Caught between intending and doing: older people ideating on a self-chosen death

Divergent Views and Experiences Regarding 'Completed Life' and Euthanasia in the Netherlands

A small proportion of older people in the Netherlands want to end their lives because they feel their lives to be 'completed' and no longer worth living. Currently, there is heated debate over whether or not these people should have the right to euthanasia. Drawing on previous research, we conduct a heuristic analysis of views and experiences of three different 'parties' involved in this debate, namely, the older people, their relatives and friends and medical professionals. The views of these three groups tend to be divergent and conflicting, posing a difficult dilemma to decision-makers.

Questioning the value of present life: The lived experience of older people who see no future for themselves

OBJECTIVES

To describe the lived experience of older people who see no future for oneself in the context of aging and the possible development of a wish to die.

METHODS

Data were collected from 34 interviews with people of 55-92 years. A phenomenological hermeneutical analysis was performed using crafted stories as an analytical device.

RESULTS

Four intertwined constituents together with the essence of the phenomenon provide a layered description of what it means to see no future for oneself. In all constituents: 1) not sharing everyday life, 2) looking for new commitments, 3) facing present losses and future fears and 4) imagining not waking up in the morning, the essence losing zest for life seeped through their daily experiences.

CONCLUSIONS

As their horizon of future possibilities is shrinking, older people in our study experience a loss of zest for life and start to questioning the value of their present lives. And although a certain languishing mood can be discovered, the phenomenon 'seeing no future for oneself' does not entail a wish to die.

Circumstances affecting patients' euthanasia or medically assisted suicide decisions from the perspectives of patients, relatives, and healthcare professionals: A qualitative systematic review

This study aims to explore circumstances affecting patients' euthanasia and medically assisted suicide (MAS) decisions from the perspectives of patients, relatives, and healthcare professionals. A qualitative systematic review was performed following PRISMA recommendations. The review protocol is registered in PROSPERO (CRD42022303034). Literature searches were conducted in MEDLINE, EMBASE, CINAHL Complete, Eric, PsycInfo, and citation pearl search in Scopus from 2012 to 2022. In total, 6840 publications were initially retrieved. The analysis included a descriptive numerical summary analysis and a qualitative thematic analysis of 27 publications, resulting in two main themes-Contexts and factors influencing actions and interactions, and Finding support while dealing with resistance in euthanasia and MAS decisions-and related sub-themes. The results illuminated the dynamics in (inter)actions between patients and involved parties that might both impede and facilitate patients' decisions related to euthanasia/MAS, potentially influencing patients' decision-making experiences, and the roles and experiences of involved parties.

Lifelong versus not lifelong death wishes in older adults without severe illness: a cross-sectional survey

BACKGROUND

Some older adults with a persistent death wish without being severely ill report having had a death wish their whole lives (lifelong persistent death wish; L-PDW). Differentiating them from older adults without severe illness who developed a death wish later in life (persistent death wish, not lifelong; NL-PDW) can be relevant for the provision of adequate help and support. This study aims to gain insight into the characteristics, experiences, and needs of older adults with a L-PDW versus older adults with a NL-PDW and into the nature of their death wishes.

METHODS

In the Netherlands, in April 2019, a cross-sectional survey study was conducted among a large representative sample of 32,477 citizens aged 55 years and older. Respondents with a L-PDW (N = 50) were compared with respondents with a NL-PDW (N = 217) using descriptive statistics, Kruskal-Wallis tests, and Fisher's exact tests.

RESULTS

Respondents with a L-PDW were relatively younger and less often had (step)children. They less often looked back on a good and satisfying life with many good memories and more often reported trauma. Older adults with a NL-PDW more often reported loss and bereavement. Overall, the groups showed a lot of similarities. Both groups reported a death wish diverse in nature, numerous health problems, and a variety of needs for help and support.

CONCLUSIONS

Some of the differences we found between the groups might be particularly relevant for the provision of adequate help and support to older adults with a L-PDW (i.e., their past and trauma) and to older adults with a NL-PDW (i.e., their loss and bereavement). The heterogeneity of both groups and the diverse nature of their death wish indicate that careful assessment of the death wish, its background, and underlying needs is required to provide personalized help and support to older adults with a death wish.

