Responding to desire to die statements from patients with advanced disease: recommendations for health professionals

Facing a request for assisted death - views of Finnish physicians, a mixed method study

BACKGROUND

Assisted death, including euthanasia and physician-assisted suicide (PAS), is under debate worldwide, and these practices are adopted in many Western countries. Physicians' attitudes toward assisted death vary across the globe, but little is known about physicians' actual reactions when facing a request for assisted death. There is a clear gap in evidence on how physicians act and respond to patients' requests for assisted death in countries where these actions are not legal.

METHODS

A survey including statements concerning euthanasia and PAS and an open question about their actions when facing a request for assisted death was sent to all Finnish physicians. Quantitative data are presented as numbers and percentages. Statistical significance was tested by using the Pearson chi-square test, when appropriate. The qualitative analysis was performed by using an inductive content analysis approach, where categories emerge from the data.

RESULTS

Altogether, 6889 physicians or medical students answered the survey, yielding a response rate of 26%. One-third of participants agreed or partly agreed that they could assist a patient in a suicide. The majority (69%) of the participants fully or partly agreed that euthanasia should only be accepted due to difficult physical symptoms, while 12% fully or partly agreed that life turning into a burden should be an acceptable reason for euthanasia. Of the participants, 16% had faced a request for euthanasia or PAS, and 3033 answers from 2565 respondents were achieved to the open questions concerning their actions regarding the request and ethical aspects of assisted death. In the qualitative analysis, six main categories, including 22 subcategories, were formed regarding the phenomenon of how physicians act when facing this request. The six main categories were as follows: providing an alternative to the request, enabling care and support, ignoring the request, giving a reasoned refusal, complying with the request, and seeing the request as a possibility.

CONCLUSIONS

Finnish physicians' actions regarding the requests for assisted death, and attitudes toward euthanasia and PAS vary substantially. Open discussion, education, and recommendations concerning a request for assisted death and ethics around it are also highly needed in countries where euthanasia and PAS are not legal.

Norwegian nurses' perceptions of assisted dying requests from terminally ill patients-A qualitative interview study

This study explores the perceptions of Norwegian nurses who have received assisted dying requests from terminally ill patients. Assisted dying is illegal in Norway, while in some countries, it is an option. Nurses caring for terminally ill patients may experience ethical challenges by receiving requests for euthanasia and assisted suicide. We applied a qualitative research design with a phenomenological hermeneutic approach using open individual interviews. A total of 15 registered nurses employed in pulmonary and oncology wards of three university hospitals and home care in one municipality were recruited. Four themes emerged from the analysis: (1) unprepared for the request; (2) meeting direct, indirect, and nonverbal requests; (3) working in a gray zone, and (4) feeling alone and powerless. The study found that nurses were unsure how to handle such requests due to professional uncertainty about assisted dying. Working in an environment where the topic is taboo made nurses morally uncertain, and some perceived this as moral distress. The hospital chaplain played a significant role in providing support to these nurses.

Palliative Care and Physician Assisted Death

In the recent decade quite a few countries and regions legalised physician assisted death. While palliative care is already or becoming the standard end of life care in many countries, the increased availability of physician assisted death coupled with the secularisation of hospice in more settings require – where this has not happened yet – a clear response of palliative care specialists to patients’ requests for physician assisted death. The paper analyses the World Health Organisation’s current description of palliative care with a special focus on its prohibition of hastening death. Some palliative care professionals do not agree with the ban on hastening death, and these professionals’ non-conventional interpretation of palliative care actually seems to meet the wishes of some patients.

Desire to Die: How Does the Patients' Chorus Sound?

Patients receiving palliative care often express a desire to die. Forms and backgrounds of these expressions can be diverse. To contribute to a better understanding of this phenomenon, we analyzed patients' desire to die expressions reported by palliative care providers participating in 11 communication trainings on desire to die. The 102 participants were asked to reproduce related patients' statements from their everyday practice. The 165 reported statements could be assigned to the four topics: "Putting an end to life by …," "Social death," "Death images," as well as "Specific and unspecific references to life, death and dying." Across these topics, phrasing differs particularly regarding sentence type (interrogative, declarative, propositional, exclamatory), explicitness and (the way of) referencing others (e.g. attribution of power). The compilation of statements reflects a chorus of expressions, which the palliative care providers might hear throughout their professional career as well as during a patient's process(ing) of disease.

Desire to Die Statements in the Era of Voluntary Assisted Dying: An Audit of Patients Known to a Victorian Consultation-Liaison Palliative Care Service

Objectives: In the new era of voluntary assisted dying (VAD) legislation in Australia, this study aimed to explore (1) underlying reasons for desire to die statements (DTDSs), (2) clinician responses to DTDSs and (3) whether DTDSs were a true request for VAD. Methods: Clinical audit using an existing prospectively collected quality assurance database, supplemented by electronic medical records. Patients known to a consultation-liaison palliative care service who expressed a DTDS between October 2019 and September 2020 were included. Results: Forty-one patients were included; 29 (71%) were male, 29 (71%) had a malignancy and 31 (76%) expressed a DTDS more than once. Uncontrolled psychological symptoms were present more often than physical (n = 30 vs 19 [73% vs 46%]), yet physical symptoms were addressed more frequently than psychological (80% vs 63% of the time). Based on available data, the VAD assessment process was commenced by 7 patients, and death by VAD occurred for 2 patients. Conclusions: In our study, DTDSs were complex, multi-layered requests that more commonly reflected psychological rather than physical suffering. Though VAD is now legally possible, a DTDS was not always synonymous with a request for VAD. Key to responding to these requests are high levels of clinician confidence and communication skills. Training in this area remains critical for the experience of both patients and clinicians.

