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

Virtual Mourning: How Filipinos Utilize Facebook to Express Grief and Seek Support - A Hermeneutic Phenomenological Study

This study explores how grieving Filipinos use Facebook to cope with loss and seek support, integrating traditional mourning practices with digital expressions of grief. Despite the growing role of social media in bereavement, research on digital mourning in collectivist cultures remains limited. Using a hermeneutic phenomenological approach, in-depth interviews were conducted with ten bereaved Filipinos to examine their online grieving experiences. Thematic analysis identified three key themes: the blending of traditional mourning rituals with Facebook for emotional support, the validation and relief provided by online interactions, and the role of digital mourning in fostering healing. Findings suggest that social media enhances Filipino bereavement practices by strengthening community connections and preserving cultural traditions. The study emphasizes the need for culturally sensitive digital spaces and grief support services that integrate both online and offline mourning. It calls for further research on the intersection of grief, culture, and social media in non-Western contexts.

'Someone must do it': multiple views on family's role in end-of-life care - an international qualitative study

Background

Family is a crucial social institution in end-of-life care. Family caregivers are encouraged to take on more responsibility at different times during the illness, providing personal and medical care. Unpaid work can be overburdening, with women often spending more time in care work than men.

Objectives

This study explored multiple views on the family's role in end-of-life care from a critical perspective and a relational autonomy lens, considering gender in a socio-cultural context and applying a relational autonomy framework. It explored patients, relatives and healthcare providers' points of view.

Design

This qualitative study was part of the iLIVE project, involving patients with incurable diseases, their relatives and health carers from hospital and non-hospital sites.

Methods

Individual interviews of at least five patients, five relatives and five healthcare providers in each of the 10 participating countries using a semi-structured interview guide based on Giger-Davidhizar-Haff's model for cultural assessment in end-of-life care. Thematic analysis was performed initially within each country and across the complete dataset. Data sources, including researchers' field notes, were translated into English for international collaborative analysis.

Results

We conducted 158 interviews (57 patients, 48 relatives and 53 healthcare providers). After collaborative analysis, five themes were identified across the countries: family as a finite care resource, families' active role in decision-making, open communication with the family, care burden and socio-cultural mandates. Families were crucial for providing informal care during severe illness, often acting as the only resource. Patients acknowledged the strain on carers, leading to a conceptual model highlighting socio-cultural influences, relational autonomy, care burden and feminisation of care.

Conclusion

Society, health teams and family systems still need to better support the role of family caregivers described across countries. The model implies that family roles in end-of-life care balance relational autonomy with socio-cultural values. Real-world end-of-life scenarios do not occur in a wholly individualistic, closed-off atmosphere but in an interpersonal setting. Gender is often prominent, but normative ideas influence the decisions and actions of all involved.

A bioethical perspective on the meanings behind a wish to hasten death: a meta-ethnographic review

BACKGROUND

The expressions of a "wish to hasten death" or "wish to die" raise ethical concerns and challenges. These expressions are related to ethical principles intertwined within the field of medical ethics, particularly in end-of-life care. Although some reviews were conducted about this topic, none of them provides an in-depth analysis of the meanings behind the "wish to hasten death/die" based specifically on the ethical principles of autonomy, dignity, and vulnerability. The aim of this review is to understand if and how the meanings behind the "wish to hasten death/die" relate to and are interpreted in light of ethical principles in palliative care.

METHODS

We conducted a meta-ethnographic review according to the PRISMA guidelines and aligned with Noblit and Hare's framework. Searches were performed in three databases, Web of Science, PubMed, CINAHL, with no time restrictions. Original qualitative studies exploring the meanings given by patients, family caregivers and healthcare professionals in any context of palliative and end-of-life care were included. A narrative synthesis was undertaken. PROSPERO registration CRD42023360330.

RESULTS

Out of 893 retrieved articles, 26 were included in the analysis, accounting for the meanings of a total of 2,398 participants. Several factors and meanings associated with the "wish to hasten death" and/or "wish to die" were identified and are mainly of a psychosocial and spiritual nature. The ethical principles of autonomy and dignity were the ones mostly associated with the "wish to hasten death". Ethical principles were essentially inferred from the content of included articles, although not explicitly stated as bioethical principles.