Intent disclosure in late-life suicide: Age group differences in correlates and associations with suicide means

Age-adjusted suicide rates declined from 2018 to 2020. However, suicide rates among older adults, particularly males 75 and older, have continued to rise, and the evidence base for effective interventions to prevent suicide in late life remains limited. One strategy to prevent older adults' suicidal behavior is to intervene when they reveal suicide intent. Previous research found that a significant proportion of older suicide decedents disclosed their suicide intent close to the fatal incident. In this study, based on the 2017-2019 United States National Violent Death Reporting System (NVDRS) data, we examined: (1) correlates of intent disclosure among three age groups (65-74, 75-84, and 85+) of older suicide decedents (N = 17,917; 14,856 men and 3,061 women); and (2) associations of suicide means with intent disclosure and suicide contributing factors. The results show that 19.9% of all suicide decedents aged 65+ (18.7%, 21.0%, and 22.0% in the 65-74, 75-84, and 85+ age groups, respectively) disclosed their suicide intent to their partner, family/friends, and healthcare providers within a month of their death. Multivariable analyses using generalized linear models for a Poisson distribution with a log link showed that physical and mental health, substance misuse, addiction problems, and relationship/other life stressors were associated with a higher likelihood of intent disclosure in the 65-74 and 75-84 age groups. However, only physical health problems were associated with a higher likelihood of intent disclosure among those aged 85 and older. Intent disclosure was not associated with using firearms and poisoning as suicide means but with a lower likelihood of hanging or suffocation. Mental health and substance misuse problems were associated with higher odds of hanging or suffocation and poisoning, and physical health problems and male sex in the 85+ age group were associated with higher odds of firearm use. Suicide prevention strategies for those who have disclosed their suicide intent or are at risk of suicidal behavior should include more patient-centered comfort and palliative care, mental health/substance misuse/addiction treatment, and restriction of access to potential suicide means. More research on older adults who disclose suicide intent and late-life suicide prevention strategies is needed.

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

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

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

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

The Darker Side of Ageing: Towards an Ethics of Suffering that Emphasises the Primacy of Witnessing

Many older adults succeed in finding meaning in life, even in deep old age. There is, however, a minority of older adults, in particular among the oldest old, who feel that life no longer makes sense: they suffer from the consequences of old age, explicated in feelings of loneliness, social isolation and disconnectedness, and fears for (further) decline and dependency. This article seeks to address this darker side of ageing. It discusses probing questions including: what can we learn from the stories of those who severely struggle with the consequences of old age? And how might these stories guide us in finding ways how we – both as fellow human beings and as a society – can face and respond to suffering in old age? To achieve this, this article first briefly outlines the scholarship on suffering and explores the idea of suffering from life in old age. Secondly, drawing on empirical work, it reflects on the phenomenological question: what is it like to suffer from life in old age? What does it mean to live with a deep sense that life is no longer worth living? Then, thirdly, building on these insights, the aim is to work towards developing an ethics of suffering that emphasises the primacy of witnessing. It is argued that in the confrontation with manifestations of meaninglessness and suffering that cannot be solved or remedied, we need bystanders who are willing to name, to narrate, to give voice and connect to these experiences of suffering.

Still ready to give up on life? A longitudinal phenomenological study into wishes to die among older adults

RATIONALE

There is a paucity of empirical studies exploring wishes to die (WTD) in older adults without a life-threatening disease or psychiatric disorder, especially on how these WTD evolve over time.

OBJECTIVE

This study aims to deepen our understanding of living with a WTD by elucidating multifaceted trajectories of death wishes in older adults without a life-threatening disease or psychiatric disorder.

METHODS

Interviews were conducted between 2013 and 2019 with Dutch men and women aged 70 and older who expressed a WTD (preferably at a self-chosen moment). Using a phenomenological, longitudinal analysis approach, 35 serial interviews were analyzed.

