1
|
Stukalin I, Olaiya OR, Naik V, Wiebe E, Kekewich M, Kelly M, Wilding L, Halko R, Oczkowski S. Medications and dosages used in medical assistance in dying: a cross-sectional study. CMAJ Open 2022; 10:E19-E26. [PMID: 35042691 PMCID: PMC8920593 DOI: 10.9778/cmajo.20200268] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND There is little evidence describing the technical aspects of medical assistance in dying (MAiD) in Canada, such as medications, dosages and complications. Our objective was to describe clinical practice in providing MAiD in Ontario and Vancouver, Canada, and explore relations between medications used, time until death and complications. METHODS We conducted a retrospective cohort study of a sample of adult (age ≥ 18 yr) patients who received MAiD in Ontario between 2016 and 2018, and patients who received MAiD in 1 of 3 Canadian academic hospitals (in Hamilton and Ottawa, Ontario, and Vancouver, British Colombia) between 2019 and 2020. We used de-identified data for 2016-2018 from the Office of the Chief Coroner for Ontario MAiD Database and chart review data for 2019-2020 from the 3 centres. We used multivariable parametric survival analysis to identify relations between medications, dosages and time from procedure start until death. RESULTS The sample included 3557 patients (1786 men [50.2%] and 1770 women [49.8%] with a mean age of 74 [standard deviation 13] yr). The majority of patients (2519 [70.8%]) had a diagnosis of cancer. The medications most often used were propofol (3504 cases [98.5%]), midazolam (3251 [91.4%]) and rocuronium (3228 [90.8%]). The median time from the first injection until death was 9 (interquartile range 6) minutes. Standard-dose lidocaine (40-60 mg) and high-dose propofol (> 1000 mg) were associated with prolonged time until death (prolonged by a median of 1 min and 3 min, respectively). Complications occurred in 41 cases (1.2%), mostly related to venous access or need for administration of a second medication. INTERPRETATION In a large sample of patients who died with medical assistance, certain medications were associated with small differences in time from injection to death, and complications were rare. More research is needed to identify the medication protocols that predict outcomes consistent with patient and family expectations for a medically assisted death.
Collapse
Affiliation(s)
- Igor Stukalin
- Department of Medicine (Stukalin), University of Calgary, Calgary, Alta.; Division of Plastic Surgery (Olaiya), Department of Surgery, McMaster University, Hamilton, Ont.; The Ottawa Hospital (Naik, Kekewich, Wilding); Department of Anesthesiology and Pain Medicine (Naik), University of Ottawa, Ottawa, Ont.; Department of Family Practice (Wiebe), University of British Columbia, Vancouver, BC; London School of Hygiene and Tropical Medicine (Kelly), University of London, London, UK; Office of the Chief Coroner for Ontario (Halko), Toronto, Ont.; Departments of Medicine (Oczkowski), and Health Research Methods, Evidence, and Impact (Olaiya, Oczkowski), McMaster University, Hamilton, Ont
| | - Oluwatobi R Olaiya
- Department of Medicine (Stukalin), University of Calgary, Calgary, Alta.; Division of Plastic Surgery (Olaiya), Department of Surgery, McMaster University, Hamilton, Ont.; The Ottawa Hospital (Naik, Kekewich, Wilding); Department of Anesthesiology and Pain Medicine (Naik), University of Ottawa, Ottawa, Ont.; Department of Family Practice (Wiebe), University of British Columbia, Vancouver, BC; London School of Hygiene and Tropical Medicine (Kelly), University of London, London, UK; Office of the Chief Coroner for Ontario (Halko), Toronto, Ont.; Departments of Medicine (Oczkowski), and Health Research Methods, Evidence, and Impact (Olaiya, Oczkowski), McMaster University, Hamilton, Ont
| | - Viren Naik
- Department of Medicine (Stukalin), University of Calgary, Calgary, Alta.; Division of Plastic Surgery (Olaiya), Department of Surgery, McMaster University, Hamilton, Ont.; The Ottawa Hospital (Naik, Kekewich, Wilding); Department of Anesthesiology and Pain Medicine (Naik), University of Ottawa, Ottawa, Ont.; Department of Family Practice (Wiebe), University of British Columbia, Vancouver, BC; London School of Hygiene and Tropical Medicine (Kelly), University of London, London, UK; Office of the Chief Coroner for Ontario (Halko), Toronto, Ont.; Departments of Medicine (Oczkowski), and Health Research Methods, Evidence, and Impact (Olaiya, Oczkowski), McMaster University, Hamilton, Ont
| | - Ellen Wiebe
- Department of Medicine (Stukalin), University of Calgary, Calgary, Alta.; Division of Plastic Surgery (Olaiya), Department of Surgery, McMaster University, Hamilton, Ont.; The Ottawa Hospital (Naik, Kekewich, Wilding); Department of Anesthesiology and Pain Medicine (Naik), University of Ottawa, Ottawa, Ont.; Department of Family Practice (Wiebe), University of British Columbia, Vancouver, BC; London School of Hygiene and Tropical Medicine (Kelly), University of London, London, UK; Office of the Chief Coroner for Ontario (Halko), Toronto, Ont.; Departments of Medicine (Oczkowski), and Health Research Methods, Evidence, and Impact (Olaiya, Oczkowski), McMaster University, Hamilton, Ont
| | - Mike Kekewich
- Department of Medicine (Stukalin), University of Calgary, Calgary, Alta.; Division of Plastic Surgery (Olaiya), Department of Surgery, McMaster University, Hamilton, Ont.; The Ottawa Hospital (Naik, Kekewich, Wilding); Department of Anesthesiology and Pain Medicine (Naik), University of Ottawa, Ottawa, Ont.; Department of Family Practice (Wiebe), University of British Columbia, Vancouver, BC; London School of Hygiene and Tropical Medicine (Kelly), University of London, London, UK; Office of the Chief Coroner for Ontario (Halko), Toronto, Ont.; Departments of Medicine (Oczkowski), and Health Research Methods, Evidence, and Impact (Olaiya, Oczkowski), McMaster University, Hamilton, Ont
| | - Michaela Kelly
- Department of Medicine (Stukalin), University of Calgary, Calgary, Alta.; Division of Plastic Surgery (Olaiya), Department of Surgery, McMaster University, Hamilton, Ont.; The Ottawa Hospital (Naik, Kekewich, Wilding); Department of Anesthesiology and Pain Medicine (Naik), University of Ottawa, Ottawa, Ont.; Department of Family Practice (Wiebe), University of British Columbia, Vancouver, BC; London School of Hygiene and Tropical Medicine (Kelly), University of London, London, UK; Office of the Chief Coroner for Ontario (Halko), Toronto, Ont.; Departments of Medicine (Oczkowski), and Health Research Methods, Evidence, and Impact (Olaiya, Oczkowski), McMaster University, Hamilton, Ont
| | - Laura Wilding
- Department of Medicine (Stukalin), University of Calgary, Calgary, Alta.; Division of Plastic Surgery (Olaiya), Department of Surgery, McMaster University, Hamilton, Ont.; The Ottawa Hospital (Naik, Kekewich, Wilding); Department of Anesthesiology and Pain Medicine (Naik), University of Ottawa, Ottawa, Ont.; Department of Family Practice (Wiebe), University of British Columbia, Vancouver, BC; London School of Hygiene and Tropical Medicine (Kelly), University of London, London, UK; Office of the Chief Coroner for Ontario (Halko), Toronto, Ont.; Departments of Medicine (Oczkowski), and Health Research Methods, Evidence, and Impact (Olaiya, Oczkowski), McMaster University, Hamilton, Ont
| | - Roxanne Halko
- Department of Medicine (Stukalin), University of Calgary, Calgary, Alta.; Division of Plastic Surgery (Olaiya), Department of Surgery, McMaster University, Hamilton, Ont.; The Ottawa Hospital (Naik, Kekewich, Wilding); Department of Anesthesiology and Pain Medicine (Naik), University of Ottawa, Ottawa, Ont.; Department of Family Practice (Wiebe), University of British Columbia, Vancouver, BC; London School of Hygiene and Tropical Medicine (Kelly), University of London, London, UK; Office of the Chief Coroner for Ontario (Halko), Toronto, Ont.; Departments of Medicine (Oczkowski), and Health Research Methods, Evidence, and Impact (Olaiya, Oczkowski), McMaster University, Hamilton, Ont
| | - Simon Oczkowski
- Department of Medicine (Stukalin), University of Calgary, Calgary, Alta.; Division of Plastic Surgery (Olaiya), Department of Surgery, McMaster University, Hamilton, Ont.; The Ottawa Hospital (Naik, Kekewich, Wilding); Department of Anesthesiology and Pain Medicine (Naik), University of Ottawa, Ottawa, Ont.; Department of Family Practice (Wiebe), University of British Columbia, Vancouver, BC; London School of Hygiene and Tropical Medicine (Kelly), University of London, London, UK; Office of the Chief Coroner for Ontario (Halko), Toronto, Ont.; Departments of Medicine (Oczkowski), and Health Research Methods, Evidence, and Impact (Olaiya, Oczkowski), McMaster University, Hamilton, Ont.