CONCLUSIONS

This meta-ethnographic review shows a reduced number of qualitative studies on the "wish to hasten death" and/or "wish to die" explicitly stating ethical principles. This suggests a lack of bioethical reflection and reasoning in the empirical end-of-life literature and a lack of embedded ethics in clinical practice. There is a need for healthcare professionals to address these topics compassionately and ethically, taking into account the unique perspectives of patients and family members. More qualitative studies on the meanings behind a wish to hasten death, their ethical contours, ethical reasoning, and implications for clinical practice are needed.

The perception of life and death in patients with end-of-life stage cancer: A systematic review of qualitative research

PURPOSE

This study aims to clarify the perceptions on life and death among patients with the end-of-life stage cancer through a systematic review.

METHODS

The search strategy combined MeSH terminology with free text searches, and was applied to the PubMed, CINAHL, Embase, and ICHUSHI (Japan Medical Abstracts Society) databases covering from 2010 to 5/2022. To ensure the quality of the research included, the Critical Appraisal Skills Program Qualitative Studies Checklist was used. Data relating to the perceptions of life and death of patients with the end-of-life stage cancer was extracted and analyzed with reference to qualitative meta-synthesis methods.

RESULTS

Ultimately, 50 studies were included. Five themes were derived based on the perceptions of life and death of patients with the end-of-life stage cancer: despair, making sense of death, how to live the rest of life, special feelings for loved ones, and fluctuation. By making sense of death in their own way, and reconciling it with their current situation, patients with the end-of-life stage cancer, even in despair over their impending death, look ahead into the future and their surroundings and consider how they would live the remaining time they have. During this time, the special feelings they have for their loved ones make an impact.

CONCLUSIONS

An important new finding from this study lies in the fact that the patients' desire to live as ordinary people who were not patients were expressed as a face that they hid from their families. Further research is needed in low-income countries/regions.

Deep continuous patient-requested sedation until death: a multicentric study

OBJECTIVES

In 2016, a new law was adopted in France granting patients the right, under specific conditions, to continuous deep sedation until death (CDSUD). The goal of this study was to measure the frequency of requests for CDSUD from patients in palliative care.

METHODS

The data collected from the medical records of patients in palliative care units (PCU) or followed by palliative care support teams (PCST) in the Rhône-Alpes area, who died after CDSUD, focused on the patient's characteristics, the drugs used (and compliance with regulatory processes).

RESULTS

All 12 PCU and 12 of the 24 PCST were included. Among the 8500 patients followed, 42 (0.5%) requested CDSUD until death. The patients were: 65.7 (SD=13.7) years old, highly educated (69%), had cancer (81%), refractory symptoms (98%) and mostly psychoexistential distress (69%). The request was rejected for 2 (5%) patients and delayed for 31 (74%) patients. After a delay of a mean 8 days, 13 (31%) patients were granted CDSUD. The drug used was midazolam at 115 mg/24 hours (15-480), during a mean of 3 days. PCUs used lower dosages than PCSTs (83 vs 147), with significantly lower initial doses (39 mg vs 132 mg, p=0.01). A life-threatening condition was recorded in 13 cases (31%) and a collegial decision was taken in 25 cases (60%).

CONCLUSION

This study highlights the low rate of request and the even lower rate of CDSUD in specialised palliative care. However, the sedation for psychoexistential distress and the lack of procedure records raise ethical questions.

The Time Moving exhibit: Exploring perceptions of time in end-of-life experiences

BACKGROUND

Conversations about end of life rarely take place beyond healthcare spaces and in advance of imminent death. As the Canadian ageing population increases and new policies and options emerge for end-of-life choices, there will be an increasing need for supports for decision-making on end of life. Time Moving was a participatory art exhibit created to engage participants in reflections on end-of-life experiences and the ways in which their perception of time fluctuated within these moments.