RESULTS

This resulted in four thematic meanings following four trajectories, namely: 1) a realized WTD, facing the ultimate decision with both freedom and a sense of fate; 2) an intensifying WTD, reaching a deadlock; 3) a diminishing WTD, experiencing tentative space for new possibilities; and 4) a vanishing WTD, being surprised by an unexpected turn. In the cases examined, the individuals' WTD was characterized by ambivalence and subject to change over time. Fluctuating, often asynchronous patterns of physical, social, psychological, and existential distress were lived intertwined. The WTD should thus be understood as dynamic and unpredictable, often impacted by external circumstances.

CONCLUSIONS

An important clinically relevant finding is that even persons with a pronounced WTD can experience openness to new possibilities, leading to a diminished or vanished WTD and/or desire to act on their WTD. Often such changes were related to (re-)establishment of connections with other people and/or society or with themselves. Since most research in this area is cross-sectional, the current longitudinal findings of this study are unique in providing insight into changes over time, thus contributing to the fields of death and suicide studies.

Current wishes to die; characteristics of middle-aged and older Dutch adults who are ready to give up on life: a cross-sectional study

BACKGROUND

Literature shows that middle-aged and older adults sometimes experience a wish to die. Reasons for these wishes may be complex and involve multiple factors. One important question is to what extent people with a wish to die have medically classifiable conditions.

AIM

(1) Estimate the prevalence of a current wish to die among middle-aged and older adults in The Netherlands; (2) explore which factors within domains of vulnerability (physical, cognitive, social and psychological) are associated with a current wish to die; (3) assess how many middle-aged and older adults with a current wish to die do not have a medically classifiable condition and/or an accumulation of age-related health problems.

METHODS

Data of 2015/16 from the Longitudinal Aging Study Amsterdam were used for this cross-sectional study (1563 Dutch middle-aged and older adults aged between 57 and 99 years), obtained through structured medical interviews and self-reported questionnaires. Three experienced physicians assessed whether the participants with a current wish to die could be classified as having a medically classifiable condition and/or an accumulation of age-related health problems.

RESULTS

N = 62 participants (4.0%) had a current wish to die. Having a current wish to die was associated with multiple characteristics across four domains of vulnerability, among which: self-perceived health, problems with memory, self-perceived quality of life and meaningfulness of life. Fifty-four participants with a current wish to die were assessed with having a medically classifiable condition, of which one was also assessed with having an accumulation of age-related health problems. Six people were assessed to have neither, and for two people it was unclear.

CONCLUSION

A small minority of middle-aged and older adults in the Netherlands have a current wish to die. Most of them can be classified with a medical condition and one person with an accumulation of age-related health problems. Furthermore, the findings show that having a current wish to die is multi-faceted. There is still a need for more knowledge, such as insight in to what extent suffering stemming from the medical classifiable disease contributes to the development of the wish to die.

Liminal space and the negotiation of care work in extra-care housing

This is a qualitative case study of care work in a liminal space, specifically the case of an extra-care housing residence, which is an innovative housing alternative for elderly people in need of care in Sweden. The study is an exploration of social care workers' perceptions about their workplaces and their understandings of themselves, which are shaped by their embeddedness in architectural space. The extra-care housing residence appeared as a liminal space in which two dominant spaces - home care services and residential care - underpinned the staff's perceptions of an unclear workplace and their identity work.

Experiences with counselling to people who wish to be able to self-determine the timing and manner of one's own end of life: a qualitative in-depth interview study

BACKGROUND

In the Netherlands, Foundation De Einder offers counselling to people who wish to be able to self-determine the timing and manner of their end of life.

AIM

This study explores the experiences with counselling that counselees receive(d) from counsellors facilitated by Foundation De Einder.

METHODS

Open coding and inductive analysis of in-depth interviews with 17 counselees.

RESULTS

Counselling ranged from solely receiving information about lethal medication to combining this with psychological counselling about matters of life and death, and the effects for close ones. Counselees appreciated the availability of the counsellor, their careful and open attitude, feeling respected and being reminded about their own responsibility. Some counselees felt dependent on the counsellor, or questioned their competency. Most counselees collected lethal medication. This gave them peace of mind and increased their quality of life, but also led to new concerns. Few were inclined to use their self-collected medication. Counselling contributed to thinking about if, when and how counselees would like to end their life.

