Francis T. Varghese

Factors associated with the wish to hasten death: a study of patients with terminal illness

BACKGROUND There is considerable debate regarding the clinical issues surrounding the wish to hasten death (WTHD) in the terminally ill. The clinical factors contributing to the WTHD need further investigation among the terminally ill in order to enhance understanding of the clinical assessment and treatment needs that underlie this problem. A more detailed understanding may assist with the development of appropriate therapeutic interventions. METHOD A sample of terminally ill cancer patients (N = 256) recruited from an in-patient hospice unit, home palliative care service and a general hospital palliative care consulting service from Brisbane Australia between 1998-2001 completed a questionnaire assessing psychological (depression and anxiety), social (family relationship, social support, level of burden on others) and the impact of physical symptoms. The association between these factors and the WTHD was investigated. RESULTS A high WTHD was reported by 14 % of patients. A discriminant function analysis revealed that the following variables were associated with a high WTHD (P < 0.001): higher levels of depressive symptoms, being admitted to an in-patient hospice setting, a greater perception of being a burden on others, lower family cohesion, lower levels of social support, higher levels of anxiety and greater impact of physical symptoms. CONCLUSIONS Psychological and social factors are related to a WTHD among terminally ill cancer patients. Greater attention needs to be paid to the assessment of psychological and social issues in order to provide appropriate therapeutic interventions for terminally ill patients.

Terminally ill cancer patients' wish to hasten death

This exploratory study investigated factors associated with the wish to hasten death among a sample of terminally ill cancer patients. Semi-structured interviews conducted on a total of 72 hospice and home palliative care patients were subjected to qualitative analysis using QSRNUDIST. The main themes to emerge suggested that patients with a high wish to hasten death had greater concerns with physical symptoms and psychological suffering, perceived themselves to be more of a burden to others, and experienced higher levels of demoralization, while also reporting less confidence in symptom control, fewer social supports, less satisfaction with life experiences and fewer religious beliefs when compared with patients who had a moderate or no wish to hasten death. The implications of these findings will be discussed.

Social Skills Training with Chronic-Schizophrenic Patients - Effects On Negative Symptoms and Community Functioning

Sixty-three patients with schizophrenia who showed social skills deficits and poor community functioning were assigned randomly to either social skills training (SST) or a discussion group condition. In both treatments, patients met in small groups for 36 sessions of therapy over 4 months, followed by booster sessions of decreasing frequency during the following six months. Social skills, community functioning, quality of life, and positive and negative psychiatric symptoms were assessed at pre- and posttreatment, and at 6-month follow-up. Relapse was assessed during the treatment and follow-up phases. Those subjects who completed SST showed greater increases in social skill than subjects who completed the discussion condition, but there were no other significant differences between the conditions. Patients who completed either treatment showed improvements on quality of life and reduced psychopathology. SST alone had limited effect on community functioning.

Assisted Suicide and Euthanasia: What about the Clinical Issues?

This paper aims to address the clinical issues involved in a patients request for assisted suicide. The psychiatric and broader psychosocial issues for the dying patient, their family and their treating doctor have been largely unaddressed in the debate concerning euthanasia to date. A range of the clinical issues that need to be incorporated in the ethical and legal considerations are reviewed. The reasons for a patient seeking suicide as a treatment are complex and go beyond questions of a patients right to die. The request for euthanasia needs to be seen in the context of the patients circumstances, including relationships with and attitudes of carers and health professionals, along with patterns of psychiatric disorder and psychiatric symptoms in the medically ill. The clinical issues involve not only the diagnosis or management of psychiatric disorder but also the acknowledgment of the factors influencing an individuals adjustment to the threat of illness and death. The dynamics of family interactions and doctor–patient relationships in this setting are factors that may impinge upon a request for assistance to die. These factors may be more important than the severity of a persons illness or their quality of life, and are less likely to be recognised and addressed in situations of professional isolation. There are critical issues facing psychiatry in new legislative developments.

Countertransference and ethics: a perspective on clinical dilemmas in end-of-life decisions.

Ethical dilemmas in end-of-life care, such as the request for assisted suicide, must be understood in the context of the relationship that exists between patients and the clinicians treating them. This context includes the way health professionals respond to the tasks in caring for a dying patient. This article reviews the literature exploring the factors the influence clinical decision making at the end of life. The interplay of ethics, countertransference and transference are explained in detail.