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

How strong is the will-to-live in frail older persons? A survey study in acute geriatric wards and nursing homes in Belgium

INTRODUCTION

Will-to-live is defined as the psychological expression of one's commitment to life and the desire to continue living. It is an important indicator of subjective wellbeing. This study aimed to assess the will-to-live in frail older hospitalized patients and nursing home residents as well as to evaluate its association with physical frailty, tiredness of life, depression and wish-to-die.

METHODS

Between March and September 2021, we interviewed 186 older adults in six nursing homes and two acute geriatric wards across Belgium. Will-to-live was assessed using a single-item numeric rating scale from 0 to 5. A linear regression analysis was performed to assess the association between will-to-live and frailty (Clinical Frailty Scale) with adjustment for age, gender and setting. Mann-Whitney U test was used to evaluate the association between will-to-live and depression, tiredness of life and wish-to-die.

RESULTS

Mean age was 85 (± 6.2) years. Mean score on the Clinical Frailty Scale was five (± 1.5) and four on the will-to-live (± 1.3). No statistical significant association was found between will-to-live and age (p = 0.991), gender (p = 0.272), setting (p = 0.627) and frailty (p = 0.629). Multiple linear regression showed no significant association with Clinical Frailty Scale (p = 0.660), after adjustment for age, gender and setting. Will-to-live was negatively associated with tiredness of life (p = 0.020) and wish-to-die (p < 0.001), but not with depression (p = 0.186).

DISCUSSION

Both nursing home residents and older hospitalized patients expressed a strong or very strong will-to-live. Will-to-live was not associated with physical frailty as measured by the Clinical Frailty Scale. Nursing home residents with a weak will-to-live were more likely to have depressive symptoms. Most nursing home residents with a wish-to-die had also a low will-to-live, although some residents had both a high will-to-live and wish-to-die.

Wish to Die Among Residents of Swiss Long-Term Care Facilities: A Multisite Cross-Sectional Study

OBJECTIVES

The wish to die (WTD) in persons near the end of life is a clinically important, ethically and practically complex phenomenon as demonstrated by the intense debates on assisted dying legislation around the world. Despite global aging and increasing institutionalization in old age, WTD among residents of long-term care facilities (LTCF) is underexplored. We aimed to assess the prevalence of WTD and identify its predictors in older LTCF residents.

DESIGN

Multisite cross-sectional observational study.

SETTING AND PARTICIPANTS

31 LTCF in the 3 major linguistic regions of Switzerland, including residents 75 years or older, admitted to the LTCF 4 to 10 months before the study, without severe cognitive impairment.

METHODS

Between February 2013 and June 2017, trained research staff interviewed residents to assess WTD using 2 validated instruments and collected information on potential predictors, including depressive symptoms, anxiety, demoralization, feeling to be a burden, spiritual distress, symptom burden, multimorbidity, and drug use. Demographic data were obtained by chart review. Descriptive statistics as well as univariate and multivariate regression analyses were performed.

RESULTS

From 427 eligible residents, 101 were excluded, 46 refused, and 280 were included in the study (acceptance rate 85.9%). In general, residents readily and openly addressed the topic of WTD. The prevalence of WTD was 16.0% and 16.2% according to the 2 instruments, with all but 1 of the residents expressing a passive WTD. The strongest independent predictors for a WTD were depressive symptoms (OR 7.45 and 5.77 for the 2 WTD assessment instruments) and demoralization (OR 2.62 and 3.66).

CONCLUSIONS AND IMPLICATIONS

The WTD is a relevant concern affecting approximately 1 in 6 LTCF residents. Further research is needed to investigate which interventions could best address the potentially modifiable factors that were associated with the WTD in this specific setting and population.

Physical multimorbidity and wish to die among adults aged ≥65 years: A cross-sectional analysis of the Irish Longitudinal Study on Ageing

BACKGROUND

Physical multimorbidity (i.e., ≥2 chronic conditions) may induce feelings of wish to die (WTD), but there is limited literature on this topic, while the mediators in this association are largely unknown. Thus, the aim of the present study was to investigate this association and its mediators among older Irish adults.

METHODS

Cross-sectional, nationally representative data from Wave 1 of the Irish Longitudinal Study on Ageing 2009-2011 were analyzed. Information on self-reported lifetime diagnosis of 14 chronic physical conditions were obtained. WTD was defined as answering affirmatively to the question "In the last month, have you felt that you would rather be dead?" Multivariable logistic regression and mediation analyses were conducted.

RESULTS

Data on 2941 adults aged ≥65 years [mean (SD) age 73.2 (5.2) years; 45.0 % males] were analyzed. Physical multimorbidity was associated with 3.39 (95%CI 1.58, 7.28) times higher odds for WTD. This association was largely explained by pain (% mediated 28.1 %), followed by depression (19.4 %), sleep problems (18.4 %), perceived stress (13.0 %), loneliness (10.4 %), anxiety (8.1 %), and disability (7.2 %).

