is not a clear risk factor for EAS or for measures more distally related to EAS. However, we acknowledge low study quality in some studies in relation to sampling, unvalidated exposure/outcome measures, cross-sectional design, unadjusted analyses, and multiple testing. Clinical assessment should focus on modifying established risk factors for suicide and EAS, such as hopelessness and depression, as well as improving any distressing aspects of social disconnectedness to improve quality of life.

FUNDING

UKRI, NIHR.

Exploring the occurrence and the risk factors of the desire for hastened death and depression in people with early-stage dementia in Greece

OBJECTIVES

To assess the factors associated with desire for hastened death and depression in early-stage dementia as well as the association between them. Also, to explore the mediator and moderator role of age in the relationship between depression and desire for hasten death.

METHODS

A prospective cross-sectional study including 100 patients diagnosed with early-stage dementia from a rehabilitation center between December 2018 and July 2019. Measurement tools used were the Mini-Mental State Examination, the Greek Montreal Cognitive Assessment, the Greek Schedule of Attitudes toward Hastened Death, and the Geriatric Depression Scale-15 item. Patients diagnosed with dementia as a result of Stroke history were excluded.

RESULTS

Factors of multifactorial analysis significantly associated with desire for hastened death were as follows: age (p = 0.009), marital status (p = 0.001), and depression (p < 0.001). The factor significantly associated with depression was age (p = 0.001). Also, a mediation/moderation analysis has shown that depression and age are significant predictors of desire for hasten death.

SIGNIFICANCE OF RESULTS

The desire for hastened death and depression in people diagnosed with early-stage dementia includes many components. Younger patients, men, higher educated patients, single, childless, and those with higher depression scores had higher desire for hastened death, while men and older patients had higher scores of desire for depression. Our study provides important information about the desire for hastened death and depression in early-stage dementia, their risk factors, and their association.

To what extent are psychological variables considered in the study of risk and protective factors for suicidal thoughts and behaviours in individuals with cancer? A systematic review of 70 years of research

Psychological variables substantially shape the risk of suicidal thoughts and behaviours (STBs). However, it is unclear to what extent they are considered in individuals with cancer. We synthesized the quantitative research landscape concerning psychological risk/protective factors of STBs in the (psycho-) oncological context. This pre-registered review (PROSPERO-ID CRD42022331484) systematically searched the databases PubMed/Medline, CINAHL, PsycInfo, Cochrane Library, and Web of Science (as well as the grey literature and preprints). Risk of bias (RoB) was estimated using the ROBINS-I tool. Of 11,159 retrieved records, 319 studies were eligible for inclusion. Of those, 163 (51.1%) had investigated psychological factors (affective: n = 155; social: n = 65; cognitive: n = 63; personality/individual differences: n = 37; life events: n = 6), in a combined 3,561,741 participants. The most common STBs were suicidal ideation (n = 107) or death wishes (n = 20) rather than behaviour (suicide deaths: n = 26; attempts: n = 14). Most studies had a serious RoB. Thus, a large body of research investigated STBs in cancer patients/survivors, but it rarely aligned with the theoretical or clinical developments in suicide research. We propose a conceptual model of STBs in cancer delineating moderation and mediation effects to advance the integration of the fields, and to inform future research and practice.

Handling the desire to die- evaluation of an elective course for medical students

BACKGROUND

The desire to die can occur in palliative care patients with a prevalence of up to 22%. Not every desire to die is accompanied by a pressure to act, but usually by a burden that can arise from various factors. To address this burden appropriately, health care workers should be trained. Based on an evaluated course on handling the desire to die, an elective course for medical students was developed and evaluated. In order to identify the impact of the elective course's content, a comparison of attitudes towards assisted dying with two other participant groups was conducted. Therefore, three questions from the evaluation of the elective course were used.

METHOD

Online evaluation of the elective and questions addressing attitude were assessed using a five-point Likert scale. The specific outcome-based assessment was determined using the Comparative Self-Assessment Gain. The main participant group (group 1) were students who took the elective. The additional survey on attitudes towards assisted dying included undergraduate medical students who had taken compulsory palliative care courses (group 2) and physicians who had taken an introductory course in intensive care or emergency medicine (group 3).

RESULTS

Group 1 (n = 13, response rate rr = 86.7%) was very satisfied with the blended learning format (100%) and the course itself (100%). They were able to deepen their knowledge (81.0%) and train skills (71.2%) through the course. In the additional surveys, there were 37 students in group 2 (rr = 66.1%) and 258 physicians in group 3 (rr = 73.6%). Willingness to assist with or accompany the various options for assisted dying varied according to the type of assistance. Among the participants, it can be summarised that the highest willingness was shown by the students of group 2 followed by the physicians of group 3 and the students of group 1.

CONCLUSIONS

A course on handling the desire to die of palliative patients can deepen knowledge and train communication skills and thus support self-confidence. Dealing with the background of the desire to die, knowledge about assisted dying, but also one's own attitudes and responsibilities can influence the attitude towards assisted dying.

Development and pre-pilot testing of STAMP + CBT: an mHealth app combining pain cognitive behavioral therapy and opioid support for patients with advanced cancer and pain

PURPOSE

We developed and piloted a mobile health app to deliver cognitive behavioral therapy for pain (pain-CBT), remote symptom monitoring, and pharmacologic support for patients with pain from advanced cancer.

METHODS

Using an iterative process of patient review and feedback, we developed the STAMP + CBT app. The app delivers brief daily lessons from pain-CBT and pain psychoeducation, adapted for advanced cancer. Daily surveys assess physical symptoms, psychological symptoms, opioid utilization and relief. Just-in-time adaptive interventions generate tailored psychoeducation in response. We then conducted a single-arm pilot feasibility study at two cancer centers. Patients with advanced cancer and chronic pain used the app for 2 or 4 weeks, rated its acceptability and provided feedback in semi-structured interviews. Feasibility and acceptability were defined as ≥ 70% of participants completing ≥ 50% of daily surveys, and ≥ 80% of acceptability items rated ≥ 4/5.

RESULTS

Fifteen participants (female = 9; mean age = 50.3) tested the app. We exceeded our feasibility and accessibility benchmarks: 73% of patients completed ≥ 50% of daily surveys; 87% of acceptability items were rated ≥ 4/5. Participants valued the app's brevity, clarity, and salience, and found education on stress and pain to be most helpful. The app helped participants learn pain management strategies and decrease maladaptive thoughts. However, participants disliked the notification structure (single prompt with one snooze), which led to missed content.

CONCLUSION

The STAMP + CBT app was an acceptable and feasible method to deliver psychological/behavioral treatment with pharmacologic support for cancer pain. The app is being refined and will be tested in a larger randomized pilot study. TRN: NCT05403801 (05/06/2022).

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.

"I'm Done": A patient's wish and will to die

BACKGROUND

A desire for hastened death is commonly expressed by cancer patients. Although efforts to define and explore this issue have been undertaken, no standardized approach exists to address these desires.

CASE DESCRIPTION

Ms. J expressed a wish for accelerated death and subsequently experienced unexpected clinical decline resulting in a quick, natural death. Our team experienced a mixture of both emotional distress and awe after witnessing the pragmatic approach our patient had to her impending decline, that we felt was worthy of further exploration.