| |
Collapse
|
2
|
Julião M, Chochinov HM, Samorinha C, da Silva Soares D, Antunes B. Prevalence and Factors Associated With Will-to-Live in Patients With Advanced Disease: Results From a Portuguese Retrospective Study. J Pain Symptom Manage 2021; 62:820-827. [PMID: 33631327 DOI: 10.1016/j.jpainsymman.2021.02.018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2020] [Revised: 02/01/2021] [Accepted: 02/11/2021] [Indexed: 01/30/2023]
Abstract
CONTEXT Will-to-live (WtL) is a complex and multifactorial dimension of end-of-life experience. Health care decisions on assisted suicide and euthanasia are rarely based on WtL evidence-based discussions. OBJECTIVES To inform the debate, we aimed to evaluate the prevalence of WtL and its associations within a tertiary home-based palliative care unit. METHODS Retrospective analysis of all WtL entries registered in our anonymized clinical registry, from October 2018 to September 2020. RESULTS One-hundred and twelve patients were included: 53% were male, average age was 66 years old; 88% had malignancies, with a mean performance status of 55%. Mean for WtL of was 3.26 (SD = 3.87) with a prevalence of 60.7% strong, 8.9% moderate and 30.4% weak WtL. Weaker WtL was observed among patients who were not well adapted to their disease (P = .001), felt a burden to others (P< .001), were depressed (P = .001), anxious (P< .001) and endorsed a desire for death (P< .001). Weaker WtL was associated with pain (P = .002) and lower well-being (P = .001). Results from the logistic regression model found that the adaptation to disease emerged as a significant predictor of WtL (P = .025), and burden to others remained marginally significant (P = .087). CONCLUSION The factors associated with lower WtL scores are consistent with previous studies, indicating that these patients experience a myriad of physical, psychological and existential symptoms requiring an interdisciplinary palliative care approach. These factors pertaining to WtL should be made known, as Portugal considers how to navigate death-hastening legislation.
Collapse
Affiliation(s)
- Miguel Julião
- Equipa Comunitária de Suporte em Cuidados Paliativos de Sintra, Sintra, Portugal.
| | - Harvey Max Chochinov
- Department of Psychiatry, Research Institute of Oncology and Hematology, CancerCare Manitoba, University of Manitoba, Manitoba, Canada
| | - Catarina Samorinha
- Sharjah Institute for Medical Research, University of Sharjah, Sharjah, United Arab Emirates
| | - Duarte da Silva Soares
- Departamento de Cuidados Paliativos da Unidade Local de Saúde do Nordeste, Bragança, Portugal
| | - Bárbara Antunes
- Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK; Centro de Estudos e Investigação em Saúde da Universidade de Coimbra, Coimbra, Portugal; Faculty of Medicine, University of Porto, Porto, Portugal; Department of Midwifery and Palliative Care, Florence Nightingale School of Nursing, King's College London, London, UK
| |
Collapse
|
3
|
Evenblij K, Pasman HRW, van Delden JJM, van der Heide A, van de Vathorst S, Willems DL, Onwuteaka-Philipsen BD. Physicians' experiences with euthanasia: a cross-sectional survey amongst a random sample of Dutch physicians to explore their concerns, feelings and pressure. BMC FAMILY PRACTICE 2019; 20:177. [PMID: 31847816 PMCID: PMC6918628 DOI: 10.1186/s12875-019-1067-8] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 04/30/2019] [Accepted: 12/05/2019] [Indexed: 11/27/2022]
Abstract
Background Physicians who receive a request for euthanasia or assisted suicide may experience a conflict of duties: the duty to preserve life on the one hand and the duty to relieve suffering on the other hand. Little is known about experiences of physicians with receiving and granting a request for euthanasia or assisted suicide. This study, therefore, aimed to explore the concerns, feelings and pressure experienced by physicians who receive requests for euthanasia or assisted suicide. Methods In 2016, a cross-sectional study was conducted. Questionnaires were sent to a random sample of 3000 Dutch physicians. Physicians who had been working in adult patient care in the Netherlands for the last year were included in the sample (n = 2657). Half of the physicians were asked about the most recent case in which they refused a request for euthanasia or assisted suicide, and half about the most recent case in which they granted a request for euthanasia or assisted suicide. Results Of the 2657 eligible physicians, 1374 (52%) responded. The most reported reason not to participate was lack of time. Of the respondents, 248 answered questions about a refused euthanasia or assisted suicide request and 245 about a granted EAS request. Concerns about specific aspects of the euthanasia and assisted suicide process, such as the emotional burden of preparing and performing euthanasia or assisted suicide were commonly reported by physicians who refused and who granted a request. Pressure to grant a request was mostly experienced by physicians who refused a request, especially if the patient was ≥80 years, had a life-expectancy of ≥6 months and did not have cancer. The large majority of physicians reported contradictory emotions after having performed euthanasia or assisted suicide. Conclusions Society should be aware of the impact of euthanasia and assisted suicide requests on physicians. The tension physicians experience may decrease their willingness to perform euthanasia and assisted suicide. On the other hand, physicians should not be forced to cross their own moral boundaries or be tempted to perform euthanasia and assisted suicide in cases that may not meet the due care criteria.
Collapse
Affiliation(s)
- Kirsten Evenblij
- Department of Public and Occupational Health, VUmc Expertise Center for Palliative Care, Amsterdam Public Health Research Institute, Amsterdam University Medical Centers, Vrije Universiteit, Amsterdam, The Netherlands.
| | - H Roeline W Pasman
- Department of Public and Occupational Health, VUmc Expertise Center for Palliative Care, Amsterdam Public Health Research Institute, Amsterdam University Medical Centers, Vrije Universiteit, Amsterdam, The Netherlands
| | - Johannes J M van Delden
- UMC Utrecht, Julius Center for Health Sciences and Primary Care, Department of Medical Humanities, Utrecht, The Netherlands
| | - Agnes van der Heide
- Department of Public Health Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Suzanne van de Vathorst
- Department of General Practice, section Medical Ethics, Amsterdam Public Health Research Institute, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, The Netherlands
| | - Dick L Willems
- Department of General Practice, section Medical Ethics, Amsterdam Public Health Research Institute, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, The Netherlands
| | - Bregje D Onwuteaka-Philipsen
- Department of Public and Occupational Health, VUmc Expertise Center for Palliative Care, Amsterdam Public Health Research Institute, Amsterdam University Medical Centers, Vrije Universiteit, Amsterdam, The Netherlands
| |
Collapse
|
4
|
Evenblij K, Pasman HRW, van der Heide A, Hoekstra T, Onwuteaka-Philipsen BD. Factors associated with requesting and receiving euthanasia: a nationwide mortality follow-back study with a focus on patients with psychiatric disorders, dementia, or an accumulation of health problems related to old age. BMC Med 2019; 17:39. [PMID: 30777057 PMCID: PMC6379969 DOI: 10.1186/s12916-019-1276-y] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2018] [Accepted: 01/31/2019] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Recently, euthanasia and assisted suicide (EAS) in patients with psychiatric disorders, dementia, or an accumulation of health problems has taken a prominent place in the public debate. However, limited is known about this practice. The purpose of this study was threefold: to estimate the frequency of requesting and receiving EAS among people with (also) a psychiatric disorder, dementia, or an accumulation of health problems; to explore reasons for physicians to grant or refuse a request; and to describe differences in characteristics, including the presence of psychiatric disorders, dementia, and accumulation of health problems, between patients who did and did not request EAS and between patients whose request was or was not granted. METHODS A nationwide cross-sectional survey study was performed. A stratified sample of death certificates of patients who died between 1 August and 1 December 2015 was drawn from the central death registry of Statistics Netherlands. Questionnaires were sent to the certifying physician (n = 9351, response 78%). Only deceased patients aged ≥ 17 years and who died a non-sudden death were included in the analyses (n = 5361). RESULTS The frequency of euthanasia requests among deceased people who died non-suddenly and with (also) a psychiatric disorder (11.4%), dementia (2.1%), or an accumulation of health problems (8.0%) varied. Factors positively associated with requesting euthanasia were age (< 80 years), ethnicity (Dutch/Western), cause of death (cancer), attending physician (general practitioner), and involvement of a pain specialist or psychiatrist. Cause of death (neurological disorders, another cause) and attending physician (general practitioner) were also positively associated with receiving euthanasia. Psychiatric disorders, dementia, and/or an accumulation of health problems were negatively associated with both requesting and receiving euthanasia. CONCLUSIONS EAS in deceased patients with psychiatric disorders, dementia, and/or an accumulation of health problems is relatively rare. Partly, this can be explained by the belief that the due care criteria cannot be met. Another explanation is that patients with these conditions are less likely to request EAS.