DESIGN

A participatory and constructivist approach informed decisions on exhibit design and analysis. The Time Moving exhibit was installed in a downtown university hall for 10 days during the 2019 annual DesignTO festival, open to all members of the public. The exhibit was used as the primary method of data collection. There were three prompts informed by concepts from prior work on time perception. Participants were invited to respond by drawing, writing or constructing.

OUTCOME

There were over 120 contributions of participants over the duration of the Time Moving exhibit. These contributions revealed new insights related to temporal perception and end-of-life experiences. Participants shared their perception of time during end-of-life experiences in a variety of ways, revealing a diversity of perceptions of time beyond calendar and clock time, including time experienced as a spiral.

CONCLUSIONS

The insights on time perception highlight opportunities for approaching dialogue on end of life and in grief support, and for exhibit as a mechanism for research and education.

PATIENT OR PUBLIC CONTRIBUTION

As a public exhibit, over 120 people contributed ideas, personal stories, drawings and other creative outputs to the exhibit. An estimated 250 people visited the exhibit.

Exploring interpersonal theory of suicide typologies in patients with cancer: A latent profile analysis

The current study examined patterns of endorsement of Interpersonal Theory of Suicide constructs in a group of patients with cancer (N = 133) via Latent Profile Analysis. Four profiles were identified: (1) Interpersonally Distressed (n = 7; 5.2%), (2) Burdened (n = 11; 8.3%), (3) Fearless About Death (n = 40; 30.1%), (4) Non-Distressed (n = 75; 56.4%). Profiles with higher levels of thwarted belongingness, perceived burdensomeness, and hopelessness were associated with greater suicide ideation. Results also suggest there may be characteristics of patients with cancer that require unique consideration about the potential meaning and relevance of such constructs.

Autonomy and control in the wish to die in terminally ill patients: A systematic integrative review

BACKGROUND/OBJECTIVE

Personal autonomy and control are major concepts for people with life-limiting conditions. Patients who express a wish to die (WTD) are often thought of wanting it because of loss of autonomy or control. The research conducted so far has not focused on personal beliefs and perspectives; and little is known about patients' understanding of autonomy and control in this context. The aim of this review was to analyze what role autonomy and control may play in relation to the WTD expressed by people with life-limiting conditions.

METHODS

A systematic integrative review was conducted. The search strategy used MeSH terms in combination with free-text searching of the EBSCO Discovery Service (which provides access to multiple academic library literature databases, including PubMed and CINAHL), as well as the large PsycINFO, Scopus, and Web of Science library literature databases from their inception until February 2019. The search was updated to January 2021.

RESULTS

After the screening process, 85 full texts were included for the final analysis. Twenty-seven studies, recording the experiences of 1,824 participants, were identified. The studies were conducted in Australia (n = 5), Canada (n = 5), USA (n = 5), The Netherlands (n = 3), Spain (n = 2), Sweden (n = 2), Switzerland (n = 2), Finland (n = 1), Germany (n = 1), and the UK (n = 1). Three themes were identified: (1) the presence of autonomy for the WTD, (2) the different ways in which autonomy is conceptualized, and (3) the socio-cultural context of research participants.

SIGNIFICANCE OF RESULTS

Despite the importance given to the concept of autonomy in the WTD discourse, only a few empirical studies have focused on personal interests. Comprehending the context is crucial because personal understandings of autonomy are shaped by socio-cultural-ethical backgrounds and these impact personal WTD attitudes.

Wish to die and hasten death in palliative care: a cross-sectional study factor analysis

OBJECTIVES

The wish to die (WTD) is a complex experience sometimes accompanied by intention to hasten death. The aim of this study is to identify the predictive factors for WTD and hastening death intention (HDI) in Spanish patients with advanced illness.

METHODS

This is a subanalysis of a larger cross-sectional study conducted on patients experiencing advanced illness (N=201). Sociodemographic data and data related to symptom burden (Edmonton Symptom Assessment System-Revised), depressive and anxious symptoms (Hospital Anxiety and Depression Scale), demoralisation (Spanish version of the Demoralisation Scale), perceived loss of dignity (Patient Dignity Inventory) and WTD (Assessing Frequency and Extent of Desire to Die) were collected. The analysis used univariate and multivariate logistic regression.