CONCLUSION

Most clinicians lack formal training in communication, potentially making cases like Ms. J's highly distressing. Clinicians should feel comfortable addressing and potentially inquiring about patients' desire to hasten death. While our initial reaction might be to correct this desire, we propose reframing this expression as an opportunity to explore more about our patients.

Meaning-centered pain coping skills training for patients with metastatic cancer: Protocol for a randomized controlled efficacy trial

BACKGROUND

Many patients with advanced cancer describe pain as a debilitating symptom that greatly interferes with daily activities and enjoyment of life. Psychosocial interventions can improve cancer-related pain but rarely address spiritual concerns (e.g., loss of meaning, peace), which can influence the pain experience for those facing life-threatening illness. To address these needs, we systematically developed and pilot tested a novel psychosocial intervention called Meaning-Centered Pain Coping Skills Training (MCPC). In this randomized controlled trial, we aim to determine MCPC's efficacy for reducing pain interference (primary outcome) and improving secondary outcomes. We will also estimate MCPC's cost-effectiveness.

METHOD/DESIGN

Patients (target N = 210) with advanced solid tumor malignancies (Stage IV) and clinically-elevated pain interference will be enrolled and block randomized with equal allocation to MCPC + enhanced usual care or enhanced usual care alone. MCPC's four, videoconferenced, 45-60 min weekly sessions will be individually delivered by trained study therapists. Primary (pain interference) and secondary (pain severity, anxiety and depressive symptoms, pain self-efficacy, social support, spiritual well-being) patient-reported outcomes will be assessed at baseline, and 8-weeks (primary endpoint) and 12-weeks after baseline.

CONCLUSION

Our MCPC intervention is the first to systematically address the biopsychosocial-spiritual aspects of pain in patients with advanced cancer. If MCPC demonstrates efficacy, next steps will involve hybrid efficacy-effectiveness and implementation work to broaden access to this brief, manualized, remotely-delivered intervention, with the goal of reducing suffering in patients with life-threatening illness.

Effects of self-management interventions for cancer patients with pain: A systematic review of randomised controlled trials

AIMS

To evaluate the effects of self-management interventions targeting individuals with cancer-related pain on pain intensity, self-efficacy, quality of life (QoL), pain medication adherence, and pain-related knowledge and provide recommendations for the content and format of self-management interventions based on the existing evidence.

DESIGN

A systematic review of randomised controlled trials (RCTs) and narrative synthesis.

DATA SOURCES

A search of six electronic databases, including Medline, PsycINFO, EMBASE, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Web of Science and Scopus.

REVIEW METHODS

This systematic review followed the Preferred Reporting for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Studies published from January 2011 to March 2022 in English were retrieved. The Cochrane Risk of Bias Tool was used to assess quality. Data were summarised using narrative synthesis.

RESULTS

This systematic review included six RCTs involving 748 patients with cancer-related pain. The results support the effectiveness of the intervention on QoL and pain-related knowledge. Mixed results were observed in the effectiveness on pain intensity, self-efficacy and medication adherence. Overall, the quality of the evidence was low. The content of self-management interventions varied across studies but with similar formats (face-to-face coaching and telephone follow-up).

CONCLUSION

The existing evidence supports the effectiveness of self-management interventions on pain-related knowledge and QoL. Further high-quality RCTs are needed to determine the most effective interventions.

RELEVANCE TO CLINICAL PRACTICE

Self-management is recommended to improve cancer patients' pain awareness, self-management behaviour and adaptability. Components for self-management of cancer pain, including patient attitude and knowledge assessment, nurse coaching and counselling, reinforcement during follow-up period, and provision of supplementary materials on pain management and medication adherence, could be covered in the intervention. In the future, it is worthwhile exploring an effective intervention using Internet-based information technology, for example WeChat, to aid the delivery of self-management intervention.

NO PATIENT OR PUBLIC CONTRIBUTION

This systematic review does not necessarily involve patients or public members in this work.

Death Anxiety in Huntington Disease: Longitudinal Heath-Related Quality-of-Life Outcomes

Objective: Death anxiety, represented by the HDQLIFE™ Concern with Death and Dying (CwDD) patient-reported outcome (PRO) questionnaire, captures a person's worry about the death and dying process. Previous work suggests that death anxiety remains an unremitting burden throughout all stages of Huntington disease (HD). Although palliative interventions have lessened death anxiety among people with advanced cancer, none has yet to undergo testing in the HD population. An account of how death anxiety is associated with longitudinal changes to aspects of health-related quality of life (HRQoL) would help optimize neuropalliative interventions for people with HD. Methods: HDQLIFE collected PROs concerning physical, mental, social, and cognitive HRQoL domains and clinician-rated assessments from people with HD at baseline and 12 and 24 months. Linear mixed-effects models were created to determine how baseline death anxiety was associated with follow-up changes in HRQoL PROs after controlling for baseline death anxiety and other disease and sociodemographic covariates. Results: Higher baseline HDQLIFE CwDD is associated with 12- and 24-month declines in HDQLIFE Speech Difficulties, neurology quality of life (NeuroQoL) Depression, Suicidality, HDQLIFE Meaning and Purpose, and NeuroQoL Positive Affect and Well-being. Interpretation: Death anxiety may be a risk factor for worsening mental health and speech difficulty. A further prospective study is required to evaluate whether interventions on death anxiety or mental health generally can reduce declines in HRQoL for people with HD over time.

Meaning-centered pain coping skills training for patients with metastatic cancer: Results of a randomized controlled pilot trial

OBJECTIVE

For patients with advanced cancer, pain is a common and debilitating symptom that can negatively impact physical, emotional, and spiritual well-being. This trial examined the feasibility and initial effects of Meaning-Centered Pain Coping Skills Training (MCPC), a cognitive-behavioral pain management intervention with an emphasis on enhancing meaning (i.e., a personal sense of purpose, worth, and significance) and peace.

METHODS

We enrolled 60 adults with stage IV solid tumor cancers and moderate-severe pain between February 2021 and February 2022. Participants were randomized 1:1 to MCPC + usual care or usual care alone. Meaning-Centered Pain Coping Skills Training consisted of four weekly 60-min individual sessions via videoconference or telephone, delivered by a trained therapist using a manualized protocol. Participants completed validated measures of pain severity, pain interference, pain self-efficacy, spiritual well-being (i.e., meaning, peace, and faith), and psychological distress at baseline and 5-week and 10-week follow-ups.

RESULTS

All feasibility metrics exceeded prespecified benchmarks. Fifty-eight percent of screened patients were eligible, and 69% of eligible patients consented. Of those assigned to MCPC, 93% completed all sessions and 100% of those who completed follow-ups reported using coping skills weekly. Retention was strong at 5-week (85%) and 10-week (78%) follow-ups. Meaning-Centered Pain Coping Skills Training participants reported better scores than control participants across outcome measures, including moderate-to-large sized differences at 10-week follow-up in pain severity (Cohen's d = -0.75 [95% confidence interval: -1.36, -0.14]), pain interference (d = -0.82 [-1.45, -0.20]), and pain self-efficacy (d = 0.74 [0.13, 1.35]).