Collapse
Affiliation(s)
- Kirsten Evenblij
- Department of Public and Occupational Health, Amsterdam Public Health Research Institute, Amsterdam UMC, Vrije Universiteit Amsterdam, P.O. Box 7057, 1007 MB, Amsterdam, The Netherlands.
| | - H Roeline W Pasman
- Department of Public and Occupational Health, Amsterdam Public Health Research Institute, Amsterdam UMC, Vrije Universiteit Amsterdam, P.O. Box 7057, 1007 MB, Amsterdam, The Netherlands
| | - Agnes van der Heide
- Department of Public Health, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Trynke Hoekstra
- Department of Health Sciences, Amsterdam Public Health Research Institute, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Bregje D Onwuteaka-Philipsen
- Department of Public and Occupational Health, Amsterdam Public Health Research Institute, Amsterdam UMC, Vrije Universiteit Amsterdam, P.O. Box 7057, 1007 MB, Amsterdam, The Netherlands
| |
Collapse
|
5
|
DeMichelis C, Zlotnik Shaul R, Rapoport A. Medical Assistance in Dying at a paediatric hospital. JOURNAL OF MEDICAL ETHICS 2019; 45:60-67. [PMID: 30242079 DOI: 10.1136/medethics-2018-104896] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/25/2018] [Revised: 08/02/2018] [Accepted: 08/12/2018] [Indexed: 06/08/2023]
Abstract
This article explores the ethical challenges of providing Medical Assistance in Dying (MAID) in a paediatric setting. More specifically, we focus on the theoretical questions that came to light when we were asked to develop a policy for responding to MAID requests at our tertiary paediatric institution. We illuminate a central point of conceptual confusion about the nature of MAID that emerges at the level of practice, and explore the various entailments for clinicians and patients that would flow from different understandings. Finally, we consider the ethical challenges of building policy on what is still an extremely controversial social practice. While MAID is currently available to capable patients in Canada who are 18 years or older-a small but important subsection of the population our hospital serves-we write our policy with an eye to the near future when capable young people may gain access to MAID. We propose that an opportunity exists for MAID-providing institutions to reduce social stigma surrounding this practice, but not without potentially serious consequences for practitioners and institutions themselves. Thus, this paper is intended as a road map through the still-emerging legal and ethical landscape of paediatric MAID. We offer a view of the roads taken and considered along the way, and our justifications for travelling the paths we chose. By providing a record of our in-progress thinking, we hope to stimulate wider discussion about the issues and questions encountered in this work.
Collapse
Affiliation(s)
- Carey DeMichelis
- Applied Psychology and Human Development, Joint Centre for Bioethics, University of Toronto, Toronto, Ontario, Canada
| | - Randi Zlotnik Shaul
- Bioethics Department, The Hospital for Sick Children, Toronto, Ontario, Canada
- Department of Paediatrics, University of Toronto, Toronto, Ontario, Canada
| | - Adam Rapoport
- Paediatric Advanced Care Team, The Hospital for Sick Children, Toronto, Ontario, Canada
- Emily's House Children's Hospice, Toronto, Ontario, Canada
- Departments of Paediatrics and Family & Community Medicine, University of Toronto, Toronto, Ontario, Canada
| |
Collapse
|
6
|
Saladin N, Schnepp W, Fringer A. Voluntary stopping of eating and drinking (VSED) as an unknown challenge in a long-term care institution: an embedded single case study. BMC Nurs 2018; 17:39. [PMID: 30186039 PMCID: PMC6119585 DOI: 10.1186/s12912-018-0309-8] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2018] [Accepted: 08/24/2018] [Indexed: 11/10/2022] Open
Abstract
Background Chronically ill persons experience conditions of life that can become unbearable, resulting in the wish to end their life prematurely. Relatives confronted with this wish experience ambivalence between loyalty to the person's desire to die and the fear of losing this person. Caring for a person during the premature dying process can be morally challenging for nurses. One way to end one's life prematurely is Voluntary Stopping of Eating and Drinking (VSED). Methods This embedded single case study explored the experiences of registered nurses (embedded units of analysis: ward manager, nursing manager, nursing expert) and relatives who accompanied a 49-year-old woman suffering from multiple sclerosis during VSED in a Swiss long-term care institution (main unit of analysis). By means of a within-analysis, we performed an in-depth analysis of every embedded unit of analysis and elaborated a central phenomenon for each unit. Afterwards, we searched for common patterns in a cross-analysis of the embedded units of analysis in order to develop a central model. Results The following central concept emerged from cross-analysis of the embedded units of analysis: As a way of ending one's life prematurely, VSED represents an unfamiliar challenge to nurses and relatives in the field of tension between one's personal attitude and the agents' concerns, fears and uncertainties. Particularly significant is the personal attitude, influenced on the one hand by one's own experiences, prior knowledge, role and faith, on the other hand by the VSED-performing person's age, disease and deliberate communication of the decision. Depending on the intention of VSED as either suicide or natural dying, an accepting or dismissing attitude evolves on an institutional and personal level. Conclusions To deal professionally with VSED in an institution, it is necessary to develop an attitude on the institutional and personal level. Educational measures and quality controls are required to ensure that VSED systematically becomes an option to hasten death. As VSED is a complex phenomenon, it is necessary to include palliative care in practice development early on and comprehensively. There is a high need of further research on this topic. Particularly, qualitative studies and hypothesis-testing approaches are required.
Collapse
Affiliation(s)
- Nadine Saladin
- Institute of Applied Nursing Science IPW-FHS, FHS St.Gallen, University of Applied Sciences, Rosenbergstrasse 59, 9001 St. Gallen, Switzerland
| | - Wilfried Schnepp
- 2Faculty of Health, Department of Nursing Science, Chair of Family Oriented and Community Based Care, Witten/Herdecke University, Stockumer Strasse 12, 58453 Witten, Germany
| | - André Fringer
- 3Institute of Nursing, School of Health Professions, ZHAW Zurich University of Applied Sciences, Technikumstr. 81, CH-8400 Winterthur, Switzerland
| |
Collapse
|
7
|
Smith KA, Harvath TA, Goy ER, Ganzini L. Predictors of pursuit of physician-assisted death. J Pain Symptom Manage 2015; 49:555-61. [PMID: 25116913 DOI: 10.1016/j.jpainsymman.2014.06.010] [Citation(s) in RCA: 66] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2014] [Revised: 06/26/2014] [Accepted: 07/06/2014] [Indexed: 11/30/2022]
Abstract
CONTEXT Physician-assisted death (PAD) was legalized in 1997 by Oregon's Death with Dignity Act. The States of Washington, Montana, Vermont, and New Mexico have since provided legal sanction for PAD. Through 2013, 1173 Oregonians have received a prescription under the Death with Dignity Act and 752 have died after taking the prescribed medication in Oregon. OBJECTIVES To determine the predictive value of personal and interpersonal variables in the pursuit of PAD. METHODS Fifty-five Oregonians who either requested PAD or contacted a PAD advocacy organization were compared with 39 individuals with advanced disease who did not pursue PAD. We compared the two groups on responses to standardized measures of depression, hopelessness, spirituality, social support, and pain. We also compared the two groups on style of attachment to intimate others and caregivers as understood through attachment theory. RESULTS We found that PAD requesters had higher levels of depression, hopelessness, and dismissive attachment (attachment to others characterized by independence and self-reliance), and lower levels of spirituality. There were moderate correlations among the variables of spirituality, hopelessness, depression, social support, and dismissive attachment. There was a strong correlation between depression and hopelessness. Low spirituality emerged as the strongest predictor of pursuit of PAD in the regression analysis. CONCLUSION Although some factors motivating pursuit of PAD, such as depression, may be ameliorated by medical interventions, other factors, such as style of attachment and sense of spirituality, are long-standing aspects of the individual that should be supported at the end of life. Practitioners must develop respectful awareness and understanding of the interpersonal and spiritual perspectives of their patients to provide such support.