Role and responsibility of oncologists in assisted suicide. Practice and views among members of the German Society of Haematology and Medical Oncology

Background

Physician-assisted suicide (PAS) is a controversial practice and regulatory frameworks differ regarding assigned physicians' roles. This study explores clinical experience and views of German oncologists concerning ethically and legally relevant aspects of PAS after change of the law.

Materials and methods

An online survey was conducted among members of the German Society of Haematology and Medical Oncology (DGHO) in March 2021. Descriptive analysis, bivariate and multivariable logistic regression of quantitative data on determinants related to (un)willingness to assist with suicide as well qualitative analysis of free-text comments were carried out.

Results

Seven hundred and forty-five of 3588 DGHO members responded (20.8%). Of these, 29.9% reported requests for a lethal drug and 3.0% (n = 22) reported to have assisted with suicide. Almost half of them (47.0%, n = 350) objected to providing PAS, whereas 45.9% indicated a willingness at least under certain conditions. Of those respondents who did not object to PAS, 25.4% would also consider assistance if those willing to die had a psychiatric disease and 10.2% if requestors had no disease at all. A majority viewed a role for physicians regarding different tasks associated with assisted suicide. Respondents with <10 years of professional experience, working in hospital with religious affiliation and with subspecialisation in palliative care were significantly less frequently willing to assist suicide.

Conclusions

Respondents are divided in their personal attitudes towards PAS but a majority supports involvement of physicians regarding different tasks related to assisted suicide. Data about the practice and envisaged professional role may inform development of an acceptable ethico-legal framework for a controversial practice.

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In Germany, as in other countries, assisted suicide has become lawful more recently.

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To be able to develop guidance on the highly controversial subject, empirical data on practice and related aspects are needed.

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30% of responding oncologists report requests for lethal drugs by their patients and 3% have assisted with suicide.

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Compared with 2015, significantly more oncologists report requests for lethal drugs and willingness to assist with suicide.

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Palliative care qualification and less professional experience were negatively associated with willingness to assist suicide.

Suicide in obstructive lung, cardiovascular and oncological disease

Healthcare institutions face increasing demands stemming from the burden of noncommunicable diseases. The personal, social, financial and societal impact of these diseases are well-documented. However, the mental health concerns and trajectories of patients afflicted by chronic medical diseases have been under-recognized and are under-resourced. Despite that chronic diseases are associated with substantially increased risk of suicide, the medical world has largely failed to properly address suicide in the medically ill. Considering their high prevalence and mortality rate, this review article will highlight the mental health burden and suicide risk in obstructive lung, cardiovascular (including stroke) and oncological disease, in light of relevant data and conceptual models of suicide. Finally, general evidence-based suicide intervention strategies and potential selective adaptation of these strategies to the chronic medically ill patient populations and medical settings will be reviewed.

"Withstanding ambivalence is of particular importance"-Controversies among experts on dealing with desire to die in palliative care

In order to investigate controversies surrounding the desire to die phenomenon in palliative care by analyzing expert opinions on the topic, we carried out a secondary qualitative data analysis of free text comments collected during a Delphi survey that was designed to develop a conversation aid for dealing with desire to die in everyday clinical practice. Between 01/2018 and 03/2018, a two-round Delphi survey was carried out with national (German) and international palliative care experts. Free text comments were reinvestigated to identify controversies surrounding the desire to die phenomenon. An additional in-depth analysis focused on statements expressing attitudes towards proactively addressing (potential) desires to die. Within the Delphi survey, 103 of 149 multi-professional participants (almost all of them with practical and only six with exclusively theoretical expertise in palliative care) generated 444 free text comments. Thereof, we identified three main categories related to dealing with desire to die: "outer framework", "extended care system" and "health-professional-patient-relationship". Ambivalences, taboos and uncertainties surrounding desire to die in palliative care became apparent. Experts are divided concerning the practice of proactively addressing desire to die. Even if these conversations-especially the proactive approach-are also viewed critically, we conclude that open-ended and respectful communication about desire to die between health professionals and patients can be understood as an eligible intervention in palliative care. Proactively addressing the topic is a possible way to open up such conversations.

Factors Associated With Terminally Ill People Who Want to Die

CONTEXT

The decision to request and proceed with euthanasia or physician-assisted dying is complex, and predictors of such decisions are heterogeneous with regard to physical health, psychological, and social factors. Local research is therefore needed.

OBJECTIVES

To examine the interplay of demographic, clinical, and psychosocial factors routinely collected by a standardized clinical instrument, the interRAI Resident Assessment Instrument for Palliative Care (interRAI-PC), in people with a prognosis of less than 12 months who wanted to die.

METHODS

All New Zealanders who had an interRAI-PC in 2018 were included. The outcome variable was the single item Wants to die now. Independent variables included biopsychosocial factors and health index scales generated by interRAI-PC. A binary logistic regression was used to determine the predictive factors of Wants to die now (yes vs. no).

RESULTS

There were 771 individuals included (mean age 76.0 years; SD 11.6; female 50.1%); 9.3% of whom reported yes to Wants to die now, 59.8% no, and for 30.9%, the assessor was unable to determine. The factors with the largest odds ratios (ORs) were awareness of terminal prognosis (OR 4.8; 95% CI 2.2-10.3), high level of depression (OR 4.6; 95% CI 1.7-12.6), not finding meaning in day-to-day life (OR 3.8; 95% CI 1.8-8.1), and pain (less than severe: OR 3.7; 95% CI 1.3-10.4 and severe to excruciating: OR 3.5; 95% CI 1.1-10.7).

CONCLUSION

Addressing the significant factors we identified should form part of a multidisciplinary assessment when terminally ill patients express a wish to die, to ensure their physical, psychological, and existential needs are adequately met.