CONCLUSION

Having obtained means to end their lives can offer people feelings of reassurance, which can increase their quality of life, but can also give rise to new concerns. Next to providing information on (collecting) lethal medication, counsellors can play an important role by having an open non-judgemental attitude, providing trustworthy information and being available. These positively valued aspects of counselling are also relevant for physicians taking care of patients who wish to self-determine the timing and manner of their end of life.

After providing end of life care to relatives, what care options do family caregivers prefer for themselves?

Objectives

We examined how caregivers who had cared for a relative at end of life (EoL) wished to be cared for in the event that they experienced advanced dementia or physical disability in the future, and what factors influenced their preferences for EoL care.

Methods

In this mixed-methods study, 83 participants, recruited from multiple sources in Israel, were interviewed concerning socio-demographic factors, health status, past experience with EoL, preference for extension of life vs. quality of life (QoL), willingness to be dependent on others, and preferences for EoL care.

Results

In case of advanced dementia, 58% preferred euthanasia or suicide; around a third chose those for physical disability. Care by family members was the least desired form of care in the advanced dementia scenario, although more desirable than institutional care in the physical disability scenario. QoL was rated as the highest factor impacting preferences for EoL care. Men demonstrated a higher preference than women for extension of life over QoL.

Conclusion

Our study points to the need for society to consider solutions to the request of participants to reject the type of EoL experienced by their relatives. Those solutions include investing in improving the quality of life at the end of life, and offering alternatives such as euthanasia, which a large proportion of our participants found ethically and medically appropriate within the current system of care in the event of severe physical disability, and more so in the event of advanced dementia.

Prevalence and characteristics of older adults with a persistent death wish without severe illness: a large cross-sectional survey

BACKGROUND

Some older persons develop a persistent death wish without being severely ill, often referred to as "completed life" or "tiredness of life". In the Netherlands and Belgium, the question whether these persons should have legal options for euthanasia or physician-assisted suicide (EAS) is intensely debated. Our main aim was to investigate the prevalence and characteristics of older adults with a persistent death wish without severe illness, as the lack of this knowledge is a crucial problem in de debate.

METHODS

We conducted a survey among a representative sample of 32,477 Dutch citizens aged 55+, comprising questions about health, existential issues and the nature of the death wish. Descriptive statistics were used to describe the group with a persistent death wish and no severe illness (PDW-NSI) and several subgroups.

RESULTS

A total of 21,294 respondents completed the questionnaire (response rate 65.6%). We identified 267 respondents (1.25%) as having a persistent death wish and no severe illness (PDW-NSI). PDW-NSI did not only occur among the oldest old. Although qualifying themselves as "not severely ill", those with PDW-NSI reported considerable health problems. A substantial minority of the PDW-NSI-group reported having had a death wish their whole lives. Within the group PDW-NSI 155 (0.73%) respondents had an active death wish, of which 36 (0.17% of the total response) reported a wish to actually end their lives. Thus, a death wish did not always equal a wish to actually end one's life. Moreover, the death wishes were often ambiguous. For example, almost half of the PDW-NSI-group (49.1%) indicated finding life worthwhile at this moment.

CONCLUSIONS

The identified characteristics challenge the dominant "completed life" or "tiredness of life" image of healthy persons over the age of 75 who, overseeing their lives, reasonably decide they would prefer to die. The results also show that death wishes without severe illness are often ambiguous and do not necessarily signify a wish to end one's life. It is of great importance to acknowledge these nuances and variety in the debate and in clinical practice, to be able to adequately recognize the persons involved and tailor to their needs.