Collapse
Affiliation(s)
- Kathryn A Smith
- Health and Counseling Center, Reed College, Portland, Oregon, USA
| | - Theresa A Harvath
- Betty Irene Moore School of Nursing, University of California-Davis, Sacramento, California, USA
| | - Elizabeth R Goy
- Mental Health and Neurosciences Division, Department of Veterans Affairs Medical Center, Portland, Oregon, USA; Department of Psychiatry, Oregon Health & Science University, Portland, Oregon, USA
| | - Linda Ganzini
- Health Services Research and Development Center of Innovation, Department of Veterans Affairs Medical Center, Portland, Oregon, USA; Department of Psychiatry, Oregon Health & Science University, Portland, Oregon, USA.
| |
Collapse
|
8
|
Newton-John TRO. Negotiating the Maze: Risk Factors for Suicidal Behavior in Chronic Pain Patients. Curr Pain Headache Rep 2014; 18:447. [DOI: 10.1007/s11916-014-0447-y] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
|
9
|
Vézina-Im LA, Lavoie M, Krol P, Olivier-D’Avignon M. Motivations of physicians and nurses to practice voluntary euthanasia: a systematic review. BMC Palliat Care 2014; 13:20. [PMID: 24716567 PMCID: PMC4021095 DOI: 10.1186/1472-684x-13-20] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2013] [Accepted: 03/27/2014] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND While a number of reviews have explored the attitude of health professionals toward euthanasia, none of them documented their motivations to practice euthanasia. The objective of the present systematic review was to identify physicians' and nurses' motives for having the intention or for performing an act of voluntary euthanasia and compare findings from countries where the practice is legalized to those where it is not. METHODS The following databases were investigated: MEDLINE/PubMed (1950+), PsycINFO (1806+), CINAHL (1982+), EMBASE (1974+) and FRANCIS (1984+). Proquest Dissertations and Theses (1861+) was also investigated for gray literature. Additional studies were included by checking the references of the articles included in the systematic review as well as by looking at our personal collection of articles on euthanasia. RESULTS This paper reviews a total of 27 empirical quantitative studies out of the 1 703 articles identified at the beginning. Five studies were in countries where euthanasia is legal and 22 in countries where it is not. Seventeen studies were targeting physicians, 9 targeted nurses and 1 both health professionals. Six studies identified the motivations underlying the intention to practice euthanasia, 16 the behavior itself and 5 both intention and behavior. The category of variables most consistently associated with euthanasia is psychological variables. All categories collapsed, the four variables most frequently associated with euthanasia are past behavior, medical specialty, whether the patient is depressed and the patient's life expectancy. CONCLUSIONS The present review suggests that physicians and nurses are motivated to practice voluntary euthanasia especially when they are familiar with the act of euthanasia, when the patient does not have depressive symptoms and has a short life expectancy and their motivation varies according to their medical specialty. Additional studies among nurses and in countries where euthanasia is legal are needed.
Collapse
Affiliation(s)
| | - Mireille Lavoie
- Faculty of Nursing, Laval University, Québec, Canada
- Équipe de Recherche Michel-Sarrazin en Oncologie psychosociale et Soins palliatifs (ERMOS), Centre de recherche du CHU de Québec - Hôtel-Dieu de Québec, Québec, Canada
| | - Pawel Krol
- Faculty of Nursing, Laval University, Québec, Canada
| | | |
Collapse
|
10
|
Kétamine et dépression : vers de nouvelles perspectives thérapeutiques en soins de support ? PSYCHO-ONCOLOGIE 2014. [DOI: 10.1007/s11839-014-0453-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
|
11
|
Brinkman-Stoppelenburg A, Vergouwe Y, van der Heide A, Onwuteaka-Philipsen BD. Obligatory consultation of an independent physician on euthanasia requests in the Netherlands: what influences the SCEN physicians judgment of the legal requirements of due care? Health Policy 2013; 115:75-81. [PMID: 24388049 DOI: 10.1016/j.healthpol.2013.12.002] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2013] [Revised: 11/23/2013] [Accepted: 12/07/2013] [Indexed: 11/17/2022]
Abstract
BACKGROUND In the Netherlands, euthanasia is allowed if physicians adhere to legal requirements. Consultation of an independent physician is one of the requirements. SCEN (Support and Consultation on Euthanasia in the Netherlands) physicians have been trained to provide such consultations. OBJECTIVE To study why euthanasia requests are sometimes judged not to meet requirements of due care and to find out which characteristics are associated with the SCEN physicians' judgments. METHODS During 5 years (2006, 2008-2011) standardized registration forms were used for data-collection. We used multilevel logistic regression analysis to assess the associations of characteristics and SCEN physicians' judgments. RESULTS We analyzed 1631 euthanasia requests, involving 415 SCEN physicians. Patient characteristics that were associated with a lower likelihood to meet due care requirements were: being tired with life, depression and not wanting to be a burden. Physical suffering and higher patient age were related to greater chances of meeting the requirements. There was no clear association between SCEN physicians' characteristics and their judgment. CONCLUSION Psychological suffering involves a greater chance that SCEN physicians judge that requirements of due care are not met. The association between SCEN physician characteristics and the judgment of euthanasia requests is limited, suggesting uniformity in their judgment.
Collapse
Affiliation(s)
| | - Yvonne Vergouwe
- Erasmus MC, University Medical Center Rotterdam, Department of Public Health, Rotterdam, The Netherlands.
| | - Agnes van der Heide
- Erasmus MC, University Medical Center Rotterdam, Department of Public Health, Rotterdam, The Netherlands.
| | - Bregje D Onwuteaka-Philipsen
- VU University Medical Center, Department of Public and Occupational Health and EMGO Institute for Health and Care Research, VUmc Expertise Center for Palliative Care, Amsterdam, The Netherlands.
| |
Collapse
|
12
|
Van Wesemael Y, Cohen J, Bilsen J, Smets T, Onwuteaka-Philipsen B, Deliens L. Process and outcomes of euthanasia requests under the belgian act on euthanasia: a nationwide survey. J Pain Symptom Manage 2011; 42:721-33. [PMID: 21570807 DOI: 10.1016/j.jpainsymman.2011.02.011] [Citation(s) in RCA: 58] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2010] [Revised: 02/10/2011] [Accepted: 02/10/2011] [Indexed: 11/23/2022]
Abstract
CONTEXT Since 2002, the administration of a lethal drug by a physician at the explicit request of the patient has been legal in Belgium. The incidence of euthanasia in Belgium has been studied, but the process and outcomes of euthanasia requests have not been investigated. OBJECTIVES To describe which euthanasia requests were granted, withdrawn, and rejected since the enactment of the euthanasia law in terms of the characteristics of the patient, treating physician, and aspects of the consultation with a second physician. METHODS A representative sample of 3006 Belgian physicians received a questionnaire investigating their most recent euthanasia request. RESULTS The response rate was 34%. Since 2002, 39% of respondents had received a euthanasia request. Forty-eight percent of requests had been carried out, 5% had been refused, 10% had been withdrawn, and in 23%, the patient had died before euthanasia could be performed. Physicians' characteristics associated with receiving a request were not being religious, caring for a high number of terminally ill patients, and having experience in palliative care. Patient characteristics associated with granting a request were age, having cancer, loss of dignity, having no depression, and suffering without prospect of improvement as a reason for requesting euthanasia. A positive initial position toward the request from the attending physician and positive advice from the second physician also contributed to having a request granted. CONCLUSION Under the Belgian Act on Euthanasia, about half of the requests are granted. Factors related to the reason for the request, position of the attending physician toward the request, and advice from the second physician influence whether a request is granted or not.
Collapse
Affiliation(s)
- Yanna Van Wesemael
- End-of-Life Care Research Group, Ghent University & Vrije Universiteit Brussel, Jette, Belgium.
| | | | | | | | | | | |
Collapse
|
13
|
Feldt KS, Bond GE, Jacobson D, Clymin J. Washington State Death with Dignity Act: Implications for Long-Term Care. J Gerontol Nurs 2011; 37:32-40. [DOI: 10.3928/00989134-20110602-09] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2010] [Accepted: 02/10/2011] [Indexed: 11/20/2022]
|
14
|
van Tilburg MAL, Spence NJ, Whitehead WE, Bangdiwala S, Goldston DB. Chronic pain in adolescents is associated with suicidal thoughts and behaviors. THE JOURNAL OF PAIN 2011; 12:1032-9. [PMID: 21684217 PMCID: PMC3178682 DOI: 10.1016/j.jpain.2011.03.004] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/26/2010] [Revised: 02/15/2011] [Accepted: 03/14/2011] [Indexed: 01/01/2023]
Abstract
UNLABELLED Adults who suffer from chronic pain are at increased risk for suicide ideation and attempts, but it is not clear whether adolescents with chronic pain are similarly at elevated risk. This study investigates whether chronic pain is associated with an increase in suicidal ideation/attempts independent of depression in a population sample of adolescents. We analyzed data from the National Longitudinal Study of Adolescent Health, a longitudinal study of a nationally representative sample of adolescents in the United States (N = 9,970). Most chronic pain was related to suicide ideation/attempt both in the last year (odds ratio [OR] 1.3-2.1) and during the subsequent year (OR 1.2-1.8). After controlling for depressive symptoms, headaches (OR = 1.3 last year, OR = 1.2 subsequent year) and muscle aches (OR = 1.3 last year) remained associated with suicide ideation but not suicide attempt. These findings show that chronic pain in adolescence is a risk factor for suicide ideation; this effect is partly but not fully explained by depression. Youth with comorbid depression and chronic pain are at increased risk of thinking about and attempting suicide. Clinicians should be alert to suicide ideation/attempt and comorbid depression in this at-risk population. PERSPECTIVE Adolescents who suffer from chronic pain are at increased risk for suicide ideation and attempt. Depressive symptoms account for the link between chronic pain and suicide attempt, but do not completely explain why adolescents with chronic pain show suicide ideation.