CONCLUSIONS

MCPC is a highly feasible, engaging, and promising approach for improving pain management in advanced cancer. Future efficacy testing is warranted.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT04431830, registered 16 June 2020.

“I want to live, but …” the desire to live and its physical, psychological, spiritual, and social factors among advanced cancer patients: evidence from the APPROACH study in India

Background

The limited access to palliative care resources along with the social stigma around cancer largely explains the poor quality of life (QoL) of Indian advanced cancer patients. As advanced cancer patients with poor QoL often harbour a desire for hastened death (DHD), it is imperative to understand factors affecting DHD, or the desire to live (DTL) among advanced cancer patients in India. We aim to examine the relationship between DTL and physical, psychological, spiritual, and social factors measuring patients’ QoL alongside their awareness of their late cancer stage.

Methods

We surveyed 200 patients from a tertiary cancer hospital in India to collect their DTL, awareness of cancer stage, demographic characteristics, and standardized measures for patients’ QoL. We used a linear probability regression model to quantify the association between these factors and patients’ DTL among the final sample of 192 patients with no missing information for the variables of interest.

Results

Among the various domains affecting cancer patients’ QoL, we found that the pain severity score (ranging from 0 to 10) and psychological distress score (ranging from 0 to 42) are negatively associated with the DTL. One point increase in each score reduced the DTL by 2.2% (p < 0.05) and 0.7% (p < 0.05), respectively. Our results also showed that patients whose perceived socio-economic status (SES) is poor have a 16% (p < 0.05) lower probability of DTL, compared to those with higher SES (lower middle class, upper middle class, and wealthy). Controlling for caste, religion, gender, age, marital status and years of education, we found psychological distress is statistically higher among patients belonging to this bottom SES.

Conclusions

We found that pain severity, psychological distress and perceived low SES are negatively associated with the desire to live in advanced cancer patients. Future research should focus on developing interventions to improve physical pain and psychological distress, particularly for patients who are socially and economically disadvantaged.

Impact of NCCN Guideline Adherence in Adult Cancer Pain on Length of Stay

To improve the management of cancer related pain, the National Comprehensive Cancer Network (NCCN) publishes the Adult Cancer Pain guideline on an annual basis. However, a large majority of oncology patients still report inadequate pain control. Single-center, retrospective cohort study of adult patients admitted for uncontrolled pain or pain crisis between 3/1/19 and 06/30/20 were assigned to cohorts of either adherent or non-adherent to NCCN guideline recommendations for management of pain crises based on their initial opioid orders. Patients must have reported a pain score >/= 4 and received at least one dose of opioids within 24 hours upon admission. The length of stay (LOS), pain scores, and naloxone administration were compared between both groups. Patients in the adherent group had a shorter median LOS (3.7 days [range: 1 to 18.93] vs 5.4 days [range: 1.45 to 19.64 days], p = 0.04). Patients that received lower doses than recommended had longer LOS compared to adherent group (6.1 vs. 3.7 days; p = 0.009). When adjusted for confounders, this significance did not remain. The lowest reported pain score within 24 hours of admission was lower in the adherent group (median 3 vs 4, p = 0.04). Predictors of LOS included opioid tolerance and a pain or palliative care consult. Adherence to NCCN guidelines for acute pain crisis management in adult patients with cancer remains poor. Patients who received guideline adherent initial opioid regimens demonstrated a trend toward a shorter LOS. Opioid-tolerant patient outcomes remain inadequate; appropriate pain management for these patients need to improve.

Psychological and Non-Pharmacologic Treatments for Pain in Cancer Patients: A Systematic Review and Meta-Analysis

CONTEXT

Pain is the most fearful symptom in cancer. Although there is a relationship between psychosocial variables and oncologic pain, psychological and non-pharmacological treatments for pain management in cancer patients are not very widespread.

OBJECTIVES

To analyze the efficacy of psychological and non-pharmacological treatments for reducing pain in cancer patients.

METHODS

We performed a systematic review following the PRISMA protocol. In January 2021, data were extracted from PubMed, Web of Science and Scopus, including randomised controlled trials (RCT) published in the last five years (from 28 January, 2015 to December 15, 2020), in the English language and whose sample was patients with cancer pain. The database search used the following keywords: cancer, cancer-related pain, psychological intervention, non-pharmacologic intervention. The Cochrane risk of bias assess ment for randomised trials (RoB 2) was used for quality appraisal.

RESULTS

After the inclusion and exclusion criteria were applied, ten papers were fully screened. The evidence suggested that the most effective interventions to reduce cancer pain were mindfulness-based cognitive therapy, guided imagery and progressive muscle relaxation and emotional and symptom focused engagement (EASE). Music therapy and brief cognitive behavioral strategies (CBS) require more research, while coping skills training and yoga did not show positive effects. Overall, we obtained a moderate size effect (d = 0.642, 95% CI: 0.125-1.158) favourable to psychological and non-pharmacologic treatments at post-treatment, which increased at follow-up (k = 5, d = 0.826, 95% CI: 0.141-1.511).

CONCLUSION

This study provides insight into psychological interventions which might be applied and contribute to cancer-related pain reduction in adults. Although the results are not completely consistent, they may shed light on psychology applications in the oncology environment.

[The right to die and assisted suicide: Review and critical analysis]

OBJECTIVES

In the context of the present re-examination of the French bioethical laws by the National Advisory Ethics Committee ("Comité consultatif national d'éthique": CCNE), a recent survey indicated a request of the public opinion to obtain a medical aid in end of life and a so-called "assisted suicide". This led psychiatrists to re-consider their role and deontological position which usually led them to consider a request for an assistance in suicide as - a priori - a pathological demand, occurring within a suicidal crisis. The present article intends to: 1) describe the laws and practices of countries which allow medically assisted end of life help procedures; 2) clarify the definitions of "assisted suicide", "assistance to suicide" and "euthanasia"; 3) consider available epidemiological data and the roles given to doctors and, more specifically psychiatrists, in these procedures; 4) analyse the rationale behind these demands. These considerations should enable French psychiatrists to clarify their position when facing requests for a medical aid in dying.

METHODS

Four European countries (Switzerland, the Netherlands, Belgium, Luxemburg) and Oregon (the first US state to introduce legislation) were considered, since they accumulated and published a large amount of experiences and data about "assisted suicide" and medical help in dying. In total, 127 articles were selected, mainly from PubMed and Cairn databases, published between 1997 and 2020. These articles deal with legal considerations, epidemiological data, ethical and sociological considerations.

