James L. Werth

The Influence of Cultural Diversity on End-of-life Care and Decisions

The heath care system in the United States is based on specific cultural beliefs that are sometimes inappropriate with groups that have different belief systems. These cultural differences can be seen in various end-of-life situations. To familiarize providers with some of the ways that culture can influence end-of-life care and decisions, the authors focus on the following three individual characteristics shown to be important in the literature: age, ethnicity, and gender. The article contains a broad overview of the (a) documented differences in the cultural interpretations of the ethical meta principles (e.g., autonomy and respect), (b) provision of medical service in general and pain management in particular to different groups, and (c) attitudes toward various end-of-life interventions and the use of advance directives. Finally, the authors summarize guidelines for making end-of-life care more culturally sensitive, which emphasize that each person must be interacted with as a unique individual.

Psychosocial issues near the end of life

End-of-life care has received increasing attention in the last decade; however, the focus continues to be on the physical aspects of suffering and care to the virtual exclusion of psychosocial areas. This paper provides an overview of the literature on the intra- and interpersonal aspects of dying, including the effects that psychosocial variables have on end-of-life decision-making; common diagnosable mental disorders (e.g., clinical depression, delirium); other types of personal considerations (e.g., autonomy/control, grief); and interpersonal/environmental issues (e.g., cultural factors, financial variables). Six roles that qualified mental health professionals can play (i.e., advocate, counselor, educator, evaluator, multidisciplinary team member, and researcher) are also outlined. Because psychosocial issues are ubiquitous and can have enormous impact near the end of life, properly trained mental health professionals can play vital roles in alleviating suffering and improving the quality of life of people who are dying.

Challenges of Work Voices of Persons With HIV Disease

Because of recent advances in medications and treatment regimens, persons with HIV disease are maintaining better health status and living longer. Thus, greater opportunities exist for these individuals to either continue their current employment or return to the world of work. The purpose of this qualitative study was to provide in-depth descriptions of related vocational experiences of persons with HIV. Data were collected from eight focus groups consisting of a diverse sample of people living with HIV (N = 93). Results support the need for counseling psychologists and other mental health professionals to address real and perceived barriers, both internal and contextual, while also becoming advocates for persons with HIV who want to work. A model derived from qualitative data analysis provides visual representation of the work experiences of people living with HIV, for potential application in assessment and treatment.

Rational Suicide and AIDS Considerations for the Psychotherapist

One of the issues arising out of the increasing incidence of acquired immunodeficiency syndrome (AIDS) is whether or not suicide may be considered to be a rational choice for a person with AIDS. In an effort to address this dilemma, this article begins by reviewing the literature pertaining to suicide and persons with terminal illnesses. Then, after recounting the suicide rate for persons with AIDS, it explores some of the physical and psychosocial factors that may be a part of a decision by a person with AIDS to commit suicide. Siegels criteria for a rational suicide are applied to the case of a person with AIDS. In addition, the role of the psychotherapist in the decision-making process is critically examined, as are some arguments against allowing suicide. Finally, suggestions for future directions by counseling psychologists are offered.

A Primer on Rational Suicide and Other Forms of Hastened Death

This article provides an overview of the major mental health issues involved in the debate over rational suicide and other forms of hastened death. In doing so, it covers the arguments for including counseling psychologists and other mental health professionals in discussions about hastened death; highlights the relevant empirical research associated with the topic, with special attention given to the studies involving psychologists and areas needing more investigation; and reviews the implications for practice and training and provides direction for those counseling psychologists who are working with persons who may be rational in their decisions to hasten death.

Requests for physician-assisted death: Guidelines for assessing mental capacity and impaired judgment.

This article fills a need in the theoretical and clinical literature by presenting a set of guidelines for assessing mental capacity and impaired judgment when a person makes a request to have physician-assisted death. Because Oregon is the only state to have a law allowing physician-assisted death, the guidelines are placed within the context of the Oregon Death with Dignity Act. A comprehensive overview of the legal and ethical issues associated with the assessment of capacity precedes the actual guidelines.

Ethical challenges of practicing in rural areas

Mental health professionals practicing in rural areas face ethical dilemmas different from those experienced by their urban counterparts and may find that the existing ethics literature and American Psychological Association (APA, 2002) ethics code not particularly helpful. We highlight parts of five standards from the APA ethics code to illustrate the dilemmas rural practitioners frequently confront and offer suggestions for how to handle them. We discuss competence, human relations, and confidentiality as specific areas and then examine assessment and therapy as broader situations in which dilemmas may occur. We use case examples to highlight complications that may arise in rural areas.

The Intersections of Work, Health, Diversity, and Social Justice: Helping People Living With HIV Disease

Although counseling psychology has discussed vocational issues, health concerns, diversity, and social justice, discussion of these topics has typically been narrowly focused. This article uses the example of persons with HIV (PWHIV) to demonstrate how these areas can be intertwined. The counseling psychology literature is also examined to determine the degree to which direction has been provided regarding clients facing health concerns, disabilities, confusion regarding career issues, or possible discrimination. Because HIV is now considered to be a chronic illness for many people, there is an increased likelihood that PWHIV will be faced with employment issues, as well as significant barriers to beginning work, returning to work, or keeping a job. After highlighting characteristics of PWHIV, we review the degree to which the vocational literature addresses the needs and issues of PWHIV. We also examine the role of social justice in relation to PWHIV who are considering work.

PHYSICIAN-ASSISTED SUICIDE IN OREGON: WHAT ARE THE KEY FACTORS?

Oregons Death with Dignity Act has been operative since late 1997. The substantial national and international interest in Oregons law makes it important to document any possible trends in the characteristics of persons who use the law. To do this, the present article examines previously reported data from various sources and places them within the context of the end-of-life decisions more generally. The Oregon data demonstrate that, regardless of the care received, a very small percentage of terminally ill Oregonians seem determined to request a lethal medication so that they may control the manner and timing of their death. College graduates and divorced persons are substantially more likely to use physician-assisted suicide to end their lives than are other persons. Control and autonomy appear to be the primary issues associated with taking legally prescribed medication to hasten ones death. A better understanding of the influence that a patients marital status, education level, and desire for control may have on her or his ability to cope with, and make decisions related to, a terminal illness may allow health care professionals to better care for dying patients.

Psychosocial issues near the end of life : a resource for professional care providers

Although numerous books have been written on the physical and practical aspects of providing services to people who are dying, relatively little has been written on the psychological, spiritual, and interpersonal issues that arise. Until now, psychologists and mental health professionals who work with the dying and their loved ones have had no resource to guide them toward empirically supported practices that can improve quality of life. This book fills that gap. Improving quality of care requires an interdisciplinary approach, and the contributors to this volume bring multiple perspectives to bear on the topic. Chapter authors from both research and clinical perspectives cover how the end-of-life environment has changed over time; the kinds of decisions that need to be made; the role of psychologists in end-of-life care; cross-cultural considerations; assessment; legal issues; practical caregiving; misinformation about depression and hopelessness; and the respective roles of caregivers and hospices. The final chapter by the editors lays out a blueprint for future research, care, education and policy. This book provides a model for the important role that psychologists can play in ensuring that end-of-life care balances physical care with psychosocial and spiritual care.