Collapse
Affiliation(s)
- Miranda A L van Tilburg
- University of North Carolina, Center for Functional GI and Motility Disorders, Chapel Hill, North Carolina 27516, USA.
| | | | | | | | | |
Collapse
|
15
|
Meeussen K, Van den Block L, Bossuyt N, Echteld M, Bilsen J, Deliens L. Dealing with requests for euthanasia: interview study among general practitioners in Belgium. J Pain Symptom Manage 2011; 41:1060-72. [PMID: 21402463 DOI: 10.1016/j.jpainsymman.2010.09.020] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2010] [Revised: 09/09/2010] [Accepted: 09/15/2010] [Indexed: 11/23/2022]
Abstract
CONTEXT In many countries, physicians are confronted with requests for euthanasia. Notwithstanding that euthanasia is legally permitted in Belgium, it remains the subject of intense debate. OBJECTIVES To gather in-depth empirical data on how general practitioners (GPs) deal with these requests in Belgium. METHODS Mortality follow-back study in 2005-2006 via the nationwide Sentinel Network of General Practitioners. Standardized face-to-face interviews were conducted with GPs for all the reported patients who did not die suddenly or totally unexpectedly at home, as judged by the GP. RESULTS We conducted 205 interviews. Of these, 27 patients had at some point expressed a wish to receive a drug administered by a physician with the explicit intention to end life, that is, euthanasia. Thirteen of these formulated their requests explicitly and repeatedly, according to their GP. Compared with patients who expressed a wish but not an explicit/repeated request for euthanasia, those patients' requests were more often documented (8 of 13 vs. 2 of 14; P=0.01), and reiterated until their final days of life (6 of 13 vs. 0 of 14; P=0.02). Five patients received euthanasia. For the other 22 patients, GPs gave different reasons for not acceding to the request, often related to criteria stipulated in the Belgian law on euthanasia, and sometimes related to personal reasons. CONCLUSION It is not uncommon for patients to ask their GP for euthanasia, although explicit requests remain relatively rare. Requests tend to vary widely in form and content, and far more are expressed than complied with. For many GPs, the Belgian law on euthanasia serves as a guiding principle in this decision-making process, although in a minority of the cases, a GP's personal opinion toward euthanasia seems to be decisive.
Collapse
Affiliation(s)
- Koen Meeussen
- End-of-Life Care Research Group, Vrije Universiteit Brussel, Brussels, Belgium.
| | | | | | | | | | | |
Collapse
|
16
|
Elman I, Zubieta JK, Borsook D. The missing p in psychiatric training: why it is important to teach pain to psychiatrists. ARCHIVES OF GENERAL PSYCHIATRY 2011; 68:12-20. [PMID: 21199962 PMCID: PMC3085192 DOI: 10.1001/archgenpsychiatry.2010.174] [Citation(s) in RCA: 83] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
CONTEXT Pain problems are exceedingly prevalent among psychiatric patients. Moreover, clinical impressions and neurobiological research suggest that physical and psychological aspects of pain are closely related entities. Nonetheless, remarkably few pain-related themes are currently included in psychiatric residency training. OBJECTIVES To provide clinical and scientific rationale for psychiatric-training enrichment with basic tenets of pain medicine and to raise the awareness and sensitivity of physicians, scientists, and educators to this important yet unmet clinical and public health need. RESULTS We present 3 lines of translational research evidence, extracted from a comprehensive literature review, in support of our objectives. First, the neuroanatomical and functional overlap between pain and emotion/reward/motivation brain circuitry suggests integration and mutual modulation of these systems. Second, psychiatric disorders are commonly associated with alterations in pain processing, whereas chronic pain may impair emotional and neurocognitive functioning. Third, given its stressful nature, pain may serve as a functional probe for unraveling pathophysiological mechanisms inherent in psychiatric morbidity. CONCLUSIONS Pain training in psychiatry will contribute to deeper and more sophisticated insight into both pain syndromes and general psychiatric morbidity regardless of patients' pain status. Furthermore, it will ease the artificial boundaries separating psychiatric and medical formulations of brain disorders, thus fostering cross-fertilizing interactions among specialists in various disciplines entrusted with the care of patients experiencing pain.
Collapse
Affiliation(s)
- Igor Elman
- Clinical Psychopathology Laboratory, Mclean Hospital, Harvard Medical School, Boston MA
| | - Jon-Kar Zubieta
- Departments of Psychiatry and Radiology and Molecular and Behavioral Neuroscience Institute, University of Michigan, Ann Arbor, MI
| | - David Borsook
- P.A.I.N. Group, Department of Psychiatry, McLean Hospital and Massachusetts General Hospital, Harvard Medical School, Boston MA
| |
Collapse
|
17
|
Experiences of living with a deteriorating body in late palliative phases of cancer. Curr Opin Support Palliat Care 2010; 4:153-7. [DOI: 10.1097/spc.0b013e32833b4f37] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|
18
|
|
19
|
Dees M, Vernooij-Dassen M, Dekkers W, van Weel C. Unbearable suffering of patients with a request for euthanasia or physician-assisted suicide: an integrative review. Psychooncology 2010; 19:339-52. [DOI: 10.1002/pon.1612] [Citation(s) in RCA: 73] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
|
20
|
Buiting H, van Delden J, Onwuteaka-Philpsen B, Rietjens J, Rurup M, van Tol D, Gevers J, van der Maas P, van der Heide A. Reporting of euthanasia and physician-assisted suicide in the Netherlands: descriptive study. BMC Med Ethics 2009; 10:18. [PMID: 19860873 PMCID: PMC2781018 DOI: 10.1186/1472-6939-10-18] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2009] [Accepted: 10/27/2009] [Indexed: 11/25/2022] Open
Abstract
Background An important principle underlying the Dutch Euthanasia Act is physicians' responsibility to alleviate patients' suffering. The Dutch Act states that euthanasia and physician-assisted suicide are not punishable if the attending physician acts in accordance with criteria of due care. These criteria concern the patient's request, the patient's suffering (unbearable and hopeless), the information provided to the patient, the presence of reasonable alternatives, consultation of another physician and the applied method of ending life. To demonstrate their compliance, the Act requires physicians to report euthanasia to a review committee. We studied which arguments Dutch physicians use to substantiate their adherence to the criteria and which aspects attract review committees' attention. Methods We examined 158 files of reported euthanasia and physician-assisted suicide cases that were approved by the review committees. We studied the physicians' reports and the verdicts of the review committees by using a checklist. Results Physicians reported that the patient's request had been well-considered because the patient was clear-headed (65%) and/or had repeated the request several times (23%). Unbearable suffering was often substantiated with physical symptoms (62%), function loss (33%), dependency (28%) or deterioration (15%). In 35%, physicians reported that there had been alternatives to relieve patients' suffering which were refused by the majority. The nature of the relationship with the consultant was sometimes unclear: the consultant was reported to have been an unknown colleague (39%), a known colleague (21%), otherwise (25%), or not clearly specified in the report (24%). Review committees relatively often scrutinized the consultation (41%) and the patient's (unbearable) suffering (32%); they had few questions about possible alternatives (1%). Conclusion Dutch physicians substantiate their adherence to the criteria in a variable way with an emphasis on physical symptoms. The information they provide is in most cases sufficient to enable adequate review. Review committees' control seems to focus on (unbearable) suffering and on procedural issues.
Collapse
Affiliation(s)
- Hilde Buiting
- Department of Public Health, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands.
| | | | | | | | | | | | | | | | | |
Collapse
|
21
|
Leeman CP. Distinguishing among irrational suicide and other forms of hastened death: implications for clinical practice. PSYCHOSOMATICS 2009; 50:185-91. [PMID: 19567753 DOI: 10.1176/appi.psy.50.3.185] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND The increasing recognition that not all hastened death is irrational challenges clinical practice. OBJECTIVE The author distinguishes among the various forms of hastened death. Psychiatrists may be consulted when patients ask to hasten their death in any of the ways described, contrasted, and illustrated in this article. CONCLUSION The rational desire to hasten death may call for unconventional psychiatric responses. The author discusses the error of failing to provide life-saving medical treatment over the objection of someone who has attempted suicide and the error of trying to prevent rational persons suffering from incurable illness from hastening their death.
Collapse
Affiliation(s)
- Cavin P Leeman
- Division of Humanities in Medicine, SUNY Downstate Medical Center, Brooklyn, NY, USA.
| |
Collapse
|
22
|
Abstract
Outpatient palliative care can provide significant benefits to seriously ill patients, but several barriers to appropriate referrals remain. No study has examined the physician factors associated with referral to outpatient palliative care. To determine physician factors, with a focus on physician beliefs, associated with referral to palliative care. Cross-sectional study of 170 primary care physicians at Kaiser Permanente (KP), a large non-profit Health Maintenance Organisation (HMO), using a self-administered questionnaire. Of the 145 respondents, 100 (70%) reported referring any patients to the palliative care program in the prior year, with a median of 3 referrals (interquartile range 2, 6). Factors associated with referral included working at KP between 10 and 20 years as compared to <10 years [Odds ratio [OR] 6.29 (95% confidence interval [CI] 1.38, 28.6)] and having personal experience with palliative care [OR 2.13 (95% CI 0.95, 4.976)]. None of the beliefs scales was associated with referral. Physician characteristics other than their beliefs about palliative care played a significant role in determining referral. Palliative care programs should aim to increase their visibility in the outpatient setting to increase referrals by primary care physicians. Tools that help physicians identify seriously ill patients who could benefit from palliative care may also serve to increase appropriate referrals.