RESULTS

Laws and practices differ notably according to the state/country. In Belgium, the Netherlands and Luxemburg, as in Oregon, the medical help in dying has been de-criminalized, as long as certain legal criteria are met. In Switzerland, where no specific law exists in the penal code, non-governmental associations have benefited from the legal vacuum and organized the practice of "assisted suicide" for "altruistic motives". In the scientific and legal literature, the terms used to describe and define the medical help in dying upon request differ greatly. In France, the National Advisory Ethics Committee defines euthanasia ("euthanasie"), assisted suicide ("suicide assisté") and suicide assistance ("assistance au suicide"). Available epidemiological data, whatever the country considered, indicate that requests for a medical aid in dying are expressed mainly by patients aged over 60 years and suffering from cancer. Psychiatric diseases account for only 1% to 3%. Most often, systematic assessment by a psychiatrist is neither requested nor made, when the demand does not occur during a primary psychiatric illness. In the case of an existing primary psychiatric pathology, a psychiatrist assesses the case against formal legal predefined criteria. This latter practice was only recently introduced, after some feedback and after legal actions had been brought to Court. When the underlying motivations of the request are considered, it appears that, even in the absence of an evolving psychiatric condition, several psychological or psychopathological reasons prevail such as spirituality, attachment style, social isolation, despair, depression… which should greatly benefit psychiatric exploration, investigation and expertise.

CONCLUSION

In some countries, the request for medically assisted help in dying has become a legal and social reality. In France, where the public debate is still open, it should be emphasized that a psychiatric assessment and interview should be systematically provided to any person requesting medical assistance to die or commit suicide. It is the commitment of psychiatrists to understand the implicit demands and unexpressed motives underlying this request which have strong links with the unique life-events and emotional experiences of the person. The psychiatrist has a unique role in the contextualization of such a request.

Complexity of desire for hastened death in terminally ill cancer patients: A cluster analysis

OBJECTIVES

The present study aims were (1) to identify the proportion of terminally ill cancer patients with desire for hastened death (DHD) receiving specialized palliative care, (2) to identify the reasons for DHD, and (3) to classify patients with DHD into some interpretable subgroups.

METHODS

Advanced cancer patients admitted to 23 inpatients hospices/palliative care units in 2017 were enrolled. Data were prospectively obtained by the primarily responsible physicians. The presence/absence of DHD and reasons for DHD were recorded. A cluster analysis was performed to identify patterns of subgroups in patients with DHD.

RESULTS

Data from 971 patients, whose Richmond Agitation-Sedation Scale score at admission was zero and who died in palliative care units, were analyzed. The average age was 72 years, common primary cancer sites were the gastrointestinal tract (31%) and the liver/biliary ducts/pancreas (19%). A total of 174 patients (18%: 95% confidence interval, 16-20) expressed DHD. Common reasons for DHD were dependency (45%), burden to others (28%), meaninglessness (24%), and inability to engage in pleasant activities (24%). We identified five clusters of patients with DHD: cluster 1 (35%, 61/173): "physical distress," cluster 2 (21%, 37/173): "dependent and burdensome," cluster 3 (19%, 33/173): "hopelessness," cluster 4 (17%, 30/173): "profound fatigue," and cluster 5 (7%, 12/173): "extensive existential suffering."

CONCLUSIONS

A considerable number of patients expressed DHD and could be categorized into five subgroups. These findings may contribute to the development of therapeutic strategies.

Chronic pain severity, impact, and opioid use among patients with cancer: An analysis of biopsychosocial factors using the CHOIR learning health care system

BACKGROUND

Despite the biopsychosocial underpinnings of chronic noncancer pain, relatively little is known about the contribution of psychosocial factors to chronic cancer pain. The authors aimed to characterize associations between biopsychosocial factors and pain and opioid use among individuals with chronic pain and cancer.

METHODS

The authors conducted a retrospective, cross-sectional study of 700 patients with chronic pain and cancer seeking treatment at an academic tertiary pain clinic. Patients completed demographic questionnaires and validated psychosocial and pain measures. Multivariable, hierarchical linear and logistic regressions assessed the relative contributions of biopsychosocial factors to the primary dependent variables of pain severity, pain interference, and opioid use.

RESULTS

Participants were 62% female and 66% White with a mean age of 59 ± 15 years, and 55% held a college degree or higher. Older age, African American or "other" race, sleep disturbance, and pain catastrophizing were significantly associated with higher pain severity (F(5,657) = 22.45; P ≤ .001; R² = 0.22). Depression, sleep disturbance, pain catastrophizing, lower emotional support, and higher pain severity were significantly associated with pain interference (F(5,653) = 9.47; P ≤ .001; R² = 0.44). Lastly, a poor cancer prognosis (Exp(B) = 1.62) and sleep disturbance (Exp(B) = 1.02) were associated with taking opioids, whereas identifying as Asian (Exp(B) = 0.48) or Hispanic (Exp(B) = 0.47) was associated with lower odds of using opioids.

CONCLUSIONS

Modifiable psychological factors-specifically sleep disturbance, depression, and pain catastrophizing-were uniquely associated with pain and opioid use in patients with chronic pain and diverse cancer diagnoses. Future behavioral pain interventions that concurrently target sleep may improve pain among patients with cancer.

LAY SUMMARY

Feeling depressed, worrying about pain, and bad sleep are related to higher pain symptoms in individuals with chronic pain and cancer. Specifically, those who struggle to sleep have worse pain and use more opioids. Also, individuals who have a bad prognosis for their cancer are more likely to be using opioid pain medications. Although race and cancer are related to chronic pain in patients, psychological well-being is also strongly related to this same pain.

[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?

Enhancing meaning in the face of advanced cancer and pain: Qualitative evaluation of a meaning-centered psychosocial pain management intervention

OBJECTIVES

The objectives of this study were to obtain patient evaluations of the content, structure, and delivery modality of Meaning-Centered Pain Coping Skills Training (MCPC), a novel psychosocial intervention for patients with advanced cancer and pain. MCPC aims to help patients connect with valued sources of meaning in their lives (e.g., family relationships), while providing training in evidence-based cognitive and behavioral skills (e.g., guided imagery) to reduce pain.

METHODS

Semi-structured interviews were conducted with 12 patients with stage IV solid tumor cancers and persistent pain. Transcripts were analyzed using methods from applied thematic analysis.

RESULTS

When evaluating MCPC's educational information and skills training descriptions, participants described ways in which this content resonated with their experience. Many coped with their pain and poor prognosis by relying on frameworks that provided them with a sense of meaning, often involving their personally held religious or spiritual beliefs. They also expressed a need for learning ways to cope with pain in addition to taking medication. A few participants offered helpful suggestions for refining MCPC's content, such as addressing common co-occurring symptoms of sleep disturbance and fatigue. Concerning MCPC's structure and delivery modality, most participants preferred that sessions include their family caregiver and described remote delivery (i.e., telephone or videoconference) as being more feasible than attending in-person sessions.

SIGNIFICANCE OF RESULTS

Participants were interested in an intervention that concurrently focuses on learning pain coping skills and enhancing a sense of meaning. Using remote delivery modalities may reduce access barriers (e.g., travel) that would otherwise prevent many patients from utilizing psychosocial services.

Current Perspectives on Spinal Cord Stimulation for the Treatment of Cancer Pain

Cancer and cancer treatment-related chronic pain affect a significant number of patients. The etiology of this pain is diverse and may include nociceptive and/or neuropathic characteristics. Treatment is often multifactorial and may require advanced interventional techniques, such as spinal cord stimulation (SCS). This narrative review provides a thorough overview of cancer-related pain mechanisms and the use of SCS for cancer-related pain. Additionally, a review of the precautions that should be considered when caring for this patient population is provided with recommendations for safe care when utilizing these techniques.