Management of Grief, Depression, and Suicidal Thoughts in Serious Illness

The varied physical, social, and psychological stressors that accompany advanced disease can be burdensome and cause intense emotional suffering, hindering the ability of patients and families to cope in day-to-day life and negatively affecting quality of life. This article addresses key concepts for the assessment and management of commonly encountered types of psychological distress in serious illness including grief, prolonged grief, major depressive disorder, death contemplation, and suicidal ideation.

The desire to die in palliative care: a sequential mixed methods study to develop a semi-structured clinical approach

BACKGROUND

Although desire to die of varying intensity and permanence is frequent in patients receiving palliative care, uncertainty exists concerning appropriate therapeutic responses to it. To support health professionals in dealing with patients´ potential desire to die, a training program and a semi-structured clinical approach was developed. This study aimed for a revision of and consensus building on the clinical approach to support proactively addressing desire to die and routine exploration of death and dying distress.

METHODS

Within a sequential mixed methods design, we invited 16 palliative patients to participate in semi-structured interviews and 377 (inter-)national experts to attend a two-round Delphi process. Interviews were analyzed using qualitative content analysis and an agreement consensus for the Delphi was determined according to predefined criteria.

RESULTS

11 (69%) patients from different settings participated in face-to-face interviews. As key issues for conversations on desire to die they pointed out the relationship between professionals and patients, the setting and support from external experts, if required. A set of 149 (40%) experts (132/89% from Germany, 17/11% from 9 other countries) evaluated ten domains of the semi-structured clinical approach. There was immediate consensus on nine domains concerning conversation design, suggestions for (self-)reflection, and further recommended action. The one domain in which consensus was not achieved until the second round was "proactively addressing desire to die".

CONCLUSIONS

We have provided the first semi-structured clinical approach to identify and address desire to die and to respond therapeutically - based on evidence, patients' views and consensus among professional experts.

TRIAL REGISTRATION

The study is registered in the German Clinical Trials Register (DRKS00012988; registration date: 27.9.2017) and in the Health Services Research Database (VfD_DEDIPOM_17_003889; registration date: 14.9.2017).

Communication about the desire to die: Development and evaluation of a first needs-oriented training concept - A pilot study

OBJECTIVE

Patients' desire to die (DD) is rarely discussed in palliative care (PC) due to health professionals' (HPs) feeling of uncertainty. The aim of the study was to develop and evaluate a training to increase HPs' self-confidence in responding professionally to patient's DD and to assess the feasibility of this approach.

METHODS

The training course was developed via focus groups and relevant literature and refined with an advisory board. An evaluation design was developed to evaluate training outcomes and to examine feasibility. To assess self-confidence, knowledge, skills, and attitudes: (1) standardized surveys were applied at T1 (before training), T2 (directly after), and T3 (3 months later), and were analyzed by descriptive and non-parametric statistics; and (2) participants' open feedback was summarized by content.

RESULTS

A two-day multi-disciplinary training was developed to improve self-confidence via diverse teaching methods. Twenty-four HPs from general and specialized PC were participated. Via self-rating on Likert scales at three time points, improvements were seen at T1, T2, and partly remained at T3, especially in the overall item of self-confidence in communicating with patients about their DD (means: 4.3. at T1, 5.7 at T2, and 5.9 at T3; on a 7-point scale with 1 = lowest value and 7 = highest value). Fewer improvements were found in skills (using different approaches) and attitudes (feeling less helplessness). Open feedback revealed a high appreciation for the training, especially the composition of participants, the role-play, and the overall increase of awareness of the topic.

SIGNIFICANCE OF RESULTS

The developed training on addressing DD meets a need and was perceived by the participants to be of added value. Future research should measure training effects with a validated instrument, including more participants, diverse participant groups, and a control group. Effects on patients should be assessed.

Voluntary Stopping Eating and Drinking

Voluntary stopping of eating and drinking (VSED) is a deliberate, self-initiated attempt to hasten death in the setting of suffering refractory to optimal palliative interventions or prolonged dying that a person finds intolerable. Individuals who consider VSED tend to be older, have a serious but not always imminently terminal illness, place a high value on independence, and have significant illness burden. VSED can theoretically be performed independent of clinician assistance and therefore avoids many of the ethical and legal concerns associated with physician-assisted dying or other palliative measures of last resort, However, VSED is an intense process fraught with new sources of somatic and emotional suffering for individuals and their caregivers, so VSED is best supervised by an experienced, well-informed clinician who can provide appropriate pre-intervention assessment, anticipatory guidance, medical treatment of symptoms, and emotional support. Before initiation of VSED, clinicians should carefully screen for inadequately treated psychiatric conditions, unaddressed symptoms, existential suffering, and evidence of coercion-consultation from palliative medicine, psychiatry, or ethics is often indicated. The most common symptoms encountered after starting VSED are extreme thirst, hunger, dysuria, progressive disability, delirium, and somnolence. Although physiologically similar to cessation of artificial nutrition and hydration, the onset and management of symptoms is often different. We propose an organized system for evaluating individual appropriateness for VSED, anticipatory guidance, and management of symptoms associated with VSED. A brief review of ethical and legal considerations follows.

CUIDADOS EM SAÚDE: SOCIABILIDADES CUIDADORAS E SUBJETIVIDADES EMANCIPADORAS

Resumo Embora predominem as aplicações técnico/tecnológicas na assistência à saúde como parâmetro e qualificação das ações de cuidado cresce a valorização de uma atenção que abranja mais amplamente a vida dos sujeitos, frente ao reconhecimento que o apoio social e a preocupação afetiva são constitutivos e fundamentais para a efetivação do cuidado. Objetivou-se apreender as reflexões sobre o cuidado à saúde enfocando os aspectos de sociabilidade e de subjetividade. Para tanto, realizou-se uma revisão sistemática de literatura, entre 2003 e 2013, em dez bases de dados. De 262 artigos identificados, foram selecionados 36 que enfocam a subjetividade nas ações de cuidado. Há um questionamento acerca do potencial de cuidado biomédico e suas limitações para atender às múltiplas demandas implícitas nos processos de saúde e doença. Conclui-se que a subjetividade e, em seu interior, a sociabilidade, são partes intrínsecas das ações de cuidado.