Collapse
Affiliation(s)
- S C Ahluwalia
- Department of Medicine, Yale School of Medicine, New Haven, Connecticut 06510, USA.
| | | |
Collapse
|
23
|
Van den Block L, Deschepper R, Bilsen J, Bossuyt N, Van Casteren V, Deliens L. Euthanasia and other end of life decisions and care provided in final three months of life: nationwide retrospective study in Belgium. BMJ 2009; 339:b2772. [PMID: 19643825 PMCID: PMC2719064 DOI: 10.1136/bmj.b2772] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
OBJECTIVE To explore the relation between the care provided in the final three months of life and the prevalence and types of end of life decisions in Belgium. Design Two year nationwide retrospective study, 2005-6 (SENTI-MELC study). SETTING Data collection via the sentinel network of general practitioners, an epidemiological surveillance system representative of all general practitioners in Belgium. SUBJECTS 1690 non-sudden deaths in practices of the sentinel general practitioners. MAIN OUTCOME MEASURES Non-sudden deaths of patients (aged >1 year) reported each week. Reported care provided in the final three months of life and the end of life decisions made. Multivariable regression analysis controlled for age, sex, cause, and place of death. RESULTS Use of specialist multidisciplinary palliative care services was associated with intensified alleviation of symptoms (odds ratio 2.1, 95% confidence interval 1.6 to 2.6), continuous deep sedation forgoing food/fluid (2.9, 1.7 to 4.9), and the total of decisions explicitly intended to shorten life (1.5, 1.1 to 2.1) but not with euthanasia or physician assisted suicide in particular. To a large extent receiving spiritual care was associated with higher frequencies of euthanasia or physician assisted suicide than receiving little spiritual care (18.5, 2.0 to 172.7). CONCLUSIONS End of life decisions that shorten life, including euthanasia or physician assisted suicide, are not related to a lower use of palliative care in Belgium and often occur within the context of multidisciplinary care.
Collapse
Affiliation(s)
- Lieve Van den Block
- Vrije Universiteit Brussel, End-of-Life Care Research Group, Laarbeeklaan 103, 1090 Brussels, Belgium.
| | | | | | | | | | | |
Collapse
|
24
|
Ballard DW, Reed ME, Wang H, Arroyo L, Benedetti N, Hsu J. Influence of patient costs and requests on emergency physician decisionmaking. Ann Emerg Med 2008; 52:643-650. [PMID: 18439723 DOI: 10.1016/j.annemergmed.2008.03.001] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2007] [Revised: 01/14/2008] [Accepted: 03/03/2008] [Indexed: 11/16/2022]
Abstract
STUDY OBJECTIVES We examine emergency physician knowledge of, attitudes about, and responses to patient cost-sharing in the emergency department (ED). METHODS A convenience sample of emergency physicians from an integrated delivery system completed a questionnaire including self-report questions about knowledge of and attitudes about cost-sharing and an experimental vignette. The vignette describes a patient with an uncomplicated asthma exacerbation, with a version in which she has a $100 ED visit copayment and a version in which she does not. Subjects responded with their "best judgment" of whether they would order a chest radiograph and their decision after specific patient request. We examined the frequency of responses overall and associated characteristics with chi(2) testing. RESULTS Of 204 respondents (349 eligible participants [58%]), 203 answered the vignette questions. No respondent reported that ordering a radiograph was clinically appropriate; however, 85% reported that they would order a radiograph if the patient requested it. There were no significant differences in the percentage of physicians ordering the test across the 2 versions. Overall, 77% of respondents reported having limited awareness of an individual patient's cost-sharing level; 67% reported that patient costs sometimes affect their clinical decisions; only 10% estimated changing their decisions in greater than 20% of encounters in which the cost-sharing level was known. CONCLUSION Emergency physicians are usually not aware of a patient's cost-sharing level and, in instances which they are, report that this knowledge rarely affects their clinical decisions. However, emergency physicians are responsive to patient requests, even when the treatment request differs from their clinical judgment.
Collapse
Affiliation(s)
- Dustin W Ballard
- Department of Emergency Medicine, Kaiser Permanente San Rafael Medical Center, San Rafael, Fairfax, CA 94930, USA.
| | | | | | | | | | | |
Collapse
|
25
|
Acute Pain at Discharge From Hospitalization is a Prospective Predictor of Long-Term Suicidal Ideation After Burn Injury. Arch Phys Med Rehabil 2007; 88:S36-42. [DOI: 10.1016/j.apmr.2007.05.031] [Citation(s) in RCA: 57] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/30/2007] [Indexed: 11/23/2022]
|
26
|
Husain MM, Rush AJ, Trivedi MH, McClintock SM, Wisniewski SR, Davis L, Luther JF, Zisook S, Fava M. Pain in depression: STAR*D study findings. J Psychosom Res 2007; 63:113-22. [PMID: 17662746 DOI: 10.1016/j.jpsychores.2007.02.009] [Citation(s) in RCA: 60] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2005] [Indexed: 11/27/2022]
Abstract
BACKGROUND Pain complaints commonly accompany major depressive disorder (MDD). However, whether patients with MDD and pain complaints differ from those without pain complaints is not well studied. OBJECTIVE The objective of this study was to compare depressed outpatients with and those without current pain complaints in terms of sociodemographic, clinical, and presenting symptom features. METHODS The baseline clinical and sociodemographic data of a large representative outpatient sample with nonpsychotic MDD (n=3745) enrolled in the STAR*D (Sequenced Treatment Alternatives to Relieve Depression) study were collected. Baseline information on pain complaints was based on Item No. 25 (somatic pain) of the 30-item Inventory of Depressive Symptomatology-Clinician Rating (IDS-C(30)). RESULTS After adjusting for sex, depression severity (IDS-C(30) less Item No. 25), and general medical comorbidities (as measured by the Cumulative Illness Rating Scale total score), we found clinically meaningful differences between patients with and those without pain complaints. Younger, African American, Hispanic, and less educated patients were more likely to report pain complaints. In addition, those with pain complaints were more likely to report anxious features with irritable mood, sympathetic nervous system arousal, and gastrointestinal problems as well as poorer quality of life. Neither a more chronic course of illness nor suicidal ideation was associated with pain. CONCLUSIONS Pain complaints are common among outpatients with MDD and are associated with certain symptom features and poorer quality of life. However, the findings of this study suggest that depression accompanied by pain complaints does not increase the clinical psychiatric burden or chronicity of depression.
Collapse
Affiliation(s)
- Mustafa M Husain
- Department of Psychiatry, University of Texas Southwestern Medical Center, Dallas, TX 75390-8898, USA.
| | | | | | | | | | | | | | | | | |
Collapse
|
27
|
Georges JJ, Onwuteaka-Philipsen BD, Muller MT, Van Der Wal G, Van Der Heide A, Van Der Maas PJ. Relatives' perspective on the terminally ill patients who died after euthanasia or physician-assisted suicide: a retrospective cross-sectional interview study in the Netherlands. DEATH STUDIES 2007; 31:1-15. [PMID: 17131559 DOI: 10.1080/07481180600985041] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/12/2023]
Abstract
This study used retrospective interviews with 87 relatives to describe the experiences of patients who died by euthanasia or physician-assisted suicide (EAS) in the Netherlands. Most of the patients suffered from cancer (85%). The relatives were most often a partner (63%) or a child (28%) of the patient. Before explicitly requesting EAS most patients (79%) had spoken about their wishes concerning medical end-of-life decisions to be made at a later date. Hopeless suffering, loss of dignity, and no prospect of recovery were the most prevalent reasons for explicitly requesting EAS. According to the relative, in 92% of patients EAS had contributed favourably to the quality of the end of life, mainly by preventing or ending suffering.