RESULTS

The prevalence of WTD in the sample was 18%, with 8 out of 36 patients reporting HDI. The independent factors predictive of WTD were (1) knowledge of approximate prognosis (OR=4.78; 95% CI 1.20 to 10.8; p=0.001); (2) symptom burden (OR=1.05; 95% CI 1.00 to 1.09; p=0.038); and (3) the Demoralisation Scale subsection 'lack of meaning and purpose in life' (OR=1.61; 95% CI 1.30 to 1.99; p=0.000). An independent predictive factor for HDI was the Demoralisation Scale subsection 'patients' distress and coping abilities' (OR=1.47; 95% CI 1.04 to 2.08; p=0.028), while having religious beliefs was a protective factor (OR=0.13; 95% CI0.17 to 0.97; p=0.047).

CONCLUSIONS

Demoralisation was found to be the only common triggering factor for WTD and HDI, although experiences share certain features. Identification of the predictive factors for WTD and HDI may contribute to their prevention and management.

Refractory psycho-existential distress and continuous deep sedation until death in palliative care: The French perspective

OBJECTIVE

Since February 2016, French Claeys-Leonetti law has recognized patients' right to confront incurable diseases with short-term prognosis and refractory physical or psychological or existential symptoms by requesting continuous deep sedation until death (CDSUD). Determining when psychological or existential distress is refractory and unbearable remains complex and controversial.This review provides a comprehensive thought on CDSUD for advanced incurable patients with refractory psychological and/or existential distress in palliative care settings. It offers guidance on psychiatric or psychological diagnosis for explaining patients' requests for CDSUD.

METHOD

A narrative literature review (2000-2019) was conducted on the MedLine search about the use of palliative sedation in cases of refractory psychological and/or existential distress.

RESULTS

(1) Definitions of "refractory symptom," "refractory psychological distress," and "refractory existential distress" are inconsistent; (2) alternative diagnoses might obscure or be obscured by psycho-existential distress; and (3) criteria on meanings, reasons for requests, decision-making processes, and functions are evolving in practice.

SIGNIFICANCE OF RESULTS

Before implementing CDSUD, palliative healthcare professionals should seek input from psycho-oncologists in palliative care. Mental health professionals should analyze and assess the reasons for psychological and/or existential distress, consider the intentionality processes of requests, and explore alternative diagnoses, such as depressive or adjustment disorders, demoralization syndrome, desire to hasten death, and desire for euthanasia. Therapeutic responses (e.g., pharmacological and psychotherapeutic) should be implemented before deciding that psycho-existential distress is refractory.

[The wish to hasten death: Definition, determinants, issues and perspectives]

In palliative care, it is not uncommon for people with serious illnesses to wish to hasten their death. These wishes present considerable challenges for health care professionals. The purpose of this review is to support healthcare professionals in their understanding and apprehension of patients' wishes to hasten their death. In order to do so, we will present the definition of this wish, and then we will study it, based on three main components, which are intentions, motivations and interactions. The common thread of this review lies in the following question: how to best support the human who faces death?

The desire for death in Portuguese home-care palliative patients: Retrospective analysis of the prevalence and associated factors

OBJECTIVE

Desire for death (DfD) is a complex and multifactorial dimension of end-of-life experience. We aimed to evaluate the prevalence of DfD and its associations, arising within the setting of a tertiary home-based palliative care (PC) unit.

METHOD

Retrospective analysis of all DfD entries registered in our anonymized database from October 2018 to April 2020.