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.

The DEsire to DIe in Palliative care: Optimization of Management (DEDIPOM) - a study protocol

BACKGROUND

A desire to die (DD) is frequent in palliative care (PC). However, uncertainty remains as to the appropriate therapeutic response. (Proactive) discussion of DD is not usually part of standard care. To support health practitioners' (HPs) reactions to a patient's DD, a training program has been developed, piloted and evaluated. Within this framework, a first draft of a semi-structured clinical interview schedule with prompts (CISP) has been developed, including recommendations for action to support HPs' self-confidence. The aim of this study is the further development of the CISP to support routine exploration of death and dying distress and proactive addressing of a DD.

METHODS

This observatory, prospective health services study comprises a three step study design: 1. Revision of the CISP and consensus finding based on semi-structured interviews with patients and a Delphi process with (inter-)national experts, patient representatives and relatives; 2. Increasing confidence in HPs through a 2 day-training program using the consented CISP; 3. A formative quantitative evaluation of conversations between HPs and patients (300 palliative patients at three time points) and a qualitative evaluation based on interview triads of patients, relatives and HPs. The evaluation of conversations will include patient-oriented outcomes, including perceived relationships with HPs and death and dying distress. We will also consider aspects of social inequality and gender.

DISCUSSION

The intervention can provide a framework for open discussion of DD and a basis for enhancing a trustful HP-patient relationship in which such difficult topics can be addressed. The benefits of this study will include (a) the creation of the first consented semi-structured approach to identify and address DD and to respond therapeutically, (b) the multi-professional enhancement of confidence in dealing with patients' DD and an intervention that can flexibly be integrated into other training and education programs and (c) an evaluation of effects of this intervention on patients, relatives and HPs, with attention to social inequality and gender.

TRIAL REGISTRATION

The study is registered in the German Clinical Trials Register ( DRKS00012988 ; registration date: 27.9.2017) and in the Health Services Research Database ( VfD_DEDIPOM_17_003889 ; registration date: 14.9.2017).

Meaning in Life as a Mediator Between Physical Impairment and the Wish to Hasten Death in Patients With Advanced Cancer

CONTEXT

Meaning in life (MiL) is a key factor for ensuring spiritual well-being and quality of life among patients with life-threatening illnesses. However, the role of MiL in relation to the wish to hasten death (WTHD) and its interaction with other physical and psychological factors in patients with advanced cancer has not yet been studied.

OBJECTIVE

The objective of this study was to analyze the relationship between the WTHD and MiL and to propose a theoretical model of functional relationships among WTHD, performance status, depression, and MiL.

METHODS

This is a cross-sectional study of 101 patients in a palliative care unit, who were assessed in the context of a clinical interview. Outcome measures included performance status, depression, MiL, and the WTHD. Structural equation modeling was used to analyze the functional relationships between these factors.

RESULTS

The WTHD correlated significantly (P < 0.01) with MiL (r = 0.60), performance status (r = 0.548), and depression (r = 0.397). The structural equation modeling analysis showed that although there was no significant direct effect between performance status and the WTHD, there was a significant total effect because of the mediation of depression and MiL. The latter played the most significant role, accounting for 76.5% of the mediation.

CONCLUSION

These results support the proposed model and provide evidence of a mediator effect of MiL and depression on the relationship between physical impairment and the WTHD in advanced patients. Our findings suggest that interventions to enhance MiL could help to address and/or prevent the emergence of a WTHD in this population.

Caring for Clients and Families With Anxiety: Home Care Nurses' Practice Narratives

This study elucidated Japanese home care nurses’ experiences of supporting clients and families with anxiety. We interviewed 10 registered nurses working in home care agencies and analyzed the data using grounded theory to derive categories pertaining to the nurses’ experiences of providing care. We conceptualized nurses’ approaches to caring for anxiety into three categories: First, they attempted to reach out for anxiety even when the client/family did not make it explicit; second, they tried to alter the outlook of the situation; and third, they created comfort in the lives of the client/family. The conceptualizations of nurses’ strategies to alleviate client/family anxiety may reflect Japanese/Eastern cultural characteristics in communication and their view of the person and social care system, but these conceptualizations may also inform the practice of Western nurses by increasing awareness of skills they may also have and use.

Exploring the interface between 'physician-assisted death' and palliative care: cross-sectional data from Australasian palliative care specialists

BACKGROUND

Legalisation of physician-assisted dying (PAD) remains a highly contested issue. In the Australasian context, the opinion and perspective of palliative care specialists have not been captured empirically, and are required to inform better the debate around this issue, moving forward.

AIM

To identify current attitudes and experiences of palliative care specialists in Australasia regarding requests for physician-assisted suicide and voluntary euthanasia, and to capture the opinion of palliative care specialists on the legalisation of these practices in the Australasian context.

METHOD

An anonymous, cross-sectional, online survey of Australasian specialists in palliative care, addressing the following six areas: (i) demographics; (ii) frequency of requests, and response given; (iii) understanding of the term 'voluntary euthanasia'; (iv) opinion regarding legalisation of physician-assisted suicide and voluntary euthanasia in Australasia, and willingness to participate if legal; (v) identification of the most important values guiding this opinion; and (vi) anticipated impact that legalisation of assisted death would have on palliative care practice.

RESULTS

Important findings include: (i) palliative care specialists are largely opposed to the legalisation of PAD; (ii) the proportional titration of opioids is not understood by any palliative care specialist studied to be 'voluntary euthanasia'; and (iii) there is a wide variation in frequency of requests, and one-third of palliative care specialists express discomfort in dealing with requests for assisted suicide or euthanasia.