Collapse
Affiliation(s)
- Jean-Jacques Georges
- Department of Public and Occupational Health, Institute for Research in Extramural Medicine, VU Medical Center, Amsterdam, The Netherlands.
| | | | | | | | | | | |
Collapse
|
28
|
Walke LM, Byers AL, Gallo WT, Endrass J, Fried TR. The association of symptoms with health outcomes in chronically ill adults. J Pain Symptom Manage 2007; 33:58-66. [PMID: 17196907 PMCID: PMC1948074 DOI: 10.1016/j.jpainsymman.2006.07.013] [Citation(s) in RCA: 45] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2006] [Revised: 07/05/2006] [Accepted: 07/07/2006] [Indexed: 11/27/2022]
Abstract
Persons with chronic disease experience multiple symptoms. Understanding the association between these symptoms and health outcomes would facilitate a targeted approach to symptom assessment and treatment. Our objectives were to determine the association of a range of symptoms with quality of life, self-rated health, and functional status among chronically ill adults, and to assess methods for evaluating the independent associations of symptoms that may be interrelated. We consecutively enrolled 226 cognitively intact, community-dwelling adults, aged 60 years or older with chronic obstructive pulmonary disease, heart failure, or cancer. Seven symptoms (physical discomfort, pain, fatigue, problems with appetite, feelings of depression, anxiety, and shortness of breath) assessed using the Edmonton Symptom Assessment Scale were examined for their association with self-rated quality of life, self-rated health, and functional status. Principal component analysis and logistic regression revealed similar results. The latter demonstrated that physical discomfort was associated with lower self-rated health (adjusted odds ratio [OR] 1.9; 95% confidence interval 1.2-2.9) and functional disability (adjusted OR 1.8; 95% confidence interval 1.2-2.7). Feelings of depression were associated with poorer quality of life (adjusted OR 1.7; 95% confidence interval 1.1-2.6), and shortness of breath was associated with lower self-rated health (adjusted OR 1.5; 95% confidence interval 1.1-2.0). The association between a range of symptoms and quality of life, self-rated health, and functional status differed across outcomes, but only three symptoms-physical discomfort, feelings of depression, and shortness of breath-maintained their associations when multiple symptoms were examined concurrently. These findings suggest that interventions targeting these symptoms could improve several health-related outcomes.
Collapse
Affiliation(s)
- Lisa M Walke
- Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut 06504, USA.
| | | | | | | | | |
Collapse
|
29
|
Edwards RR, Smith MT, Kudel I, Haythornthwaite J. Pain-related catastrophizing as a risk factor for suicidal ideation in chronic pain. Pain 2006; 126:272-9. [PMID: 16926068 DOI: 10.1016/j.pain.2006.07.004] [Citation(s) in RCA: 120] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2006] [Revised: 06/13/2006] [Accepted: 07/06/2006] [Indexed: 11/30/2022]
Abstract
Living with chronic pain is associated with many deleterious outcomes, including a substantially increased risk of suicide. While many general risk factors for suicidal ideation and behavior have been identified, few studies have examined pain-related factors that confer increased or decreased risk for suicidality. The present study assessed individual differences in the use of pain-related coping strategies and pain-related catastrophizing as correlates of suicidal ideation in patients with chronic pain. A total of 1512 patients seeking treatment for chronic pain completed a variety of questionnaires assessing pain, coping, and psychosocial functioning. On written questionnaires, approximately 32% of this clinic sample reported some form of recent suicidal ideation. The two most consistent predictors of the presence and degree of suicidal ideation were the magnitude of depressive symptoms and the degree of pain-related catastrophizing, a maladaptive cognitive/emotional pain-coping strategy. Demographic and other pain-related variables such as pain severity and duration were not generally robust predictors of suicidal ideation in this sample of patients with chronic pain. These are the first findings to suggest a unique (e.g., independent of pain severity or depressive symptomatology) association between pain-coping strategies and suicide-related cognitions in the context of chronic pain. Further research in this area, including the addition of suicide prevention materials to pain-coping skills training programs, may benefit large numbers of individuals who are at elevated suicide risk as a consequence of chronic pain.
Collapse
Affiliation(s)
- Robert R Edwards
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, 600 N. Wolfe Street, Meyer 1-108, Baltimore, MD 21287, USA.
| | | | | | | |
Collapse
|
30
|
|
31
|
Hicks MHR. Physician-assisted suicide: a review of the literature concerning practical and clinical implications for UK doctors. BMC FAMILY PRACTICE 2006; 7:39. [PMID: 16792812 PMCID: PMC1550404 DOI: 10.1186/1471-2296-7-39] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 03/02/2006] [Accepted: 06/22/2006] [Indexed: 11/16/2022]
Abstract
BACKGROUND A bill to legalize physician-assisted suicide in the UK recently made significant progress in the British House of Lords and will be reintroduced in the future. Until now there has been little discussion of the clinical implications of physician-assisted suicide for the UK. This paper describes problematical issues that became apparent from a review of the medical and psychiatric literature as to the potential effects of legalized physician-assisted suicide. DISCUSSION Most deaths by physician-assisted suicide are likely to occur for the illness of cancer and in the elderly. GPs will deal with most requests for assisted suicide. The UK is likely to have proportionately more PAS deaths than Oregon due to the bill's wider application to individuals with more severe physical disabilities. Evidence from other countries has shown that coercion and unconscious motivations on the part of patients and doctors in the form of transference and countertransference contribute to the misapplication of physician-assisted suicide. Depression influences requests for hastened death in terminally ill patients, but is often under-recognized or dismissed by doctors, some of whom proceed with assisted death anyway. Psychiatric evaluations, though helpful, do not solve these problems. Safeguards that are incorporated into physician-assisted suicide criteria probably decrease but do not prevent its misapplication. SUMMARY The UK is likely to face significant clinical problems arising from physician-assisted suicide if it is legalized. Terminally ill patients with mental illness, especially depression, are particularly vulnerable to the misapplication of physician-assisted suicide despite guidelines and safeguards.
Collapse
Affiliation(s)
- Madelyn Hsiao-Rei Hicks
- Section of Community (PRiSM), Department of Health Services Research, Institute of Psychiatry, King's College London, University of London, UK.
| |
Collapse
|
32
|
Albert SM, Rabkin JG, Del Bene ML, Tider T, O'Sullivan I, Rowland LP, Mitsumoto H. Wish to die in end-stage ALS. Neurology 2006; 65:68-74. [PMID: 16009887 PMCID: PMC1201540 DOI: 10.1212/01.wnl.0000168161.54833.bb] [Citation(s) in RCA: 95] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND In retrospective studies, estimates of hastened dying among seriously ill patients range from <2% in one national survey to as much as 20% in end-stage disease cohorts. OBJECTIVE To examine, in prospective studies, dying patients in the months before death, in order to understand the wish to die. METHODS Patients with advanced ALS with a high likelihood of death or need for tracheostomy within 6 months were identified. Patients were assessed monthly with an extensive psychosocial interview, including a diagnostic interview for depression. Family caregivers were interviewed on the same schedule and also after patient deaths. RESULTS Eighty patients with ALS were enrolled, 63% of eligible patients; 53 died over follow-up. Ten (18.9%) of the 53 expressed the wish to die, and 3 (5.7%) hastened dying. Patients expressing the wish to die did not differ in sociodemographic features, ALS severity, or perceived burden of family caregivers. They were more likely to meet criteria for depression, but differences were smaller when suicidality was excluded from the depression interview. Patients who expressed the wish to die reported less optimism, less comfort in religion, and greater hopelessness. Compared with patients unable to act on the wish to die, patients who hastened dying reported reduction in suffering and increased perception of control over the disease in the final weeks of life. CONCLUSION These findings suggest caution in concluding that the desire to hasten dying in end-stage disease is simply a feature of depression.
Collapse
Affiliation(s)
- S M Albert
- The Eleanor and Lou Gehrig MDA/ALS Research Center, Department of Neurology, Columbia University, New York, NY 10032, USA.
| | | | | | | | | | | | | |
Collapse
|
33
|
Procureur O, Pochard F. Suicide médicalement assisté. Presse Med 2006; 35:296-9. [PMID: 16493332 DOI: 10.1016/s0755-4982(06)74573-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
In physician-assisted suicide, the patient performs the deadly act, aided by a physician. Although not legal, physician-assisted suicide exists in France. Its legalization in other countries has been the source of problems and abuses. Palliative care is a credible alternative. We do not think that legalization is desirable.
Collapse
|
34
|
Georges JJ, Onwuteaka-Philipsen BD, van der Wal G, van der Heide A, van der Maas PJ. Differences between terminally ill cancer patients who died after euthanasia had been performed and terminally ill cancer patients who did not request euthanasia. Palliat Med 2005; 19:578-86. [PMID: 16450874 DOI: 10.1191/0269216305pm1069oa] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Palliative care, directed at improving the quality of life of terminally ill patients, is generally not aimed at any form of postponing or hastening death. It is possible that high quality palliative care could prevent requests for euthanasia. However, empirical evidence on this issue is scarce. In a national survey of end-of-life medical decisions in The Netherlands the subject of care at the end of life has been addressed. Data on terminally ill cancer patients who died after their request was granted and euthanasia had been performed were compared with those of terminally ill cancer patients who did not request euthanasia. The results show that the prevalence and severity of symptoms e.g., pain, feeling unwell, nausea, was higher in patients who died after their request was granted and euthanasia had been performed. No differences concerning the treatment of symptoms or the care provided were found between the two groups. The results suggest that the practice of euthanasia is mainly related to the patient's suffering.