RESULTS

Of the 163 patients anonymously registered in our database, 122 met entry criteria; 52% were male, the average age was 69 years old; 85% had malignancies, with a mean performance status (PPS) of 56%. The prevalence of DfD was 20%. No statistical differences were observed between patients with and without DfD regarding sex, age, marital status, religion, social support, prior PC or psychological follow-up, type of diagnosis, presence of advanced directives/living will, time since diagnosis and PC team's follow-up time. Statistically significant associations were found between higher PPS scores and DfD (OR = 0.96; 95% confidence interval (CI) [0.93-0.99]); Edmonton Symptom Assessment Scale scores for drowsiness (OR = 4.05; 95% CI [1.42-11.57]), shortness of breath (OR = 3.35; 95% CI [1.09-10.31]), well-being (OR = 7.64; 95% CI [1.63-35.81]). DfD was associated with being depressed (OR = 19.24; 95% CI [3.09-+inf]); feeling anxious (OR = 11.11; 95% CI [2.51-49.29]); HADS anxiety subscale ≥11 (OR = 25.0; 95% CI [2.10-298.29]); will-to-live (OR = 39.53; 95% CI [4.85-321.96]). Patients feeling a burden were more likely to desire death (OR = 14.67; 95% CI [1.85-116.17]), as well as those who were not adapted to the disease (OR = 4.08; 95% CI [1.30-12.84]). In multivariate regression analyses predicting DfD, three independent factors emerged: higher PPS scores were associated with no DfD (aOR = 0.95; 95% CI [0.91-0.99]), while the sense of being a burden (aOR = 12.82; 95% CI [1.31-125.16]) and worse well-being (aOR = 7.72; 95% CI [1.26-47.38]) predicted DfD.

SIGNIFICANCE OF RESULTS

Prevalence of DfD was 20% and consistent with previous Portuguese evidence on DfD in PC inpatients. Both physical and psychosocial factors contribute to a stronger DfD.

Factors Associated With Terminally Ill People Who Want to Die

CONTEXT

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSION

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

Perception of Medical Assistance in Dying Among Asian Buddhists Living in Montreal, Canada

In the Western world including Canada, grievous and irredeemable health conditions, which cause unbearable suffering, has given support to the legalization of medical aid in dying (MAiD). It is unknown how Asian Buddhists who are in contact with the Western culture perceive MAiD. In this qualitative study, 16 Asian Buddhists living in Montreal took part in a semi-structured interview. Contrary to general findings in the literature, religious affiliation do not always determine moral stances and practical decisions when it comes to MAiD. Some participants were willing to take some freedom with the doctrine and based their approval of MAiD on the right to self-determination. Those who disapproved the use of MAiD perceived it as causing unnatural death, creating bad karma, and interfering with a conscious death. End-of-life (EoL) care providers have to remain sensitive to each patient's spiritual principles and beliefs to understand their needs and choices for EoL care.

Fodder for Despair, Masquerading as Hope: Diagnosing the Postures of Hope(lessness) at the End of Life

Hope is needed for persons confronting the limits of human life, antagonised by the threats of death. It is needed also for those health and medical professionals constrained by the institution of medicine, determined by market metaphors and instrumental reasoning. Yet, despair can masquerade as hope for such persons when functional hoping for particular outcomes or aims proves futile and aimless. The following will examine such masquerades, while giving attention to particular expressions of autonomy, which persist as fodder for despair in our late modern milieu. The late classical account of Hercules and his death, as well as contemporary reasons for soliciting medical assistance in dying, will focus on the diagnostics of despair, while a Christian account practicing presence, and of hope as a concrete posture enfleshed by habits of patience, among other virtues, will point toward counter-narratives that might sustain persons in times of crisis and enable persons’ flourishing as human beings, even unto death.

End-of-Life Decision Making in Palliative Care and Recommendations of the Council of Europe: Qualitative Secondary Analysis of Interviews and Observation Field Notes

BACKGROUND

End-of-life decisions (ELDs) are embedded in clinical, sociocultural, political, economic, and ethical concerns. In 2014, the Council of Europe (CoE) through its Committee on Bioethics launched the "Guide on the decision-making process regarding medical treatment in end-of-life situations," aiming at improving decision-making processes and empowering professionals in making ELDs.

OBJECTIVE

To analyze if end-of-life decision making in palliative care (PC) is consistent with this Guide and to identify if disputed/controversial issues are part of current ELDs.

DESIGN

Qualitative secondary analysis.

SETTING/SUBJECTS

Four qualitative datasets, including 44 interviews and 9 team observation field notes from previous studies with PC teams/professionals in Portugal.

