Assisted suicide, depression, and the right to die

When jurors' moral judgments result in jury nullification: moral outrage at the law as a mediator of euthanasia attitudes on verdicts

In a mock-trial study, jurors read evidence about a doctor who had killed a terminally ill patient at the patient's request. We tested whether instructing jurors about jury nullification (ie jurors' power to return a not-guilty verdict even when legal guilt is beyond doubt, often because the law would result in unjust convictions) would exacerbate the effect of pre-trial euthanasia attitudes on their verdicts - compared to standard, pattern jury instructions. We also hypothesized that anti-euthanasia pre-trial attitudes would result in moral outrage at the defendant and higher conviction rates, but pro-euthanasia attitudes would prompt feelings of moral outrage at the law and lower conviction rates. Moderated mediation analyses revealed that nullification instructions bolstered the effect of attitudes on verdicts by encouraging jurors to rely on their feelings of moral outrage toward the defendant. Jurors' moral outrage toward the law mediated the effect of attitudes on verdicts regardless of nullification instructions.

Comment la marge peut-elle déplacer le centre en matière d’accompagnement de fin de vie ?

Les associations d’aide au suicide en Suisse peuvent assister des personnes âgées institutionnalisées à certaines conditions. Cet article présente les résultats préliminaires d’une étude qualitative menée auprès de professionnel.le.s d’établissements médico-sociaux pour personnes âgées confronté.e.s à l’assistance au suicide. Il présente quelques défis que celle-ci pose à la mission professionnelle et au fonctionnement institutionnel ainsi qu’au positionnement personnel. Le suicide assisté en institution engendre de nouvelles pratiques par ajustements successifs, entre résistance et normalisation, l’enjeu ultime étant l’intégration ou non de la mort par suicide assisté comme une des modalités de l’accompagnement de fin de vie au sein des institutions.

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.

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.

The rationality of suicide bombers: There is a little bit of crazy in all of us

Despite Lankford's descriptions of escapist suicide victims as being unstable, they were making rational decisions, based on their current knowledge and values. Similarly, those who are allegedly indirectly suicidal are not different from other risk-takers. The psychological differences between those who engage in suicidal attacks and those who do not are less than most of us would prefer.

Validation of the German version of the Schedule of Attitudes Toward Hastened Death (SAHD-D) with patients in palliative care

OBJECTIVE

Reliable and validated instruments are needed in order to study the desire for hastened death (DHD). As there is no instrument in the German language to measure DHD, our aim was to validate a German version of the Schedule of Attitudes Toward Hastened Death (SAHD-D).

METHOD

The SAHD was translated following guidelines promulgated by the European Organization for Research and Treatment of Cancer (EORTC). In eligible patients (clinical situation adequate, MMSE ≥21), the following instruments were employed: a symptom checklist (HOPE), the HADS-D (Hospital Anxiety and Depression Scale), the EORTC-QLQ-PAL15, and the SAHD-D, as well as an external estimation of DHD provided by the attending physician. A high level of DHD was defined as the mean plus one standard deviation (SD).

RESULTS

Of the 869 patients assessed, 92 were eligible for inclusion (66% females, mean age of 64.5 years). The SAHD-D total score ranged from 0 to 18, with a mean of 5 and a standard deviation (SD) of 3.7. A high level of DHD was found in 20% (n = 19). For discriminant validity, significant correlations were found between the SAHD-D and depression (r rho = 0.472), anxiety (r rho = 0.224), and clinical state (r rho = 0.178). For criterion validity, the external estimate of DHD showed a low significant correlation with patient score (r rho = 0.290). Factor analysis of the SAHD-D identified two factors.

SIGNIFICANCE OF RESULTS

Validation of the SAHD-D illustrated good discriminant validity, confirming that a desire to hasten death is a construct separate from depression, anxiety, or physical state. The unidimensionality of the SAHD could not be reproduced. Our findings support the multifactorial interdependencies on DHD and suggest that the SAHD-D should be refined by considering actual wishes, general attitudes, and options of patients.

Prevalence and risk factors of depressive symptoms in a Canadian palliative home care population: a cross-sectional study

Background

Depression in palliative care patients is important because of its intrinsic burden and association with elevated physical symptoms, reduced immunity and increased mortality risk. Identifying risk factors associated with depression can enable clinicians to more readily diagnose it, which is important since depression is treatable. The purpose of this cross-sectional study was to determine the prevalence of depressive symptoms and risk factors associated with them in a large sample of palliative home care patients.

Methods

The data come from interRAI Palliative Care assessments completed between 2006 and 2012. The sample (n = 5144) consists of adults residing in Ontario (Canada), receiving home care services, classified as palliative, and not experiencing significant cognitive impairment. Logistic regression identified the risk factors associated with depressive symptoms. The dependent variable was the Depression Rating Scale (DRS) and the independent variables were functional indicators from the interRAI assessment and other variables identified in the literature. We examined the results of the complete case and multiple imputation analyses, and found them to be similar.