CONCLUSION

Key areas for future research at the interface between PAD and best practice end-of-life care are identified, including exploration into why palliative care specialists are largely opposed to PAD, and consideration of the impact 'the opioid misconception' may have on the literature informing this debate.

Palliative Care of Adult Patients With Cancer

BACKGROUND

In Germany, the annual mortality rate from cancer in the year 2011 was 269.9 deaths per 100 000 persons; every fourth death was due to cancer. A central objective of palliative care is to maintain the best possible quality of life for cancer patients right up to the end of their lives.

METHODS

The PubMed, Embase, and Cochrane Library databases were systematically searched for pertinent publications, and the ones that were selected were assessed as recommended by the Scottish Intercollegiate Guidelines Network. As part of the German Guideline Program in Oncology, recommendations for the S3 Guideline on Palliative Care concerning seven different topics in the management of adult patients with incurable cancer were developed by a representative expert panel employing a consensus process.

RESULTS

Opioids are the drugs of first choice for severe and moderately severe cancer-related pain, and for breathlessness. No clinically relevant respiratory depression was observed in any study. When opioids are used, accompanying medication to prevent constipation is recommended. Drugs other than opioids are ineffective against breathlessness, but clinical experience has shown that benzodiazepines and opioids can be used in combination in advanced stages of disease, or if the patient suffers from marked anxiety. Depression should be treated even in patients with a short life expectancy; psychotherapy is indicated, and antidepressant medication is indicated as well if depression is at least moderately severe. Communication skills, an essential component of palliative care, play a major role in conversations between the physician and the patient about the diagnosis, the prognosis, and the patient's wish to hasten death. When the dying phase begins, tumor-specific treatments should be stopped.

CONCLUSION

Palliative care should be offered to cancer patients with incurable disease. Generalist and specialist palliative care constitute a central component of patient care, with the goal of achieving the best possible quality of life for the patient.

Patients Feeling Severely Affected by Multiple Sclerosis

Eleven months after being interviewed in a study on unmet needs of severely affected multiple sclerosis patients, one participant died by assisted suicide. We reanalyzed the data to find out if our 15 study patients might have brought up the topic of death and dying during episodic interviews that had not primarily addressed this issue. Secondary analysis with regard to the thematic field of death and dying revealed that patients unsolicited brought up this issue within the following categories: “Passing over death and dying,” “Death is not relevant to me,” “We want to keep up the life challenge,” “Death as an option,” and “Wish to have the opportunity to address end of life issues.” We conclude that the topic of death and dying is of importance to these patients, as they spontaneously mentioned it in multiple varieties. Health professionals should individually acknowledge patients' needs to address death and dying.

Clinical Criteria for Physician Aid in Dying

More than 20 years ago, even before voters in Oregon had enacted the first aid in dying (AID) statute in the United States, Timothy Quill and colleagues proposed clinical criteria AID. Their proposal was carefully considered and temperate, but there were little data on the practice of AID at the time. (With AID, a physician writes a prescription for life-ending medication for a terminally ill, mentally capacitated adult.) With the passage of time, a substantial body of data on AID has developed from the states of Oregon and Washington. For more than 17 years, physicians in Oregon have been authorized to provide a prescription for AID. Accordingly, we have updated the clinical criteria of Quill, et al., based on the many years of experience with AID. With more jurisdictions authorizing AID, it is critical that physicians can turn to reliable clinical criteria. As with any medical practice, AID must be provided in a safe and effective manner. Physicians need to know (1) how to respond to a patient's inquiry about AID, (2) how to assess patient decision making capacity, and (3) how to address a range of other issues that may arise. To ensure that physicians have the guidance they need, Compassion & Choices convened the Physician Aid-in-Dying Clinical Criteria Committee, in July 2012, to create clinical criteria for physicians who are willing to provide AID to patients who request it. The committee includes experts in medicine, law, bioethics, hospice, nursing, social work, and pharmacy. Using an iterative consensus process, the Committee drafted the criteria over a one-year period.

The desire to hasten death: Using Grounded Theory for a better understanding "When perception of time tends to be a slippery slope"

BACKGROUND

Some patients with advanced and progressive diseases express a desire to hasten death.

AIM

This study evaluated the motivations of patients expressing such a desire in a country with prohibitive legislation on euthanasia and physician-assisted suicide.

DESIGN

A modified form of Grounded Theory was used.

SETTING/PARTICIPANTS

Patients from the departments of palliative medicine in three hospitals in Germany were recruited when they had made a statement or request to hasten death. Participants were interviewed face to face. Recruitment was stopped with 12 participants because of data saturation.

RESULTS

Thematic analysis revealed three main motivational themes: self-determination, agony, and time. Expectations toward health professionals, attitudes toward death, and secureness related to the end of life were additional main themes emerging from the analysis.

CONCLUSIONS

The desire to hasten death may be used as an extreme coping strategy to maintain control against anticipated agony. Patients expected health professionals to listen to and respect their experiences. Emerging hypotheses included the following: (a) patients try to balance life time and anticipated agony, and the perception of time is distressing in this balancing act; (b) anticipated images of agony and suffering in the dying process occur frequently and are experienced by patients as intrusive; (c) patients expressing a desire to hasten death are in need of more information about the dying process; and (d) patients wanted their caregivers to listen to and respect their wish to hasten death, and they did not expect the caregivers to understand this as an order to actually hasten their death.