The Experience of Adults Bereaved by the Suicide of a Close Elderly Relative: A Qualitative Pilot Study

Suicide in older persons is a serious issue in many countries. The act of intentionally causing one’s own death is often associated with lack of social support, thwarted belongingness, or chronic interpersonal difficulties. Therefore, suicide has a significant interpersonal dimension that can influence those left behind. However, studies that have investigated the impact of older adults’ suicide on their family are scarce. The objective of this pilot study was to assess the feasibility of a qualitative research on the psychosocial experience of adults bereaved by the suicide of an elderly relative. This research could recruit three participants (daughter, grand-son, and grand-niece) who had lost to suicide a close family member aged between 75 and 90. The analysis of the content of the semi-structured interviews revealed seven main themes: (1) finding an explanation to the suicide, (2) give meaning to the loss, (3) the emotional processes of mourning, (4) the repercussions of the suicide on the individual and the family, (5) looking for support, (6) the taboo and secrecy of suicide, and (7) perceptions of aging and the end of life. To explain the suicide of their loved one, the bereaved mentioned various factors related to aging, such as loss of autonomy, illness, and fear of placement. Although the older relative was perceived to be approaching death because of his/her age, the suicide was still unexpected and shocking and led to various emotions (shock, anger, and guilt) and to family conflicts. Suicide remains a taboo subject, but the newly legalized medical assistance in dying is seen as a potential solution to suffering in old age. Further investigation is clearly needed on this topic and this pilot study indicates that the main difficulties will lie in the choice of selection criteria for participants and in the recruitment process.

Relational autonomy in end-of-life care ethics: a contextualized approach to real-life complexities

Background

Respect for autonomy is a paramount principle in end-of-life ethics. Nevertheless, empirical studies show that decision-making, exclusively focused on the individual exercise of autonomy fails to align well with patients’ preferences at the end of life. The need for a more contextualized approach that meets real-life complexities experienced in end-of-life practices has been repeatedly advocated. In this regard, the notion of ‘relational autonomy’ may be a suitable alternative approach. Relational autonomy has even been advanced as a foundational notion of palliative care, shared decision-making, and advance-care planning. However, relational autonomy in end-of-life care is far from being clearly conceptualized or practically operationalized.

Main body

Here, we develop a relational account of autonomy in end-of-life care, one based on a dialogue between lived reality and conceptual thinking. We first show that the complexities of autonomy as experienced by patients and caregivers in end-of-life practices are inadequately acknowledged. Second, we critically reflect on how engaging a notion of relational autonomy can be an adequate answer to addressing these complexities. Our proposal brings into dialogue different ethical perspectives and incorporates multidimensional, socially embedded, scalar, and temporal aspects of relational theories of autonomy. We start our reflection with a case in end-of-life care, which we use as an illustration throughout our analysis.

Conclusion

This article develops a relational account of autonomy, which responds to major shortcomings uncovered in the mainstream interpretation of this principle and which can be applied to end-of-life care practices.

Autonomy and dying: Notes about decision-making and "completed life" euthanasia in the Netherlands

Euthanasia in the Netherlands is based on the notion that the person seeking assistance to die is able to make an autonomous decision. The objective of this study is to explore this notion, in particular, in the case of "tiredness of life." The article is mainly based on two qualitative researches and two selected case histories that provide an in-depth insight into the complex process of (not) reaching a clear decision. We found three obstacles that cast doubt over autonomous decision-making in the face of death: (1) Doctors - not patients - have the final say in "measuring" the "amount" of pain and suffering that entitles a person to be granted euthanasia. (2) Human decisions are always taken in a context of complex circumstances involving relatives, friends, and medical professionals. Decisions may therefore be changed, mitigated, or not taken at all. (3) People lose much of their autonomy when they grow old and fragile, and will be increasingly inclined or forced to leave decisions to others.

Rational Suicide in Late Life: A Systematic Review of the Literature

Background and Objectives: The complex concept of rational suicide, defined as a well-thought-out decision to die by an individual who is mentally competent, is even more controversial in the case of older adults. Materials and Methods: With the aim of better understanding the concept of rational suicide in older adults, we performed a systematic review of the literature, searching PubMed and Scopus databases and eventually including 23 published studies. Results: The main related topics emerging from the papers were: depression, self-determination, mental competence; physicians' and population's perspectives; approach to rational suicide; ageism; slippery slope. Conclusions: Despite contrasting positions and inconsistencies of the studies, the need to carefully investigate and address the expression of suicidal thoughts in older adults, as well as behaviours suggesting "silent" suicidal attitudes, clearly emerges, even in those situations where there is no diagnosable mental disorder. While premature conclusions about the "rationality" of patients' decision to die should be avoided, the possibility of rational suicide cannot be precluded.