MEASUREMENTS

An analysis grid based on the abovementioned guide was created considering three dimensions: ethical and legal frameworks, decision-making process, and disputed/controversial issues.

RESULTS

The majority of the professionals considered the ethical principle of autonomy paramount in end-of-life decision making. Justice and beneficence/nonmaleficence were also valued. Although not mentioned in the Guide, the professionals also considered other ethical principles when making ELDs, namely, responsibility, integrity, and dignity. Most of the interviewees and field notes referred to the collective interprofessional dimension of the decision-making process. Palliative sedation and the wish to hasten death were the most mentioned disputed/controversial issues. The nature, limitations, and benefits of qualitative secondary analysis are discussed.

CONCLUSIONS

End-of-life decision-making processes made by Portuguese PC teams seem to be consistent with the guidelines of the CoE. Further research is needed about disputed/controversial issues and the actual use, effectiveness, and impact of ethical guidelines for end-of-life decision making on professionals' empowerment and for all parties involved.

Assumptions and moral understanding of the wish to hasten death: a philosophical review of qualitative studies

It is not uncommon for patients with advanced disease to express a wish to hasten death (WTHD). Qualitative studies of the WTHD have found that such a wish may have different meanings, none of which can be understood outside of the patient's personal and sociocultural background, or which necessarily imply taking concrete steps to ending one's life. The starting point for the present study was a previous systematic review of qualitative studies of the WTHD in advanced patients. Here we analyse in greater detail the statements made by patients included in that review in order to examine their moral understandings and representations of illness, the dying process and death. We identify and discuss four classes of assumptions: (1) assumptions related to patients' moral understandings in terms of dignity, autonomy and authenticity; (2) assumptions related to social interactions; (3) assumptions related to the value of life; and (4) assumptions related to medicalisation as an overarching context within which the WTHD is expressed. Our analysis shows how a philosophical perspective can add to an understanding of the WTHD by taking into account cultural and anthropological aspects of the phenomenon. We conclude that the knowledge gained through exploring patients' experience and moral understandings in the end-of-life context may serve as the basis for care plans and interventions that can help them experience their final days as a meaningful period of life, restoring some sense of personal dignity in those patients who feel this has been lost.

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

CONTEXT

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Understanding patients' experiences of the wish to hasten death: an updated and expanded systematic review and meta-ethnography

OBJECTIVES

Patients with advanced disease sometimes express a wish to hasten death (WTHD). In 2012, we published a systematic review and meta-ethnography of qualitative studies examining the experience and meaning of this phenomenon. Since then, new studies eligible for inclusion have been reported, including in Europe, a region not previously featured, and specifically in countries with different legal frameworks for euthanasia and assisted suicide. The aim of the present study was to update our previous review by including new research and to conduct a new analysis of available data on this topic.

SETTING

Eligible studies originated from Australia, Canada, China, Germany, The Netherlands, Switzerland, Thailand and USA.

PARTICIPANTS

Studies of patients with life-threatening conditions that had expressed the WTHD.

DESIGN

The search strategy combined subject terms with free-text searching of PubMed MEDLINE, Web of Science, CINAHL and PsycInfo. The qualitative synthesis followed the methodology described by Noblit and Hare, using the 'adding to and revising the original' model for updating a meta-ethnography, proposed by France et al. Quality assessment was done using the Critical Appraisal Skills Programme checklist.

RESULTS

14 studies involving 255 participants with life-threatening illnesses were identified. Five themes emerged from the analysis: suffering (overarching theme), reasons for and meanings and functions of the WTHD and the experience of a timeline towards dying and death. In the context of advanced disease, the WTHD emerges as a reaction to physical, psychological, social and existential suffering, all of which impacts on the patient's sense of self, of dignity and meaning in life.

CONCLUSIONS

The WTHD can hold different meanings for each individual-serving functions other than to communicate a genuine wish to die. Understanding the reasons for, and meanings and functions of, the WTHD is crucial for drawing up and implementing care plans to meet the needs of individual patients.