Physician-assisted suicide and/or euthanasia: Pragmatic implications for palliative care [corrected]

OBJECTIVE

Despite the availability of palliative care in many countries, legalization of euthanasia and physician-assisted suicide (EAS) continues to be debated-particularly around ethical and legal issues--and the surrounding controversy shows no signs of abating. Responding to EAS requests is considered one of the most difficult healthcare responsibilities. In the present paper, we highlight some of the less frequently discussed practical implications for palliative care provision if EAS were to be legalized. Our aim was not to take an explicit anti-EAS stance or expand on findings from systematic reviews or philosophical and ethico-legal treatises, but rather to offer clinical perspectives and the potential pragmatic implications of legalized EAS for palliative care provision, patients and families, healthcare professionals, and the broader community.

METHOD

We provide insights from our multidisciplinary clinical experience, coupled with those from various jurisdictions where EAS is, or has been, legalized.

RESULTS

We believe that these issues, many of which are encountered at the bedside, must be considered in detail so that the pragmatic implications of EAS can be comprehensively considered.

SIGNIFICANCE OF RESULTS

Increased resources and effort must be directed toward training, research, community engagement, and ensuring adequate resourcing for palliative care before further consideration is given to allocating resources for legalizing euthanasia and physician-assisted suicide.

Unbearable suffering and requests for euthanasia prospectively studied in end-of-life cancer patients in primary care

Background

An international discussion about whether or not to legally permit euthanasia and (or) physician assisted suicide (EAS) is ongoing. Unbearable suffering in patients may result in a request for EAS. In the Netherlands EAS is legally permitted, and unbearable suffering is one of the central compulsory criteria. The majority of EAS is performed in cancer patients in the primary care practice. In around one in every seven end-of-life cancer patients dying in the primary care setting EAS is performed. The prevalence of unbearable symptoms and overall unbearable suffering in relationship to explicit requests for EAS was studied in a cohort of end-of-life cancer patients in primary care.

Methods

A prospective study in primary care cancer patients estimated to die within six months was performed. Every two months suffering was assessed with the State-of-Suffering V (SOS-V). The SOS-V is a comprehensive instrument for quantitative and qualitative assessment of unbearable suffering related to 69 physical, psychological and social symptoms in five domains.

Results

Out of 148 patients who were asked to participate 76 (51%) entered the study. The studied population were 64 patients who were followed up until death; 27% explicitly requested EAS, which was performed in 8% of the patients. The final interview per patient was analyzed; in four patients the SOS-V was missing. Unbearable symptoms were present in 94% of patients with an explicit request for EAS and in 87% of patients without an explicit request. No differences were found in the prevalence of unbearable suffering for physical, psychological, social and existential symptoms, nor for overall unbearable suffering, between patients who did or who did not explicitly request EAS.

Conclusions

In a population of end-of-life cancer patients cared for in primary care no differences in unbearable suffering were found between patients with and without explicit requests for EAS. The study raises the question whether unbearable suffering is the dominant motive to request for EAS. Most patients suffered from unbearable symptoms, indicating that the compulsory criterion of unbearable suffering may be met a priori in most end-of-life cancer patients dying at home, whether they request EAS or not.

Intentions in wishes to die: analysis and a typology--a report of 30 qualitative case studies of terminally ill cancer patients in palliative care

OBJECTIVE

To investigate the variations in and intentions of wishes to die (WTD) of palliative care cancer patients.

METHODS

Thirty terminally ill cancer patients, their caregivers and relatives in a hospice, an oncology palliative care ward of a general hospital, and an outpatient palliative care service. 116 semistructured qualitative interviews analyzed by a combined approach using Grounded Theory and Interpretive Phenomenological Analysis.

RESULTS

A WTD is dynamic and interactive. Its subjective phenomenology can be described by three aspects: intentions, motivations, and interactions. In this article, we present a typology of the possible intentions. We identified nine different (ideal) types of intentions that WTD statements might have, other than wishing to live and accepting death. Many WTD statements do not imply a desire to hasten death. The intentions of statements differ according to whether a WTD is related to as imaginary or as an action. Often WTD statements contain several partial wishes, which can be in tension with each other and form a dynamic, sometimes unstable equilibrium.

CONCLUSIONS

Terminally ill persons' WTD statements differ in their intention, and deeper knowledge about these differences is ethically relevant.

What a wish to die can mean: reasons, meanings and functions of wishes to die, reported from 30 qualitative case studies of terminally ill cancer patients in palliative care

BACKGROUND

Despite research efforts over recent decades to deepen our understanding of why some terminally ill patients express a wish to die (WTD), there is broad consensus that we need more detailed knowledge about the factors that might influence such a wish. The objective of this study is to explore the different possible motivations and explanations of patients who express or experience a WTD.

METHODS

Thirty terminally ill cancer patients, their caregivers and relatives; from a hospice, a palliative care ward in the oncology department of a general hospital, and an ambulatory palliative care service; 116 semi-structured qualitative interviews analysed using a complementary grounded theory and interpretive phenomenological analysis approach.

RESULTS

THREE DIMENSIONS WERE FOUND TO BE CRUCIAL FOR UNDERSTANDING AND ANALYSING WTD STATEMENTS: intentions, motivations and social interactions. This article analyses the motivations of WTD statements. Motivations can further be differentiated into (1) reasons, (2) meanings and (3) functions. Reasons are the factors that patients understand as causing them to have or accounting for having a WTD. These reasons can be ordered along the bio-psycho-socio-spiritual model. Meanings describe the broader explanatory frameworks, which explain what this wish means to a patient. Meanings are larger narratives that reflect personal values and moral understandings and cannot be reduced to reasons. Functions describe the effects of the WTD on patients themselves or on others, conscious or unconscious, that might be part of the motivation for a WTD. Nine typical 'meanings' were identified in the study, including "to let death put an end to severe suffering", "to move on to another reality", and - more frequently- "to spare others from the burden of oneself".

