Rational suicide among patients who are terminally ill

A COVID-19 Patient's Request to Die and Ensuing Conflict: Psychodynamic Considerations

The role of psychodynamic theory in consultation-liaison (C-L) work, and particularly the importance of countertransference, has been well established. The psychological impact of the COVID-19 pandemic on healthcare workers is a new factor that must now be taken into account as C-L psychiatrists traverse a changed healthcare landscape. In this article, we highlight the case of a critically ill COVID-19 patient who endorsed a desire for hastened death. This request generated significant conflict between the physicians and nurses caring for him, and it became challenging for the C-L team to perform our typical liaison function. We briefly review the existing literature on the psychological impact of the pandemic on healthcare workers, and examine how psychodynamic factors within this context impacted the events that unfolded. Themes under consideration include the effect of mass trauma on clinician defense mechanisms, and specifically the impact on countertransference toward patients who express a desire for hastened death. C-L psychiatrists themselves are not immune to such reactions and must be particularly attentive to emergent conflict in such cases. Interdisciplinary meetings to discuss and process these disagreements may be effective in repairing staff ruptures.

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

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

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

It is not uncommon for patients with advanced incurable disease to express a desire to hasten their death. Health professionals often have difficulty responding to such statements, and find it challenging to ascertain why these statements are made. Health professionals may struggle to determine whether a 'desire to die' statement (DTDS) is about a request for hastened death, a sign of psychosocial distress, or merely a passing comment that is not intended to be heard literally as a death wish. Given the lack of guidelines to assist health professionals with this issue, we have prepared multidisciplinary recommendations for responding to a DTDS, underpinned by key principles of therapeutic communication and a systematic review of empirical literature. Where the relevant literature was lacking, the recommendations were drafted by the authors (clinicians and/ or academics from the following disciplines: nursing, medicine, psychiatry, psychology, sociology, aged care and theology), based on their expert opinion. Multiple drafts of the recommendations were circulated to the authors for refinement until consensus was reached. Strategies for advancing the evidence base for the maturation of guidelines in this area are offered.

Rational suicide: uncertain moral ground

BACKGROUND

The ambiguities involving end-of-life issues, such as physician-assisted suicide and voluntary stopping of eating and drinking, have caused a blurring of the definition of rational suicide and have prompted rich dialogue with moral deliberations that seem to be on disparate paths among bioethicists and other health care professionals. With the evolution of advanced medical technology extending life expectancy in older, disabled, and terminally ill people, rational suicide has become a critical issue of debate.

AIM

The purpose of this article is to address the ethical positions supporting and opposing rational suicide and to consider whether coherence can be achieved through an ethic of care.

FINDINGS

Attitudes towards suicide have been controversial, varying from acceptance to non-acceptance depending on social, political and religious influences. Nursing attitudes are no different from general societal attitudes and, consequently, nurses are treading on uncertain moral ground.

CONCLUSION

Nurses who have not reflected on the moral issues involved with rational suicide may be unprepared psychologically and professionally when working with patients who may be contemplating such actions.

Assisted Dying and End-of-Life Symptom Management

This qualitative study aimed to describe symptom management strategies oncology nurses have used in responding to and preventing requests of terminally ill patients with cancer for assisted dying (AD). The study involved secondary analysis of written stories from 36 nurses who agreed to describe their experiences with a request for assisted dying. Of the 36 nurses, 12 refused to support patient requests for AD and described their attempts to control the circumstances of dying by controlling symptoms. The remaining 24 nurses denied ever receiving requests for AD and described symptom management practices believed to prevent such requests. Data were analyzed using Denzin's process of interpretive interactionism. Two themes emerged from the participant's stories: alternative strategies for AD and prevention of requests for AD. The participants shared many examples of clinical interventions and other features of nursing responses to relieve or prevent suffering including physical, emotional, and spiritual care practices; comfort and medication management; and service as teacher-advocate. Both the nurses who had received requests for AD and those who had not used a variety of similar symptom management approaches to alleviate suffering. In doing so, these nurses upheld current standards of both their professional and specialty organizations.

Ms B and legal competence: examining the role of nurses in difficult ethico-legal decision-making

The case of Ms B throws up some interesting issues regarding the role of the nurse in assisting patients in making and implementing their decisions. The High Court transcript makes it clear who the voices with influence in legal matters were, and why the decisions they took were made. Absent from the myriad voices is that of the profession of nursing. Are nurses silenced by professional boundaries, the legal framework or lack of confidence? The concept of nursing advocacy is once again thrown into relief and critical questions need asking about the limits of professional nursing practice.

Moral problems experienced by nurses when caring for terminally ill people: a literature review

This article is a review of the literature on the subject of how nurses who provide palliative care are affected by ethical issues. Few publications focus directly on the moral experience of palliative care nurses, so the review was expanded to include the moral problems experienced by nurses in the care of the terminally ill patients. The concepts are first defined, and then the moral attitudes of nurses, the threats to their moral integrity, the moral problems that are perceived by nurses, and the emotional consequences of these moral problems are considered in turn. The results show that the moral behaviour of nurses, which is theoretically grounded in commitment to care and to the patient, appears to be shaped by specific processes that lead to engagement or to mental and behavioural disengagement in morally difficult situations. Nurses often appear to fail to recognize the moral dimensions of the problems they experience and also to lack the skills they need to resolve moral problems adequately. Although the findings show that several elements that are beyond the control of nurses, owing to their lack of autonomy and authority, influence their moral experience, intrinsic factors such as feelings of insecurity and powerlessness have a profound effect on nurses' perceptions and attitudes in the face of moral problems. The moral problems perceived by these nurses are related to end-of-life issues, communication with patients, the suffering of patients, and the appropriateness of the medical treatment.

End-of-life issues

A patient's desire to discuss end-of-life (EOL) choices may be among the most stressful situations for clinicians. Research confirms the importance of discussions between caregivers and patients or their surrogates about options for current and future care. Often, terminally ill patients want to discuss EOL options to avoid undue suffering, pain, and other symptoms and want some reassurance that caregivers can provide effective physical, psychosocial, and spiritual care. Patients often approach nurses first and ask for their assistance before they ask other professionals; they are more likely to ask nurses in home care than in other settings.

Telephone support for Canadian nurses in HIV/AIDS care

An assessment study was conducted with Canadian nurses (N = 177) in HIV/AIDS care to determine how social support influences the relationship between job stress and health (job satisfaction and burnout). The assessment study revealed that social support and coping both moderate the effects of these stressors on nurses' health and functioning outcomes (i.e., job satisfaction and burnout). Accordingly, the follow-up study tested the effectiveness of an intervention designed to enhance social support, promote the use of certain coping strategies for managing occupational stress, and prevent burnout in nurses. Telephone support groups, co-led by an expert facilitator and an expert AIDS nurse, were tested in a demonstration project for nurses in HIV/AIDS care (n = 30). The nurse participants reported that the intervention enhanced their coping, confidence, relationships, client care, and connections to the HIV/AIDS nursing community.