CONCLUSIONS

Multimorbidity was associated with increased odds for WTD among Irish older adults. Addressing the identified mediators may contribute to reducing feelings of WTD among older adults with multimorbidity.

How do trained palliative care providers experience open desire to die-conversations? An explorative thematic analysis

OBJECTIVES

Despite the potential benefits of open communication about possible desires to die for patients receiving palliative care, health professionals tend to avoid such conversations and often interpret desires to die as requests for medical aid in dying. After implementing trainings to foster an open, proactive approach toward desire to die, we requested trained health professionals to lead and document desire to die-conversations with their patients. In this article, we explore how trained health professionals experience an open (proactive) approach to desire to die-conversations with their patients.

METHODS

Between April 2018 and March 2020, health professionals recorded their conversation-experiences on documentation sheets by answering seven open questions. A subsample was invited to offer deeper insights through semi-structured qualitative interviews. Interviews and documentation sheets were transcribed verbatim and analyzed thematically, then findings from both sources were compared and synthesized.

RESULTS

Overall, N = 29 trained health professionals documented N = 81 open desire to die-conversations. A subsample of n = 13 health professionals participated in qualitative interviews. Desire to die-conversations after the training were reported as a complex but overall enriching experience, illustrated in seven themes: (1) beneficial (e.g., establishing good rapport) and (2) hindering aspects (e.g., patients' emotional barriers) of desire to die-conversations, (3) follow-up measures, (4) ways of addressing desire to die, as well as (5) patient reactions to it. The interviews offered space for health professionals to talk about (6) content of desire to die-conversation and (7) (self-)reflection (e.g., on patients' biographies or own performance).

SIGNIFICANCE OF RESULTS

As part of an open (proactive) approach, desire to die-conversations hold potential for health professionals' (self-)reflection and a deeper understanding of patient background and needs. They may lead to a strengthened health professional-patient relationship and potentially prevent suicide.

The course of depressive symptoms and mortality in older patients with cancer

OBJECTIVE

The Geriatric Depression Scale (GDS-15), a self-report questionnaire, emphasizes the psychological dimension of depression. We aimed to investigate whether GDS-15 scores were associated with mortality in older patients with cancer and describe the course of individual symptoms on the GDS-15.

METHODS

An observational, multicenter, prospective study of 288 patients 70 years or older with cancer followed over 24 months. The patients were assessed with the GDS-15 at inclusion, and after four and 12 months. An extended Cox regression model assessed the association between time-dependent GDS-15 scores and mortality.

RESULTS

After adjusting for cancer-related prognostic factors, a one-point increase in GDS-15 sum score increased risk of death by 12%. GDS-15 mean score increased during the first four months of the study, as did odds for the presence of the GDS-15 symptoms 'feel you have more problems with memory than most', 'not feel full of energy', and 'think that most people are better off than you'. The most prevalent and persistent GDS-15 symptom was 'prefer to stay at home, rather than going out and doing new things', and 'not to be in good spirits most of the time' was the least prevalent.

CONCLUSIONS

More severe depressive symptoms, as measured by the GDS-15, were associated with higher mortality in older patients with cancer. The importance of emotional distress and how to alleviate it should be investigated further in these patients.

The 'Wish to Die' in later life: prevalence, longitudinal course and mortality. Data from TILDA

BACKGROUND

'Wish to Die' (WTD) involves thoughts of or wishes for one's own death or that one would be better off dead.

OBJECTIVE

To examine the prevalence, longitudinal course and mortality-risk of WTD in community-dwelling older people.

DESIGN

Observational study with 6-year follow-up.

SETTING

The Irish Longitudinal Study on Ageing, a nationally representative cohort of older adults.

SUBJECTS

In total, 8,174 community-dwelling adults aged ≥50 years.

METHODS

To define WTD, participants were asked: 'In the last month, have you felt that you would rather be dead?' Depressive symptoms were measured using the CES-D. Mortality data were compiled by linking administrative death records to individual-level survey data from the study.

RESULTS

At Wave 1, 3.5% of participants (279/8,174) reported WTD. Both persistent loneliness (OR 5.73 (95% CI 3.41-9.64)) and depressive symptoms (OR 6.12 (95% CI 4.33-8.67)) were independently associated with WTD.Of participants who first reported WTD at Wave 1 or 2, 72% did not report WTD when reassessed after 2 years, and the prevalence of depressive symptoms (-44%) and loneliness (-19%) was more likely to decline in this group at follow-up.Fifteen per cent of participants expressing WTD at Wave 1 died during a 6-year follow-up.

CONCLUSIONS

WTD amongst community-dwelling older people is frequently transient and is strongly linked with the course of depressive symptoms and loneliness. An enhanced focus on improving access to mental health care and addressing social isolation in older people should therefore be a public health priority, particularly in the current context of the Covid-19 pandemic.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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