CONCLUSIONS

The distinction between reasons, meanings and functions allows for a more detailed understanding of the motivation for the WTD statements of cancer patients in palliative care situations. Better understanding is crucial to support patients and their relatives in end-of-life care and decision making. More research is required to investigate the types of motivations for WTD statements, also among non-cancer patients.

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.

Defending the indefensible? Psychiatry, assisted suicide and human freedom

The siege guns of the forces for change to euthanasia and assisted suicide laws have been pounding for decades, but the longstanding proscription on these practices has held out in all but a few jurisdictions. A few psychiatrists have enlisted with the challengers, but many remain on the battlements, defending the impermissibility of active assistance in dying. Given the long history of the separation of church and state and the significant secularisation of society; the recognition by the law of both acts and omissions as legal causes; lenient sentences for mercy killers; critiques of the "psychiatriatisation" of different aspects of life; and the consistency of public opinion, this recalcitrant stand bespeaks undercurrents and positions that are often by rationalised or camouflaged, and which call for exploration. In this paper, I examine connections between psychiatry and conceptualisations of harm, suffering and natural death; medicalisation, psychiatrisation and medical paternalism; decision-making capacity, rationality and diagnosis; recent legal developments; social pluralism; and religious intuitionism. I conclude that psychiatrists and the psychiatry profession, concerned as they are with enlarging the province of human freedom, should begin a more transparent rapprochement with those they would repel.

Suicidality and its associated factors in cancer patients: results of a multi-center study in Korea

OBJECTIVE

The current study examined the prevalence and associated factors of suicidality among Korean cancer patients. Moreover, the association of multiple psychological morbidities with suicidality was investigated among cancer patients.

METHODS

A cross-sectional, multi-center survey of 400 cancer patients was administered in five cancer-treatment hospitals throughout South Korea. Study variables were assessed using standardized measures including the Mini International Neuropsychiatric Interview suicidality module, the Hospital Anxiety and Depression Scale, and the Impact of Event Scale-Revised.

RESULTS

20.1% (80/399) of patients were positive cases of suicidality. Having no religion (p = .010), poor performance status (p = .000), and psychological comorbidity (p = .021) were significantly associated with the experience of suicidality in the multivariate analysis. Compared to "fully active" patients, patients who were capable of self-care but unable to perform any work activities had about a six times higher risk of suicidality (p = .000). Compared to patients with no psychological morbidity, the risk of suicidality was significantly higher among patients with comorbid anxiety and depression (p = .024), those experiencing comorbid depression and post-traumatic stress disorder (PTSD) (p = 0.051), and those experiencing comorbid anxiety, depression and PTSD (p = .001).

CONCLUSIONS

This study found that having no religion, impaired levels of overall functioning, and "multiple psychological morbidities" were associated with suicidality in Korean cancer patients. These findings suggest a need for careful monitoring of these factors and enhanced comprehensive care addressing both the physical and psychosocial functioning of patients with cancer in suicide prevention efforts.

'Doubly deprived': a post-death qualitative study of primary carers of people who died in Western Australia

This paper explores the daily experiences and occupational needs of family carers of people who were dying, with particular reference to their daily routines and ability to undertake other varied activities during the period of care. The impact of the caring experience on these occupations was then examined to determine how, and if, these occupational needs were addressed in the community using potential and available services. An exploratory approach using grounded theory was employed to examine these experiences. Participants were recruited from metropolitan (n = 10) and rural (n = 4) locations across Western Australia between February and June 2009, using a purposive sampling method. A semi-structured interview guide was developed following consultation with the literature, expert opinion and piloting. Interviews were conducted in participants' homes and questions were asked about their experiences as a carer including routines, engagement in usual activities and the impact of the caring role on their daily life during and after the period of care. Each interview was transcribed verbatim and analysed to determine potential themes. Two important themes were identified: (1) Carers experienced disengagement and deprivation from their usual occupations during and after the period of care; and (2) Participants described significant disempowerment in their role as carer. Carers are 'doubly disadvantaged' as a result of their caring role; they are unable to participate in their usual occupations and they are not recognised for their contributions as carers. Carers experienced disengagement and deprivation from their usual occupations, contributing to physical, psychological and emotional difficulties and this may result in long term consequences for health and well-being. In addition, the current services and support available for carers in the community are deemed inadequate; placing further stress on a health care system which needs to cope with increasing demands as a result of the ageing population in Australia.

[A wish to hasten death : what is behind it]

"There's nothing more to do, so let's come to an end, Doc!" A request for euthanasia or physician-assisted suicide is a dramatic expression of patients' suffering and causes difficulties for staff members to react to these questions. Great efforts have been made in the last two centuries to gain a deeper understanding of the wish for hastened death of terminally ill patients and to develop conclusions for the management of these situations. This article presents differences in international legislation on euthanasia and summarises the ethical background. The current results from the literature according to motivations for the wish for hastened death, communicative functions of the request, attitudes and practices of physicians and their willingness to accompany the patient in euthanasia as well as practical implications for clinical practice are discussed.

Moral distress among nursing and non-nursing students

Their nursing experience and/or training may lead students preparing for the nursing profession to have less moral distress and more favorable attitudes towards a hastened death compared with those preparing for other fields of study. To ascertain if this was true, 66 undergraduates (54 women, 9 men, 3 not stated) in southeastern USA completed measures of moral distress and attitudes towards hastening death. Unexpectedly, the results from nursing and non-nursing majors were not significantly different. All the present students reported moderate moral distress and strong resistance to any efforts to hasten death but these factors were not significantly correlated. However, in the small sample of nurses in training, the results suggest that hastened death situations may not be a prime reason for moral distress.

Considerations about hastening death among parents of children who die of cancer

OBJECTIVES

To estimate the frequency of hastening death discussions, describe current parental endorsement of hastening death and intensive symptom management, and explore whether children's pain influences these views in a sample of parents whose child died of cancer.