Physical Health Problems as a Late-Life Suicide Precipitant: Examination of Coroner/Medical Examiner and Law Enforcement Reports

BACKGROUND AND OBJECTIVES

In light of high late-life suicide rates, we compared older suicide decedents with and without physical health problems as a suicide precipitant with respect to their clinical characteristics and suicide means. We also examined health-related concerns noted in summary coroner/medical examiner or law enforcement (CME/LE) reports.

RESEARCH DESIGN AND METHODS

The National Violent Death Reporting System, 2005-2014, provided data (N = 16,924 aged 65 or older). Quantitative data were analyzed using logistic regression models with physical health problems as a suicide precipitant as the dependent variable and depressive symptoms, other precipitating/risk factors, and suicide means as the independent variables. CME/LE reports were analyzed using content analysis and descriptive statistics.

RESULTS

Physical health problems were recorded as a suicide precipitant for 50% of the older decedents. Compared to those without, those with physical health problems as a precipitant were older and more likely to have had depressed mood (adjusted odds ratios [AOR] = 2.39, 95% confidence interval [CI] = 2.21-2.59 for men and AOR = 1.79, 95% CI = 1.50-2.14 for women), disclosed suicide intent, left a suicide note, and used a firearm as suicide means. In CME/LE reports, pain and cancer were mentioned most frequently (29% and 28%, respectively). Dementia-related functional decline, fear of becoming a burden to loved ones, refusal of nursing homes, and loss of independence were also mentioned.

DISCUSSION AND IMPLICATIONS

Study findings call for more targeted, intensive suicide prevention strategies for older adults suffering from debilitating and painful health conditions. Training health care providers and informal support systems to assess suicide risk and in evidence-based intervention plans/guidelines is needed.

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

RESEARCH AIMS

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

STUDY POPULATION

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

STUDY DESIGN AND METHODS

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

RESULTS

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

INTERPRETATION

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

The social-political challenges behind the wish to die in older people who consider their lives to be completed and no longer worth living

In the Netherlands, physician-assisted dying has been legalized since 2002. Currently, an increasing number of Dutch citizens are in favour of a more relaxed interpretation of the law. Based on an ethos of self-determination and autonomy, there is a strong political lobby for the legal right to assisted dying when life is considered to be completed and no longer worth living. Building on previous empirical research, this article provides a critical ethical reflection upon this social issue. In the first part, we discuss the following question: what is the lived experience of older people who consider their lives to be completed and no longer worth living? We describe the reported loss of a sense of autonomy, dignity and independence in the lives of these older people. In the second part, from an ethics of care stance, we analyse the emerging social and political challenges behind the wish to die. Empirically grounded, the authors argue that the debate on 'completed life in old age' should primarily focus not on the question of whether or not to legitimize a self-directed death but on how to build an inclusive society where people may feel less unneeded, useless and marginalized.

First-line nurse managers' perceptions of the challenges involved in decision-making when older patients' wish to die

Aim

The aim of this study was to explore first‐line nurse managers’ perceptions of the challenges involved in decision‐making concerning older patients who wish to die.

Design

A descriptive qualitative design in three communities in Norway between January 2016 and June 2016.

Methods

Qualitative focus group interviews with eight first‐line nurse managers.

Results

One main theme and two themes were identified: Struggling to make the right decision, The challenge of social isolation and loneliness and When life becomes too painful and problematic. The sub‐themes revealed that: Arranging social meeting places where the older patients can talk to other older people is crucial. The participants explained that it was not an easy task to gain an overview of the older patients situation. The right decision could be encouraging the patients to talk about their problems by giving them more time, thereby showing that somebody cares about them.

Older Suicide Decedents: Intent Disclosure, Mental and Physical Health, and Suicide Means

INTRODUCTION

This study examined: (1) associations of suicide intent disclosure with depressed mood and health problems; (2) age-group differences in those associations; and (3) relationship between disclosure and suicide means among suicide decedents aged ≥50 years (N=46,857).