Collapse
Affiliation(s)
- Jean-Jacques Georges
- Department of Public and Occupational Health, Institute for Research in Extramural Medicine, VU Medical Center, Amsterdam.
| | | | | | | | | |
Collapse
|
35
|
Martínez-Urionabarrenetxea K. Sobre la moralidad de la eutanasia y del suicidio asistido. ACTA ACUST UNITED AC 2005. [DOI: 10.1016/s1134-282x(05)70785-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
|
36
|
Rurup ML, Onwuteaka-Philipsen BD, Jansen-van der Weide MC, van der Wal G. When being ‘tired of living’ plays an important role in a request for euthanasia or physician-assisted suicide: patient characteristics and the physician's decision. Health Policy 2005; 74:157-66. [PMID: 16153476 DOI: 10.1016/j.healthpol.2005.01.002] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2004] [Accepted: 01/04/2005] [Indexed: 11/15/2022]
Abstract
BACKGROUND In the Netherlands physicians are allowed to grant requests for euthanasia or physician-assisted suicide (EAS) if they meet several requirements of due care. According to jurisprudence, a physician is not allowed to end the life of a patient whose request for EAS is based on being 'tired of living', because such a request falls outside the medical domain. Our previous studies have shown that in spite of this, such requests are made approximately 400 times a year. OBJECTIVES To learn more about patients who request EAS because they are tired of living, and about factors that influence the decision of the physician. DESIGN Questionnaires (n=4842) completed by general practitioners (n=3994). RESULTS According to the physicians, 17% of patients who requested EAS were 'tired of living'. Of 139 patients in whose request for EAS being tired of living played a major role, 47% suffered from cancer, 25% suffered from another severe disease and 28% had no severe disease. In all three groups the same three symptoms occurred most frequently, 'feeling bad', 'tired', and 'not active'. Each of these symptoms occurred in more than half of the patients in each group. Most of the requests from patients with cancer were granted, but those from patients who had some other severe disease, or no severe disease at all, were refused. Factors that were related to granting a request were: the presence of unbearable and hopeless suffering, the absence of alternatives, and the absence of depressive symptoms. CONCLUSIONS Being tired of living can play a major role in requests for EAS, both in the absence and the presence of a severe disease. The high occurrence of symptoms in the absence of a classifiable severe disease implies that physical symptoms are prevalent in this group of patients, leaving the legal requirement for EAS of 'a medical cause' open to interpretation in the more complex medical practice.
Collapse
Affiliation(s)
- Mette L Rurup
- VU University Medical Center, Department of Public and Occupational Health and Institute for Research in Extramural Medicine, van der Boechorst straat 7, 1081 BT Amsterdam, The Netherlands.
| | | | | | | |
Collapse
|
37
|
Abstract
As the field of pain management nears the halfway point of the Congressionally declared "Decade of Pain Control and Research," the prevalence of chronic pain and disability related thereto continue to escalate. In the context of rising costs and suffering associated with persistent pain worldwide, the chronic pain research community has increasingly recognized and investigated the role of the cognitive and affective dimensions of pain. In this paper, the authors review psychologic aspects of pain, psychopathology in chronic pain syndromes, suicidality in this population, and the use of psychotropic medications for treatment in these patients. Where possible, the authors have outlined limitations of previous research in these areas, and have highlighted and described recent studies that have addressed these perceived shortcomings. The role of the psychiatrist in the treatment of patients with chronic pain is reviewed.
Collapse
Affiliation(s)
- John Sharp
- Department of Psychiatry, Beth Israel Deaconess Medical Center 1101 Beacon Street Brookline, MA 02446, USA.
| | | |
Collapse
|
38
|
O'Mahony S, Goulet J, Kornblith A, Abbatiello G, Clarke B, Kless-Siegel S, Breitbart W, Payne R. Desire for hastened death, cancer pain and depression: report of a longitudinal observational study. J Pain Symptom Manage 2005; 29:446-57. [PMID: 15904747 DOI: 10.1016/j.jpainsymman.2004.08.010] [Citation(s) in RCA: 110] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/07/2004] [Indexed: 11/17/2022]
Abstract
Desire for hastened death (DHD) is reported in the literature as being common in patients with cancer pain. However, there is currently little evidence to suggest that improvement in pain results in improvement in DHD. Our objectives were to assess 1) the impact of improvements in cancer pain severity and pain's interference with daily functioning and depression on DHD, and 2) the role of factors such as social and spiritual well-being, educational level, and patient age in moderating the impact of pain and depression on DHD. This observational study included patient-rated and clinician-rated scales administered twice at 4-week intervals. We enrolled 131 newly-referred patients to the Pain and Palliative Care Service at Memorial Sloan-Kettering Cancer Center or newly-admitted patients to Calvary Hospital in New York. One hundred and sixteen patients completed the baseline measures and 64 patients completed both baseline and follow-up measures. The main outcome measures included the Brief Pain Inventory (BPI), Beck Depression Inventory (BDI), and the Desire for Hastened Death Scale (DHD). Sixty-six percent of patients had no DHD at baseline and 45% of patients had BDI scores of 14 or greater ('mild' depression). Only 40% of patients with moderate/severe depression were receiving antidepressants. BPI scores improved significantly from baseline to follow-up (6.36 vs. 4.86, P < 0.01). DHD scores increased significantly from baseline to follow-up (0.84 to 1.38, P = 0.03). All other measures including depression were stable. DHD scores were moderately correlated with depression (r = 0.43), low social support (r = 0.38), poor spiritual well-being (r = -0.38), religious well being (r = -0.25), pain interference (r = 0.27), higher educational level (F = 4.50, P = 0.02) and lower physical functioning (KPRS, r = -0.40), but were unrelated to sex, age, race, or marital status. In multivariate regression analyses, baseline DHD (beta = 0.30, P = 0.05) and change in depression (beta=0.36, P = 0.02) were predictive of follow-up DHD. Improvement in pain interference was not predictive of follow-up DHD. The results suggest that improvement in depression moderated the severity of desire for hastened death in a population of patients with cancer pain. Depression was common in this population and was often untreated. Improvements in functional impairment due to pain did not moderate the severity of DHD in a setting of aggressive pain management. Strategies to preemptively screen for depression in the routine assessment of patients with cancer pain may be important to address DHD.
Collapse
|
39
|
Chochinov HM, Hack T, Hassard T, Kristjanson LJ, McClement S, Harlos M. Understanding the Will to Live in Patients Nearing Death. PSYCHOSOMATICS 2005; 46:7-10. [PMID: 15765815 DOI: 10.1176/appi.psy.46.1.7] [Citation(s) in RCA: 108] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
This study examined concurrent influences on the will to live in 189 patients with end-stage cancer The authors found significant correlations between the will to live and existential, psychological, social, and, to a lesser degree, physical sources of distress. Existential variables proved to have the most influence, with hopelessness, burden to others, and dignity entering into the final model. Health care providers must learn to appreciate the importance of existential issues and their ability to influence the will to live among patients nearing death.
Collapse
|
40
|
Smith MT, Edwards RR, Robinson RC, Dworkin RH. Suicidal ideation, plans, and attempts in chronic pain patients: factors associated with increased risk. Pain 2004; 111:201-8. [PMID: 15327824 DOI: 10.1016/j.pain.2004.06.016] [Citation(s) in RCA: 115] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2004] [Revised: 06/10/2004] [Accepted: 06/24/2004] [Indexed: 10/26/2022]
Abstract
This study describes suicidal behavior in a cross-sectional sample of chronic pain patients and evaluates factors associated with increased risk for suicidal ideation. One hundred-fifty-three adults with nonmalignant pain (42% back pain) who were consecutively referred to a tertiary care pain center completed a Structured Clinical Interview for Suicide History, the McGill Pain Questionnaire, and the Beck Depression Inventory. Nineteen-percent reported current passive suicidal ideation (PSI), 13% had active thoughts of committing suicide (ASI), 5% had a current suicide plan, and 5% reported a previous suicide attempt. Drug overdose was the most commonly reported plan and method of attempt (75%). Thirteen-percent reported a family history of suicide attempt/completion. Pain-specific and traditional suicide risk factors were evaluated as predictors of current PSI and ASI. Logistic regression analyses revealed that a family history of suicide attempts/completions was associated with a 7.5 fold increase in risk of PSI (P=0.001) and a 6.6 fold increase in ASI (P=0.003), after adjusting for significant covariates. Having abdominal pain was associated with an adjusted 5.5 fold increase in PSI (P=0.05) and a 4.2 fold increase in ASI (P=0.10). Neuropathic pain significantly reduced risk for both PSI (P=0.002) and ASI (P=0.01). Demographics, pain severity, and depression severity were not associated with suicidal ideation in multivariate analyses. These findings highlight the need for routine evaluation and monitoring of suicidal behavior in chronic pain, especially for patients with family histories of suicide, those taking potentially lethal medications, and patients with abdominal pain.
Collapse
Affiliation(s)
- Michael T Smith
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, 600 N. Wolfe Street, Meyer 101, Baltimore, MD 21287, USA.
| | | | | | | |
Collapse
|
41
|
Basta LL. Ethical issues in the management of geriatric cardiac patients. THE AMERICAN JOURNAL OF GERIATRIC CARDIOLOGY 2004; 13:92-4. [PMID: 15010656 DOI: 10.1111/j.1076-7460.2004.02701.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/29/2023]
Affiliation(s)
- L L Basta
- The University of South Florida, Project GRACE, Clearwater, FL 33756, USA
| |
Collapse
|