Results

The prevalence of depressive symptoms was 9.8%. The risk factors associated with depressive symptoms were (pooled estimates, multiple imputation): low life satisfaction (OR = 3.01 [CI = 2.37-3.82]), severe and moderate sleep disorders (2.56 [2.05-3.19] and 1.56 [1.18-2.06]), health instability (2.12 [1.42-3.18]), caregiver distress 2.01 [1.62-2.51]), daily pain (1.73 [1.35-2.22]), cognitive impairment (1.45 [1.13-1.87]), being female (1.37 [1.11-1.68]), and gastrointestinal symptoms (1.27 [1.03-1.55]). Life satisfaction mediated the effect of prognostic awareness on depressive symptoms.

Conclusions

The prevalence of depressive symptoms in our study was close to the median of 10-20% reported in the palliative care literature, suggesting they are present but by no means inevitable in palliative patients. Most of the factors associated with depressive symptoms in our study are amenable to clinical intervention and often targeted in palliative care programs. Designing interventions to address them can be challenging, however, requiring careful attention to patient preferences, the spectrum of comorbid conditions they face, and their social supports. Life satisfaction was one of the strongest factors associated with depressive symptoms in our study, and is likely to be among the most challenging to address.

Depression and suicide are natural kinds: implications for physician-assisted suicide

In this article, I argue that depression and suicide are natural kinds insofar as they are classes of abnormal behavior underwritten by sets of stable biological mechanisms. In particular, depression and suicide are neurobiological kinds characterized by disturbances in serotonin functioning that affect various brain areas (i.e., the amygdala, anterior cingulate, prefrontal cortex, and hippocampus). The significance of this argument is that the natural (biological) basis of depression and suicide allows for reliable projectable inferences (i.e., predictions) to be made about individual members of a kind. In the context of assisted suicide, inferences about the decision-making capacity of depressed individuals seeking physician-assisted suicide are of special interest. I examine evidence that depression can hamper the decision-making capacity of individuals seeking assisted suicide and discuss some implications.

Where are the Women in End-of-Life Research?

This article reviews research on attitudes towards, and the practice of, hastening death. The central aim of this review is to elucidate what is known about the role played by gender in shaping the behaviours of people in the diverse roles of healthcare provider, carer, and patient. It is concluded that, on the whole, researchers have neglected to acknowledge gender differences in the experience of dying. Also lacking is carefully conducted research which is contextualised so that the dying person is better understood as a member of society rather than an isolated individual.

Why do patients agree to a "Do not resuscitate" or "Full code" order? Perspectives of medical inpatients

BACKGROUND

The majority of patients who die in hospital have a "Do Not Resuscitate" (DNR) order in place at the time of their death, yet we know very little about why some patients request or agree to a DNR order, why others don't, and how they view discussions of resuscitation status.

METHODS

We conducted semi-structured interviews of English-speaking medical inpatients who had clearly requested a DNR or full code (FC) order after a discussion with their admitting team, and analyzed the transcripts using a modified grounded-theory approach.

RESULTS

We achieved conceptual saturation after conducting 44 interviews (27 DNR, 17 FC) over a 4-month period. Patients in the DNR group were much older than those in the FC group, but they had broadly similar admission diagnoses and comorbidities. DNR patients reported much greater familiarity with the subject and described a more positive experience than FC patients with their resuscitation discussions. Participants typically requested FC or DNR orders based on personal, relational or philosophical considerations, but these considerations manifested differently depending on the participant's preference for resuscitation. Most FC patients stated that would not want a prolonged period of life support, and they would not want resuscitation in the event of a poor quality of life. FC and DNR patients understood resuscitation and DNR orders differently. DNR patients described resuscitation in graphic, concrete terms that emphasized suffering and futility, and DNR orders in terms of comfort or natural processes. FC patients understood resuscitation in an abstract sense as something that restores life, while DNR orders were associated with substandard care or even euthanasia.

CONCLUSION

Our study identified important differences and commonalities between the perspectives of DNR and FC patients. We hope that this information can be used to help physicians better understand the needs of their patients when discussing resuscitation.

End games: euthanasia under interminable scrutiny

It is increasingly asserted that the disagreements of abstract principle between adversaries in the euthanasia debate fail to account for the complex, particular and ambiguous experiences of people at the end of their lives. A greater research effort into experiences, meaning, connection, vulnerability, and motivation is advocated, during which the euthanasia 'question' should remain open. I argue that this is a normative strategy, which is felicitous to the status quo and further medicalises the end of life, but which masquerades as a value-neutral assertion about needing more knowledge.