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.

Evaluation of A Training Program to Assist Care Staff to Better Recognize and Manage Depression among Palliative Care Patients and Their Families

This study was designed to evaluate the effectiveness of a training program to improve the knowledge, attitudes, and self-efficacy of palliative care staff and thus enable them to better detect and manage depression among palliative care patients and their families. Participants were 90 professional carers who completed a four-session training program. Knowledge, attitudes, self-efficacy, and barriers to working with depressed patients were assessed pre-intervention, post-intervention, and at a three-month follow-up. The results demonstrated that compared to the control group, the intervention group had improved in all of these areas. Improvements were maintained at the three-month follow-up in all areas except attitudes. The results of this study indicate the importance of training in managing depression among palliative care staff. Booster sessions will likely be needed to ensure that training program gains are maintained.

Burden of cancer pain in developing countries: a narrative literature review

Cancer pain is one of the most common, feared, debilitating, and often undertreated symptoms among cancer patients. It needs attention since it has a significant impact on the quality of life (QoL) of the patients. Also, since cancer has emerged as a major health problem in developing countries, there is a need to strengthen preventive strategies for effective cancer pain management and provide comfort to cancer patients. Nonetheless, various barriers limit developing countries toward optimal cancer pain management. To bridge the gap between adequate pain management and burden of cancer pain in developing countries, a comprehensive understanding of the limitations faced and the prevalence of cancer pain should be addressed. The aim of this literature review is to provide a deeper understanding on the factors associated with cancer pain as well as barriers toward optimal cancer pain management in developing countries. Some of the barriers addressed were administrative, judicial, economic, and professional barriers. Also, estimates on the prevalence of cancer pain and detrimental effects of pain on the QoL of cancer patients have been addressed. In summary, pain, which is one of the most debilitating symptoms of cancer, remains uncontrolled and undertreated in developing countries. It has a profound impact on the patient’s QoL and can have physical, psychological, and social consequences; therefore, it needs to be managed urgently and appropriately. Most importantly, optimal treatment of cancer pain should be highlighted as a priority in developing countries and concerted efforts should be made to eliminate different barriers discussed in this review for effective and humane care.

Chronic Pain, TBI, and PTSD in Military Veterans: A Link to Suicidal Ideation and Violent Impulses?

The polytrauma clinical triad refers to the co-occurrence of chronic pain, traumatic brain injury (TBI), and posttraumatic stress disorder (PTSD). Despite research implicating dyadic relationships between these conditions and adverse outcomes, scant research has examined the polytrauma clinical triad's relation to suicide or violence. The present cross-sectional study was designed to examine whether this complex clinical presentation increases risk of suicidal ideation and violent impulses after accounting for other established risk factors. Veterans who served in the military since September 11, 2001 (N = 667) who reported chronic pain completed an interview and self-report battery. Bivariate analyses showed that suicidal ideation and violent impulses both correlated with PTSD, TBI+PTSD, pain intensity and interference, drug abuse, and major depressive disorder (MDD). Multiple regression analyses showed that: 1) race, chronic pain with PTSD, alcohol abuse, and MDD significantly predicted suicidal ideation, 2) pain interference, chronic pain with TBI, chronic pain with PTSD, chronic pain with TBI+PTSD, drug abuse, and MDD significantly predicted violent impulses, and 3) pain interference was a more critical predictor of suicidal and violent ideation than pain intensity. Implications for risk assessment and treatment are discussed.

PERSPECTIVE

This article presents results from a study examining predictors of suicide and violence risk among a sample of post-9/11 U.S. Veterans with chronic pain. Health care professionals should assess for pain interference, TBI, PTSD, depression, and alcohol/drug abuse when conducting risk assessments with this population.

[Cancer and suicide among the elderly: psychosocial determinants of risks, psychopathology and opportunities for prevention]

Suicide is a serious public health problem worldwide. Increasing age is directly associated with the rising rates of cancer and physical and functional limitations are important factors regarded as being associated with suicidal behavior among the elderly. This study sought to conduct a critical review of the literature on the risk factors associated with suicide among elderly cancer patients published between 2000 and 2015. Psychosocial precipitants of risks and psychopathology in 20 selected articles were conducted. The studies consistently identified a number of factors that have been considered to be associated with suicidal behavior among the elderly diagnosed with cancer. These include physical and mental health constraints (particularly major depression), social isolation, and the manner in which these factors and others interact. Further research is needed given the importance of the issue and to examine whether further education for healthcare providers and their abilities in suicide risk assessment and management could have positive effects on reducing the suicide rates among elderly patients with cancer. Considerations for upcoming studies encourage the adoption of empirically supported interventions for individualized management of the elderly cancer patient.

Exploring attitudes toward physician-assisted death in patients with life-limiting illnesses with varying experiences of palliative care: a pilot study

Background

On February 6th, 2015, the Supreme Court of Canada ruled that competent adults suffering intolerably from a grievous and irremediable medical condition have the right to the assistance of a physician in ending their own lives, an act known as physician-assisted death, and later defined as medical assistance in dying, allowing for provision by a physician or a nurse practitioner. As of June 6th, 2016, this is no longer illegal across Canada. There is strong support amongst the general population for physician-assisted death, however there is no recent data on the attitudes of terminally ill patients. Our main objective was to gain information on terminally ill patients’ general and personal attitudes toward physician-assisted death.

Methods

This is an exploratory pilot study. We surveyed three groups of patients with life-limiting diagnoses: one with new referrals to palliative care; one with no palliative care involvement; and one with prior and ongoing management by a palliative care team. Respondents were surveyed twice, approximately two weeks apart, and rated their general attitudes toward physician-assisted death and the hypothetical consideration of physician-assisted death for oneself on a five-point Likert scale at baseline and follow-up. Respondents with new referrals to palliative care were surveyed before and after palliative care consultation. This study was approved by The Western University Health Sciences Research Ethics Board and Lawson Health Research Institute.

Results

We surveyed 102 participants, 70 of whom completed both surveys (31% dropout rate). Participants in all groups predominantly responded between somewhat agree (4 on a 5-point Likert scale) and strongly agree (5 on the Likert scale) when asked about their general attitude toward physician-assisted death. Patients with prior palliative care involvement reported the highest average ratings of hypothetical consideration of physician-assisted death for oneself on a 5-point Likert scale (3.4 at baseline; 3.9 at follow-up), followed by patients with a new palliative consultation (3.2 at baseline; 3.3 at follow-up), and patients with no palliative involvement (2.6 at baseline; 2.9 at follow-up).

Conclusions

Given the preliminary results of this pilot study, we can conclude that terminally ill patients generally agree that physician-assisted death should be available to patients with life-limiting illnesses. Furthermore, descriptive data show a trend for higher hypothetical consideration of physician-assisted death in those patients with prior and ongoing palliative care involvement than patients without palliative involvement. Responses in all groups remained fairly consistent over the two-week period.

Electronic supplementary material

The online version of this article (10.1186/s12904-018-0304-6) contains supplementary material, which is available to authorized users.