DESIGN

Cross-sectional survey.

SETTING

Two tertiary-care US pediatric institutions.

PARTICIPANTS

A total of 141 parents of children who died of cancer (response rate, 64%).

OUTCOME MEASURES

Proportion of parents who (1) considered or (2) discussed hastening death during the child's end of life and who endorsed (3) hastening death or (4) intensive symptom management in vignettes portraying children with end-stage cancer.

RESULTS

A total of 19 of 141 (13%; 95% confidence interval [CI], 8%-19%) parents considered requesting hastened death for their child and 9% (95% CI, 4%-14%) discussed hastening death; consideration of hastening death tended to increase with an increase in the child's suffering from pain. In retrospect, 34% (95% CI, 26%-42%) of parents reported that they would have considered hastening their child's death had the child been in uncontrollable pain, while 15% or less would consider hastening death for nonphysical suffering. In response to vignettes, 50% (95% CI, 42%-58%) of parents endorsed hastening death while 94% (95% CI, 90%-98%) endorsed intensive pain management. Parents were more likely to endorse hastening death if the vignette involved a child in pain compared with coma (odds ratio, 1.4; 95% CI, 1.1-1.8).

CONCLUSIONS

More than 10% of parents considered hastening their child's death; this was more likely if the child was in pain. Attention to pain and suffering and education about intensive symptom management may mitigate consideration of hastening death among parents of children with cancer.

End of life care preferences

PURPOSE OF REVIEW

This review considers how end of life care preferences have been dealt with recently in the scientific literature.

RECENT FINDINGS

The ability to make decisions about one's own dying and death is commonly considered a necessary component of a 'good death'. It is important to allow people to express, if they wish, their end of life preferences. Most of the studies were conducted in patients at advanced stages of terminal illness and involved asking them about what their wishes would be in certain scenarios. Half of the papers specifically addressed the issues of life-shortening medical decisions. On considering the findings of the various studies reported in detail here, it becomes clear that end of life preferences would best be studied using a longitudinal design, because of the fluctuation of these preferences over time and their association with dynamic components of quality of life, such as functional status, and psychosocial and spiritual dimensions.

SUMMARY

Both patients and health care workers can be assisted in addressing the issue of what is the right time for a patient to record their preferences, in recognizing psychological defences and their evolution during the end of life process, and in managing conflicts and suffering in the patient-family unit. Guidelines and practical tools have begun to be designed and tested.

Family meetings in palliative care: Multidisciplinary clinical practice guidelines

Background

Support for family carers is a core function of palliative care. Family meetings are commonly recommended as a useful way for health care professionals to convey information, discuss goals of care and plan care strategies with patients and family carers. Yet it seems there is insufficient research to demonstrate the utlility of family meetings or the best way to conduct them. This study sought to develop multidisciplinary clinical practice guidelines for conducting family meetings in the specialist palliative care setting based on available evidence and consensus based expert opinion.

Methods

The guidelines were developed via the following methods: (1) A literature review; (2) Conceptual framework; (3) Refinement of the guidelines based on feedback from an expert panel and focus groups with multidisciplinary specialists from three palliative care units and three major teaching hospitals in Melbourne, Australia.

Results

The literature review revealed that no comprehensive exploration of the conduct and utility of family meetings in the specialist palliative care setting has occurred. Preliminary clinical guidelines were developed by the research team, based on relevant literature and a conceptual framework informed by: single session therapy, principles of therapeutic communication and models of coping and family consultation. A multidisciplinary expert panel refined the content of the guidelines and the applicability of the guidelines was then assessed via two focus groups of multidisciplinary palliative care specialists. The complete version of the guidelines is presented.

Conclusion

Family meetings provide an opportunity to enhance the quality of care provided to palliative care patients and their family carers. The clinical guidelines developed from this study offer a framework for preparing, conducting and evaluating family meetings. Future research and clinical implications are outlined.

The response of a Swiss university hospital's palliative care consult team to assisted suicide within the institution

In January 2006 the Centre Hospitalier Universitaire Vaudois (CHUV), a large university hospital in Lausanne, Switzerland, became the first hospital in Switzerland to allow assisted suicide (AS) in exceptional cases within its walls. However, euthanasia is illegal. This decision has posed several ethical and practical dilemmas for the hospital's palliative care consult service. To address these, the team embarked on a formal process of open dialogue amongst its members with the goal of identifying a collective response and position. This process involved meetings every 4 to 6 weeks over the course of 10 months. An iterative process unfolded. One of the principal dilemmas relates to finding a balance between the team's position against AS and the patient's autonomy and the institution's directive. Although all team members expressed opposition to AS, there were mixed opinions as to whether or not the team members should be present during the act if requested so by patients. Some thought this could be misinterpreted as complicity in the act and could send out mixed messages to the public and other health professionals about palliative care. Others felt that the team's commitment to nonabandonment obliged them to be present even if they did not provide the drug or give any advice or assistance. The implications of nonabandonment are explored, as are several other questions such as whether or not the teams are obliged to provide detailed information on AS when requested by patients.

Patient and family requests for hastened death

Patient and family requests for hastened death, upsetting as they are to the treating team, are usually a way for patients and their families to express their need for an increase in the intensity of communication, improved symptom control, or acknowledgment of an existential or spiritual crisis. Rarely do they represent the need for patients to control the time, place, and manner of their death. Using a hypothetical case study, this paper reviews the unspoken concerns underlying these requests; characteristics of patients who request a hastened death, and when and why they make the request; the Oregon Death with Dignity Act and its implementation since its passage in 1997; the effect these requests have on clinicians, their common reactions, and suggestions for self-care after such requests; techniques for responding to the requests and keeping the dialogue open with the patient and family; and the legal and ethical options available to clinicians outside of Oregon.