METHODS

Data came from the National Violent Death Reporting Systems, 2005-2014. Data analysis was conducted in 2017. Chi-square tests were used to compare disclosers and nondisclosers on sociodemographic and precipitating factors and suicide means. Logistic regression analyses were used to examine the research questions.

RESULTS

The overall disclosure rate was 23.4%. Logistic regression results showed that both depressed mood (AOR=1.57, 95% CI=1.50, 1.65, p<0.001) and health problems (AOR=1.56, 95% CI=1.48, 1.64, p<0.001) were associated with increased odds of disclosure. Compared with decedents aged 50-59 years, those aged 70-79 years and ≥80 years had greater disclosure odds. When interaction terms of age group X health problems were entered in the model, disclosure odds increased among those with health problems in the groups aged 60-69 years (ratio of AOR=1.19, 95% CI=1.06, 1.34, p=0.003), 70-79 years (ratio of AOR=1.29, 95% CI=1.13, 1.48, p<0.001), and ≥80 years (ratio of AOR=1.41, 95% CI=1.20, 1.66, p<0.001). Compared with other suicide means, both firearm use and hanging/suffocation were associated with lower disclosure odds.

CONCLUSIONS

The older the decedents were, the more likely they were to have disclosed suicidal intent, and health problems largely explained their higher odds of disclosure. Healthcare providers need better preparation to screen and aid those in need to prevent suicide. Social support system members should also be assisted in identifying warning signs and linking older adults to services.

A Captive, a Wreck, a Piece of Dirt: Aging Anxieties Embodied in Older People With a Death Wish

The aims of this present study were to explore the use and meaning of metaphors and images about aging in older people with a death wish and to elucidate what these metaphors and images tell us about their self-understanding and imagined feared future. Twenty-five in-depth interviews with Dutch older people with a death wish (median 82 years) were analyzed by making use of a phenomenological-hermeneutical metaphor analysis approach. We found 10 central metaphorical concepts: (a) struggle, (b) victimhood, (c) void, (d) stagnation, (e) captivity, (f) breakdown, (g) redundancy, (h) subhumanization, (i) burden, and (j) childhood. It appears that the group under research does have profound negative impressions of old age and about themselves being or becoming old. The discourse used reveals a strong sense of distance, disengagement, and nonbelonging associated with their wish to die. This study empirically supports the theory of stereotype embodiment.

Researching Health Care as a Meaningful Practice: Toward a Nondualistic View on Evidence for Qualitative Research

Being able to describe how research findings become evidence is crucial in providing a justification for all kinds of research findings. However, qualitative researchers in health care, including those who conduct phenomenological research, are usually fairly modest when it comes qualifying their research findings as such. We advocate a view of evidence for phenomenological research, an approach that is rooted in philosophy of science, including perspectives of ontology, epistemology, and methodology. We suggest that phenomenology can become an exemplar for how qualitative research can make convincing arguments and thus can be better appreciated. In this article, we present a philosophical foundation for phenomenological evidence by exploring the notions of objectivity, validity, and generalizability in terms of openness, meaning, and essence.

Disconnectedness from the here-and-now: a phenomenological perspective as a counteract on the medicalisation of death wishes in elderly people

When elderly people are ideating on manners to end their lives, because they feel life is over and no longer worth living, it is important to understand their lived experiences, thoughts and behaviour in order to appropriately align care, support and policy to the needs of these people. In the literature, the wish to die in elderly people is often understood from a medical, psychopathological paradigm, referred to as cognitive impairment, depressive disorder, pathological bereavement, and suicidality. In this paper, we evaluate this dominant paradigm by considering three serious limitations, namely: (1) the risk of epistemic transformation; (2) the risk of reduction; and (3) the risk of obscuring the social and cultural embeddedness. Drawing on insights from our empirical-phenomenological research on the issue of elderly and the self-chosen death, this paper argues for a phenomenological perspective to counteract the medicalisation of death wishes in elderly people.