Comparison of Indicators for Achievement of Pain Control With a Personalized Pain Goal in a Comprehensive Cancer Center

CONTEXT

The achievement of a personalized pain goal (PPG) is advocated as an individualized pain relief indicator.

OBJECTIVES

Pain relief indicators, including PPG, pain intensity (PI), and interference with daily activities (interference), were compared herein.

METHODS

This was a single-center cross-sectional study. Adult patients with cancer on opioid medications who visited the outpatient clinic at the National Cancer Center Hospital East between March and September 2015 were consecutively enrolled. Patients conducted a self-report questionnaire, including reports of average PI, interference, PPG, and the need for further analgesic treatment. We compared the proportion of patients achieving PPG (PI ≤ PPG) and other pain relief indicators including PI ≤3 or interference ≤3 and the percentage of patients who did not need further analgesic treatment among those who fulfilled each pain relief indicator.

RESULTS

A total of 347 patients (median age 64; 38% females) were analyzed. Median (interquartile range [IQR]) of PPG, PI, and interference was 2 (IQR 1-3), 2 (IQR 1-4), and 2 (IQR 0-5), respectively. The proportion of patients achieving PPG was 45.3% and significantly lower than those with PI ≤3 (69.0%; P < 0.001) and interference ≤3 (70.2%; P < 0.001). Eighty percent of patients achieving PPG did not need further analgesic treatment, whereas 70.8% of patients with PI ≤3 (P < 0.001) and 73.3% with interference ≤3 did need further analgesic treatment (P < 0.001).

CONCLUSION

The achievement of PPG was a stricter pain relief indicator than PI and interference and may reflect a real need for pain control.

Managing Pain in Patients With Chronic Medical Illnesses and Serious Mental Illnesses

OBJECTIVES

This study investigated the use of opioid treatment plans that included the implementation of opioid dependence risk with a validated screening tool and opioid dependence risk tool (UDT) in a noncancer palliative pain clinic.

METHODS

We retrospectively reviewed the medical records for diagnostic information, information on analgesic medications, daily morphine equivalent dose, presence of pain management agreements and opioid dependence risk tools (ORT), and UDT. We recorded hospital days and emergency department visits.

RESULTS

Seventy-four patients were followed for a mean of 15.9 months. Ninety-three percent of patients had pain management agreements and 74% had ORT. The median score was 8: consistent with a high risk. More than half had UDT and 17.6% of patients had unexpected findings. Fifty-nine percent of patients had a psychiatric diagnosis. Hospital days and emergency department visits decreased by more than 30% ( P = .015 and P = .019). Significance of Findings: Both mental health problems and aberrant drug use were common in patients seen in a noncancer palliative care clinic. There were significant reductions in acute care utilization in the 12 months post intake in the clinic.

Efficacy and safety of celecoxib monotherapy for mild to moderate depression in patients with colorectal cancer: A randomized double-blind, placebo controlled trial

Cancer-related inflammation is an essential process in malignancies. Celecoxib, a nonsteroidal anti-inflammatory drug that acts via the selective inhibition of cyclooxygenase (COX)-2, has shown favorable effects in several psychiatric disorders. The present study aimed to assess the safety and efficacy of celecoxib single therapy on depressive symptoms of patients with colorectal cancer who underwent chemotherapy. The study was conducted as a 6-week, parallel-group, randomized, double-blind, placebo-controlled trial. Forty participants randomly received either 400mg/day celecoxib or placebo. Treatment effect was assessed using the Hamilton Depression Rating Scale (HDRS) and Visual Analogue Scale (VAS) score at baseline and at week 2, 4 and 6 of the trial. Over 6 weeks, patients who received celecoxib showed significant improvement in scores of the Hamilton Depression rating Scale (P=0.003). When comparing the Mean Difference (95% CI) between the two groups of therapy, the celecoxib group demonstrated greater reduction in HDRS score during the study period at weeks 4 (1.95, 95% CI 0.27-3.63, P value =0.024) and 6 (2.60, 95% CI 0.96-4.23, P=0.003). This study indicates celecoxib as a potential monotherapy treatment strategy for mild to moderate depression in patients with colorectal cancer who underwent chemotherapy.

[Attitudes and experiences regarding physician assisted suicide : A survey among members of the German Association for Palliative Medicine]

BACKGROUND

The need to regulate physician-assisted suicide (PAS) and organizations offering assisted suicide has been controversially debated in Germany. Before the German parliament voted on various drafts in November 2015, the German Association for Palliative Medicine surveyed its members on their attitudes and experiences regarding PAS.

METHOD

Items for the survey were derived from the literature and consented in a focus group.

LITERATURE SEARCH

2005-2015 - PubMed: PAS [Title/Abstract] UND survey (all countries), grey literature. We invited 5152 members of the DGP to participate in the online/paper survey. Descriptive quantitative and content analytic qualitative analysis of data using SPSS and MaxQDA.

RESULTS

We obtained 1811 valid data sets (response rate 36.9%). 33.7% of the participants were male, 43.6% were female, and 0.4% identifed as other. Physicians accounted for 48.5% of the respondents, 17.8% nurses, other professions 14.3%, and about 20% of the data was missing socio-demographic information. More than 90% agreed that "wishes for PAS may be ambivalent" and "are rather a wish to end an unbearable situation". Of the 833 participating physicians, 56% refused participating in PAS and 74.2% had been asked to perform PAS. PAS was actually performed by 3%. Of all participating members, 56% approved of a legal ban of organizations offering assisted suicide. More than 60% of all professions agreed that PAS is not a part of palliative care.

CONCLUSION

The respondents show a broad spectrum of attitudes, only partly supporting statements of relevant bodies, such as DGP. Because many are confronted with the issue, PAS is relevant to professionals in palliative care.

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.

Spiritual Well-being May Reduce the Negative Impacts of Cancer Symptoms on the Quality of Life and the Desire for Hastened Death in Terminally Ill Cancer Patients

BACKGROUND

Spirituality is a central component of the well-being of terminally ill cancer patients.

OBJECTIVE

The aim of this study was to examine the mediating or moderating role of spiritual well-being in reducing the impact of cancer-related symptoms on quality of life and the desire for hastened death in terminally ill cancer patients.

METHODS

Eighty-five terminally ill cancer patients were assessed using the Taiwanese version of the M. D. Anderson Symptom Inventory, the Functional Assessment of Cancer Therapy-General, the Functional Assessment of Chronic Illness Therapy-Spiritual Well-being, the Beck Hopelessness Scale, and the Schedule of Attitudes Toward Hastened Death.

RESULTS

Spiritual well-being was significantly negatively correlated with symptom severity (r = -0.46, P < .01). Symptom severity negatively correlated with quality of life (r = -0.54) and positively correlated with hopelessness (r = 0.51, P < .01) and the desire for hastened death (r = 0.61, P < .01). Spiritual well-being was a partial mediator and moderator between symptom severity and quality of life. Spiritual well-being was a partial mediator between symptom severity and the desire for hastened death. The meaning subscale of spiritual well-being was a more significant predictor of the desire for hastened death and quality of life than the faith subscale was.