Euthanasia and physician-assisted suicide: A white paper from the European Association for Palliative Care

BACKGROUND

In recognition of the ongoing discussion on euthanasia and physician-assisted suicide, the Board of Directors of the European Association for Palliative Care commissioned this white paper from the palliative care perspective.

AIM

This white paper aims to provide an ethical framework for palliative care professionals on euthanasia and physician-assisted suicide. It also aims to provide an overview on the available evidence as well as a discourse of ethical principles related to these issues.

DESIGN

Starting from a 2003 European Association for Palliative Care position paper, 21 statements were drafted and submitted to a five-round Delphi process

PARTICIPANTS

A panel with 17 experts commented on the paper in round 1. Board members of national palliative care or hospice associations that are collective members of European Association for Palliative Care were invited to an online survey in rounds 2 and 3. The expert panel and the European Association for Palliative Care board members participated in rounds 4 and 5. This final version was adopted as an official position paper of the European Association for Palliative Care in April 2015.

RESULTS

Main topics of the white paper are concepts and definitions of palliative care, its values and philosophy, euthanasia and physician-assisted suicide, key issues on the patient and the organizational level. The consensus process confirmed the 2003 European Association for Palliative Care white paper and its position on the relationship between palliative care and euthanasia and physician-assisted suicide.

CONCLUSION

The European Association for Palliative Care feels that it is important to contribute to informed public debates on these issues. Complete consensus seems to be unachievable due to incompatible normative frameworks that clash.

"Doctors Shouldn't Underestimate the Power that they Have": NZ Doctors on the Care of the Dying Patient

Rapidly aging populations and increased prevalence of chronic rather than acute illnesses have seen growing public and professional interest in medical decision making at the end of life and greater attention being paid to the factors that influence how individuals make such decisions. This study comprised 2 components: The first, a postal survey, based on the Remmelink questionnaire was sent in May 2013 to 3420 general practitioners (GPs) in New Zealand. Results from this component are reported elsewhere. The second component (reported here) sought information by inviting GPs to ring a free-phone number to be interviewed about their experiences caring for their dying patients. Interviews were recorded then transcribed with identifying information deleted to preserve anonymity. With an aging population, the provision of end-of-life care will increase in general practice. There is no doubt that hospice and specialist palliative care have transformed the quality of care for the dying and their families in New Zealand. However, while respondents in this study seemed realistic about what palliative care can and cannot achieve, patients and their families may have unrealistic expectations of both hospice and palliative medicine. Many GPs appear confused over the legality of the assistance they provide to the terminally ill, concerned that actions such as increasing medication to address refractory symptoms, or stopping food and fluids may put them at risk of legal censure when they foresee that their actions may hasten death.

Palliative care professionals' willingness to perform euthanasia or physician assisted suicide

Background

Euthanasia and physician assisted suicide (PAS) are highly debated upon particularly in the light of medical advancement and an aging society. Little is known about the professionals’ willingness to perform these practices particularly among those engaged in the field of palliative care and pain management. Thus a study was performed among those professionals.

Methods

An anonymous questionnaire was handed out to all participants of a palliative care congress and a pain symposium in 2013. The questionnaire consisted of 8 questions regarding end of life decisions. Proposed patient vignettes were used.

Results

A total of 470 eligible questionnaires were returned, 198 by physicians, 272 by nurses. The response rate was 64 %. The majority of professionals were reluctant to perform euthanasia or PAS: 5.3 % of the respondents would be willing to perform euthanasia on a patient with a terminal illness if asked to do so. The reluctance grew in case of a patient with a non-terminal illness. The respondents were more willing to perform PAS than euthanasia. Nurses were more reluctant to take action as opposed to the physicians. The majority of the respondents would attempt to treat the patient’s symptoms first before considering life-ending measures. As regards any decision making process the majority would consult with a colleague.

Conclusions

This is the first German study to ask about the willingness of professionals to take action as regards euthanasia and PAS without biased phrasing. As opposed to the general acceptance that is respectively high, the actual willingness to perform life-ending measures is low. The German debate on physician assisted suicide and its possible legalization should also incorporate clarifications regarding the responsibility who should eventually perform these acts.