Characteristics of persons approving of physician-assisted death

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

The schedule of attitudes toward hastened death: Validation analysis in terminally ill cancer patients

Objective: The faithful translation of the English version of the Schedule of Attitudes toward Hastened Death (SAHD) into Greek and its validation as an assessment tool in terminally ill cancer patients receiving palliative treatment.

Methods: 120 terminally ill cancer patients attending a Palliative Care Unit, at the University of Athens, Greece, between June 2003 and November 2003 for palliative treatment.

Results: SAHD would be a useful instrument for measuring desire for hastened death with valid psychometric properties in a Greek cancer population. The SAHD demonstrated high reliability. Desire for hastened death was significantly associated with Hospital Anxiety and Depression Scale (HAD) depression (r = 0.607, p < 0.0005) and substantially correlated with HAD anxiety (r = 0.502, p < 0.0005). “Pain intensity” had a moderate correlation with SAHD scores (r = 0.28, p = 0.01) and SAHD scores correlated significantly with “pain interference in mood” (r = 0.38, p = 0.01) and in “enjoyment of life” (r = 0.34, p = 0.03). SAHD correlation with quality of life was statistically significant (r = −0.38, p < 0.01) as was health status (r = −0.36, p < 0.01). Patients with a Poor Performance Status (from Eastern Cooperative Oncology Group scale) correlated significantly with high scores in SAHD (p = 0.038). Factor analysis supported the unidimentionality of the measurement.

Significance of results: SAHD could be a useful and valid instrument for measuring desire for hastened death in Greek terminally ill cancer patients.

Pain and Desire for Hastened Death in Terminally Ill Cancer Patients

The purpose of this study was to assess the relationship between pain and the desire for hastened death in terminally ill cancer patients. The participants were 120 terminally ill cancer patients under palliative treatment from June 2003 to November 2004. Patients completed a pain assessment tool, the Greek Brief Pain Inventory (G-BPI), and a self-report measure of the desire for hastened death, the Greek Schedule of Attitudes Toward Hastened Death (G-SAHD). Moderate but statistically significant associations were found between some of the severity and interference items of G-BPI and G-SAHD; more specifically, between G-SAHD and G-BPI3, "worst pain in the last 24 hours" (r = 0.279, P = .002); G-SAHD and G-BPI4, "least pain in the last 24 hours" (r = 0.253, P = .005); and G-SAHD and G-BPI5, "average pain in the last 24 hours" (r = 0.283, P = .002). A stronger association was revealed between G-SAHD and G-BPI8, "relief provided by pain treatment and medications in the last 24 hours" (r = -0.326, P = .000). Multiple regression analyses including the enter model and the forward model were conducted. According to the enter model, the strongest predictors of hastened death were items G-BPI6, "current pain"; G-BPI8, "relief provided by pain treatment and medications in the last 24 hours"; G-BPI9i, "interference of pain in general activity"; and G-BPI9iii, "interference of pain in walking." According to the forward model, significant predictors of the desire for death were items G-BPI5, "average pain in the last 24 hours"; G-BPI6, "current pain"; G-BPI9i, "interference of pain in general activity"; and G-BPI9ii, "interference of pain in mood," all of which were statistically significant (P = .000-.042). Pain appeared to have a statistically significant relationship with the desire for hastened death. Effective treatment by healthcare professionals should be provided to reduce pain and cancer-related symptoms as well as the desire for hastened death.

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

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

Influence of pain and quality of life on desire for hastened death in patients with advanced cancer

OBJECTIVE

to assess the relationship between quality of life, pain and desire for hastened death in advanced cancer patients.

METHODS

120 Greek patients with advanced cancer were interviewed with the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire C30 version 3.0 (EORTC QLQ-C30), the Greek Brief Pain Inventory (G-BPI), the Greek Hospital Anxiety and Depression Scale (G-HADS) and the Greek Schedule of Attitudes toward Hastened Death (G-SAHD).

RESULTS

statistically significant associations were found between total G-SAHD scores and scores for the worst level of pain in the previous 24 hours (G-BP13) (r = 0.279, P = 0.002), and between total G-SAHD scores and scores for the level of pain relief obtained in the last 24 hours (G-BP18) (r = -0.326, P = 0.0005). The strongest correlations were found between G-SADH and emotional functioning (r = 0.569, P<0.0001) and global quality of life (r = -0.331, P<0.0001) from EORTC QLQ-C30. In multivariate analyses, emotional functioning, social functioning, financial impact, and the interference of pain in general activity and mood were significant predictors of G-SAHD (all P<0.0001).

CONCLUSION

quality of life and pain appeared to have a statistically significant relationship with desire for hastened death. Adequate palliative care should alleviate pain and the desire for hastened death, improving quality of life.