CONCLUSION

Spiritual well-being may reduce the negative impacts of cancer on quality of life and the desire for hastened death.

IMPLICATIONS FOR PRACTICE

Appropriate spiritual care may reduce the negative impact of severe cancer symptoms on quality of life and the desire for hastened death in terminally ill cancer patients.

[Attitudes towards euthanasia: The impact of experiencing end-of-life care]

BACKGROUND

It is a matter of debate whether euthanasia should be part of medical practice.

OBJECTIVES

The current study investigates the attitudes of bereaved family members of cancer patients towards euthanasia.

MATERIALS AND METHODS

We conducted a survey with 211 people who had recently lost a close relative to cancer. Participants were asked whether euthanasia should be part of medical practice.Two logistic regression models were calculated in order to determine the factors influencing the attitude towards active euthanasia and assisted suicide.

RESULTS

About 70% and 75% of the respondents approved active euthanasia and assisted suicide, respectively. Religious denomination and psychological distress had a significant impact on the attitude towards active euthanasia. About 10%of the deceased patients had asked for active euthanasia.

CONCLUSIONS

There was no difference between bereaved family members and the general population regarding the acceptance of euthanasia. Attitudes towards active euthanasia are associated with psychological distress and shaped by cultural values rather than by the experience of end-of-life care.

The Impact of Massage Therapy on Function in Pain Populations-A Systematic Review and Meta-Analysis of Randomized Controlled Trials: Part II, Cancer Pain Populations

PURPOSE

Pain is multi-dimensional and may be better addressed through a holistic, biopsychosocial approach. Massage therapy is commonly practiced among patients seeking pain management; however, its efficacy is unclear. This systematic review and meta-analysis is the first to rigorously assess the quality of massage therapy research and evidence for its efficacy in treating pain, function-related and health-related quality of life in cancer populations.

METHODS

Key databases were searched from inception through February 2014. Eligible randomized controlled trials were assessed for methodological quality using the SIGN 50 Checklist. Meta-analysis was applied at the outcome level. A diverse steering committee interpreted the results to develop recommendations.

RESULTS

Twelve high quality and four low quality studies were subsequently included in the review. Results demonstrate massage therapy is effective for treating pain compared to no treatment [standardized mean difference (SMD)  = -.20] and active (SMD = -0.55) comparators. Compared to active comparators, massage therapy was also found to be beneficial for treating fatigue (SMD = -1.06) and anxiety (SMD = -1.24).

CONCLUSION

Based on the evidence, weak recommendations are suggested for massage therapy, compared to an active comparator, for the treatment of pain, fatigue, and anxiety. No recommendations were suggested for massage therapy compared to no treatment or sham control based on the available literature to date. This review addresses massage therapy safety, research challenges, how to address identified research gaps, and necessary next steps for implementing massage therapy as a viable pain management option for cancer pain populations.

Using item response theory (IRT) to reduce patient burden when assessing desire for hastened death

Desire for hastened death (DHD) represents a wish to die sooner than might occur by natural disease progression. Efficient and accurate assessment of DHD is vital for clinicians providing care to terminally ill patients. The Schedule of Attitudes Toward Hastened Death (SAHD) is a commonly used self-report measure of DHD. The goal of this study was to use methods grounded in item response theory (IRT) to analyze the psychometric properties of the SAHD and identify an abbreviated version of the scale. Data were drawn from 4 studies of psychological distress at the end of life. Participants were 1,076 patients diagnosed with either advanced cancer or AIDS. The sample was divided into 2 subsamples for scale analysis and development of the shortened form. IRT was used to estimate item parameters. A 6-item version of the SAHD (SAHD-A) was identified through examination of item parameter estimations. The SAHD-A demonstrated adequate convergent validity. Receiver operating characteristic analyses indicated comparable cut scores to identify patients with high levels of DHD. These analyses support the utility of the SAHD-A, which can be more easily integrated into research studies and clinical assessments of DHD. (PsycINFO Database Record

The wish to die among palliative home care clients in Ontario, Canada: A cross-sectional study

Background

In the pursuit to provide the highest quality of person centered palliative care, client preferences, needs, and wishes surrounding end of life should be used to inform the plan of care. During a clinical assessment for care services, clients may voluntarily express a ‘wish to die’ either directly to the clinician or it may be indirectly reported second-hand to the clinician through an informal caregiver or family member. This is the first study using data gathered from the interRAI Palliative Care Assessment instrument (interRAI PC) to examine socio-demographic, clinical, and psycho-social factors of palliative home care clients with the voluntary expression of a ‘wish to die now’. Factors associated with the risk for depression within this group were also identified. Awareness and understanding of clients who express the ‘wish to die’ is needed to better tailor a person-centered approach to end-of-life care.

Methods

This cross-sectional study included assessment records gathered from 4,840 palliative home care clients collected as part of pilot implementation of the interRAI PC assessment instrument in Ontario, Canada from 2006 through 2011.

Results

During the clinical assessment, 308 palliative home care clients (6.7 %) had voluntarily expressed a ‘wish to die now’. Independent factors emerging from multivariate logistic regression analyses predicting the expression of a ‘wish to die’ included not being married/widowed, a shorter estimated prognosis, depressive symptoms, functional impairment, too much sleep (excessive amount), feeling completion regarding financial/legal matters, and struggling with the meaning of life. Among persons who expressed a ‘wish to die now’, those who exhibited depressive symptoms (23.8 %, n = 64) were also more likely to exhibit cognitive impairment, have decline in cognition in the last 90 days, exhibit weight loss, have informal caregivers exhibiting distress, ‘not have a consistent positive outlook on life’ and report ‘struggling with the meaning of life’.

Conclusion

When clients voluntary express a wish to die clinicians should take notice and initiate follow-up to better understand the context of this meaning for the individual. Clients who expressed a ‘wish to die’ did not all experience pain, depression, and psychological distress suggesting an individualized approach to care management be taken.

Psychiatric considerations in the oncology setting

An aging population and advances in diagnostics and treatment have resulted in a rapidly growing population of people impacted by cancer. People live longer after a cancer diagnosis and tolerate more aggressive treatments than in the past. Younger patients struggle with diversions from the normal developmental milestones in career and relationships, while older patients deal with the dual challenges of aging and cancer. Cancer's transition from likely death to survival has increased interest in its impact on psychosocial issues and quality of life, rather than just longevity. In this article, the authors review the psychiatric diagnosis and management of the mental health issues most often encountered in oncology. Oncology treatment teams, including oncologists, nurses, social workers, and other ancillary staff, are often on the front lines of addressing psychiatric distress and clinical syndromes when psychiatrists are not easily available. The purpose of this review article is to highlight opportunities for nonpsychiatrists to improve identification and treatment of psychosocial distress and psychiatric syndromes and to request formal psychiatric consultation in appropriate situations. Psychotherapeutic, psychopharmacologic, cognitive, and behavioral-oriented interventions, as well as supportive interventions, are discussed for treating patients who are facing challenges during active cancer treatment, survivorship, and at the end of life. This review is not exhaustive but highlights the more common psychosomatic medicine and palliative care scenarios that impact cancer patient care. The importance of recognizing and addressing burnout and compassion fatigue in multidisciplinary professionals who care for those treated for cancer is also discussed given the secondary impact this can have on patient care.

Survival Prediction in Ambulatory Patients With Stage III/IV Non-Small Cell Lung Cancer Using the Palliative Performance Scale, ECOG, and Lung Cancer Symptom Scale

OBJECTIVES

Patients with advanced non-small cell lung cancer (NSCLC) have a life expectancy of less than 1 year. Therefore, it is important to maximize their quality of life and find a tool that can more accurately predict survival.

MATERIALS

The Palliative Performance Scale (PPS) is used to predict survival for patients with advanced disease based on functional dimensions. The value of the PPS in ambulatory patients with cancer has not been examined to date. The Lung Cancer Symptom Scale (LCSS) measures six major symptoms and their effect on symptomatic distress and activity. We evaluated 62 patients with stage III or IV NSCLC and Eastern Cooperative Oncology Group (ECOG) Scale Score ≥1 at baseline in a thoracic oncology clinic. In all, 62 patients had LCSS and PPS evaluated at baseline and 54 patients had 4-week follow-up using LCSS, PPS, and ECOG.

RESULTS

Fifty-four patients completed baseline and follow-up. Mean age was 63.7 years. Sixty-three percent were receiving chemotherapy at evaluation. Seventeen patients died. Mean baseline measures were LCSS 6.18 (1-14); PPS 66.6 (40-90); and ECOG 1.82 (1-4). Censored survival times were calculated from enrollment of the first patient for 380 days. A proportional hazardous model was computed for survival status. Hazard ratios for death were 1.25 (P = .013) for LCSS, 2.12 (P = .027) for ECOG, and 1.02 for PPS (P = .49).

CONCLUSIONS

The LCSS predicted prognosis best in this study. The PPS did not accurately predict prognosis in our patient population.

Does the Experience of Interpersonal Predictors of Suicidal Desire Predict Positive Attitudes Toward Physician Assisted Suicide?

The current study examined the relationship between Physician Assisted Suicide (PAS) attitudes and interpersonal risk factors of suicidal desire as outlined by the interpersonal-psychological theory of suicidal behavior (Joiner, 2005). It was hypothesized that both thwarted belongingness and perceived burdensomeness would be positively related to PAS acceptance. Results indicated that thwarted belongingness and perceived burdensomeness predicted significance of favorable attitudes toward PAS in a college sample. Results suggest that attitudes toward PAS may be influenced by the experience of thwarted belongingness and perceived burdensomeness and provide a clear rationale for the study of these variables in populations more apt to consider hastened death. Future work regarding the application of the interpersonal-psychological theory of suicidal behavior in hastened death research is discussed.

State of art of managing pain in patients with cancer

Pain in cancer patients involves complex interactions between physiological, psychological, sociocultural, sensory, cognitive, and behavioral dimensions. Pain management interventions will be most effective when pharmacological and nonpharmacological treatments are individualized after exploring the various contributors to pain and suffering, and the patient and family are educated and involved in decision making. This entails a systematic multidimensional approach with frequent reassessments of pain and related outcomes.

Role of rehabilitation medicine and physical agents in the treatment of cancer-associated pain

PURPOSE

To provide an overview of rehabilitation medicine- and physical modality-based approaches to cancer pain management, and to highlight the fact that these approaches are generally used in conjunction and that a majority are focused on minimizing pain during periods of mobility and the performance of activities of daily living.

METHODS

We performed a nonsystematic literature review and provide a description of the current standard of care.

RESULTS

Rehabilitative and physical modalities used to manage pain can be grouped into four categories: those that modulate nociception, stabilize or unload painful structures, influence physiological processes that indirectly influence nociception, or alleviate pain arising from the overloading of muscles and connective tissues that often occurs after surgery or with sarcopenia in late-stage cancer. Most modalities have been pragmatically refined over the years, and many have an evidence base, although few have been explicitly validated in the oncologic setting. With few exceptions, they are patient controlled and free of adverse effects.

CONCLUSION

Physical modalities and rehabilitation medicine offer a range of pain management approaches that may serve as beneficial adjuncts to the conventional systemic and interventional analgesic strategies used to control cancer-related pain. These approaches may be particularly beneficial to patients with movement-associated pain and those who are ambivalent regarding pharmacoanalgesia.

Does desire for hastened death change in terminally ill cancer patients?

Understanding why some terminally ill patients may seek a hastened death (a construct referred to as "desire for hastened death" or DHD) is critical to understanding how to optimize quality of life during an individual's final weeks, months or even years of life. Although a number of predictor variables have emerged in past DHD research, there is a dearth of longitudinal research on how DHD changes over time and what factors might explain such changes. This study examined DHD over time in a sample of terminally ill cancer patients admitted to a palliative care hospital. A random sample of 128 patients completed the Schedule of Attitudes toward Hastened Death (SAHD) at two time points approximately 2-4 weeks apart participated. Patients were categorized into one of four trajectories based on their SAHD scores at both time points: low (low DHD at T1 and T2), rising (low DHD at T1 and high DHD at T2), falling (high DHD at T1 and low DHD at T2) and high (high DHD at T1 and T2). Among patients who were low at T1, several variables distinguished between those who developed DHD and those who did not: physical symptom distress, depression symptom severity, hopelessness, spiritual well-being, baseline DHD, and a history of mental health treatment. However, these same medical and clinical variables did not distinguish between the falling and high trajectories. Overall, there appears to be a relatively high frequency of change in DHD, even in the last weeks of life. Interventions designed to target patients who are exhibiting subthreshold DHD and feelings of hopelessness may reduce the occurrence of DHD emerging in this population.

Mental disorders and the desire for death in patients receiving palliative care for cancer

OBJECTIVES

The desire for death in terminally ill patients is associated with depression and anxiety, but not all patients who report it meet criteria for mental disorders. We examined the characteristics of subgroups of palliative cancer patients who expressed a desire for death that occurred either with or without a concurrent depressive or anxiety disorder.

DESIGN

Cross-sectional survey.

SETTING

Eight Canadian palliative care programs.

PARTICIPANTS

377 patients with cancer.

MAIN OUTCOME MEASURES

Desire for Death Rating Scale; Structured Interview of Symptoms and Concerns.

RESULTS

Most participants (69.5%) had no desire for death. Of the remainder, 69 (18.3%) acknowledged occasional transient thoughts, and 46 (12.2%) reported an apparently genuine desire to die. In the latter group, 24 individuals (52.2%) were diagnosed with a mental disorder and 22 (44.8%) were not. Individuals with no serious desire for death and no mental disorder reported the least distress in physical, social, existential, and psychological symptoms and concerns; those with a mental disorder and a significant desire for death reported the most. The subgroup of patients with a serious desire for death but no concurrent mental disorders still reported increased distress due to physical symptoms and social concerns, as well as a higher prevalence of global suffering.

CONCLUSIONS

The expression of a desire for death by a terminally ill patient should raise a suspicion about mental health problems, but is not in itself clearly indicative of one. Nevertheless, it may serve as a catalyst to review the individual's physical symptom management and interpersonal concerns, and overall sense of suffering.