Desire for death near the end of life: the role of depression, anxiety and pain

doi:10.1016/j.genhosppsych.2005.02.004

General Hospital Psychiatry

Volume 27, Issue 4, July–August 2005, Pages 258-262

https://doi.org/10.1016/j.genhosppsych.2005.02.004 Get rights and content

Abstract

Objective

This study evaluated the desire of patients with advanced cancer for hastened death to determine its relationship to psychological distress, anxiety and pain.

Methods

One hundred twenty terminally ill cancer patients were surveyed from June to November 2003 at a palliative care unit in Athens, Greece. Greek versions of the Schedule of Attitudes Toward Hastened Death (G-SAHD), the Hospital Anxiety and Depression Scale (G-HADS) and the Brief Pain Inventory were administered.

Results

Significant correlations were seen between desire for hasten death and HADS-Depression (r=.605; P<.0005) and HADS-Anxiety (r=.636; P<.0005) scores. Results of multiple regression analyses showed that the HADS-Depression scale (B=.443; P<.0005) as well as the HADS-Anxiety scale (B=.326; P<.0005) and the interaction between HADS-Depression and opioids (B=−.159; P=.012), but not pain intensity, pain-related interference, age, sex, patient's performance status as defined by the Eastern Cooperative Oncology Group as well as the interactions between average pain and opioids and average pain and HADS-Depression, were significant predictors of G-SAHD scores.

Conclusions

In terminally ill cancer patients, depression and anxiety as well as the interaction between HADS-Depression and opioids appeared to have a significant impact on the desire for hastened death while pain does not. Effective management of psychological symptoms seems to be an important aspect of adequate palliative care in order to reduce the desire for hastened death.

Introduction

Requests to hasten death as well as the desire for death have become major topics in the palliative care literature [1], [2], [3]. Previous studies have found that the desire of patients with terminal cancer for death has been linked to multidimensional factors including psychiatric disorders, suicidal ideation, physical suffering and pain [2], [4], [5], [6]. The conditions that are most commonly mentioned when discussing psychological issues near the end of life are depression and pain [7]. Depression is a significant symptom for approximately 25% of cancer patients but is frequently unrecognized and untreated, while around 35% of cancer patients, during the induction and consolidation phase of treatment, have been found to have high levels of anxiety and depression [8]. Pain is also a common occurrence in cancer patients and is often inadequately treated. Moreover, pain and depression often co-occur and their implications can be profound [9], [10]. Patients with advanced cancer who have persistent pain are twice as likely to suffer from a psychiatric complication (depression or anxiety) as those without pain [11]. Nevertheless, some authors have suggested that emotional disturbance is more likely to be a consequence than a cause of chronic pain [12], [13].

Chochinov et al. [5] found that the desire for hastened death was significantly related to both severe pain and the presence of depression. Still, other studies have failed to observe a significant role of pain in causing desire for hastened death [14]. Furthermore, virtually no research has examined the role of anxiety in the desire for hastened death.

Anxiety is quite common in patients receiving palliative care and can reduce a patient's tolerance for physical distress, especially pain [15]. Symptoms of unresolved past losses, acute stress and even posttraumatic stress disorder may occur when a person is facing the end of life [7]. However, because of the overlap between anxiety and depression, distinguishing between these two constructs is often difficult [16], [17]. A high concordance between the two symptoms in cancer patients suggests that both will need to be attended [16].

The current study attempted to further this growing literature on desire for hastened death by assessing the relationships between depression, anxiety, pain and desire for hastened death in a sample of Greek adults who are terminally ill. In addition, because most of the research on desire for hastened death have focused on American samples, our study of terminally ill cancer patients from Greece has the potential to identify cultural differences in the factors that drive desire for hastened death.

Section snippets

Patients and methods

The current study was performed at a palliative care unit of the Areteion University Hospital in Athens, Greece, between June and November 2003. One hundred ninety-one terminally ill cancer patients were treated in this unit for pain relief and cancer-related symptoms. Forty-eight of these patients were excluded from the study because they were cognitively impaired or were too sick to communicate.

Eligibility criteria for participation were age over 18 years, a diagnosis of terminal cancer and

Procedures and measurements

Patients were interviewed by a member of the palliative care unit in order to elicit background medical history, demographic data, prior mental health and current medical condition. The evaluations were completed in the patients' first visit to the unit in a brief interview. The dependent variable in this study was the Greek version of the Schedule for Attitudes Toward Hastened Death (G-SAHD), a 20-item true/false measure of the desire for hastened death that has demonstrated a high degree of

Statistical analysis

The relationship between HADS-Depression and HADS-Anxiety scores, pain (G-BPI) and desire for hastened death (G-SAHD) was examined using Spearman's ρ because of the skewed distribution of SAHD scores [18]. Univariate analysis was performed using Spearman's correlations coefficients and independent-samples t test. A stepwise multiple regression model predicting G-SAHD scores was then used, with average pain, pain interference, HADS-Depression and HADS-Anxiety scores, strong and mild opioids,

Results

Descriptive statistics are presented in Table 2. The average total score on the G-SAHD for this sample was 2.90±3.70, a median of 2 (range, 0–17). The distribution of scores was positively skewed, with few individuals endorsing large numbers of items and most patients (70%) endorsing no, one or two items. In this sample, 8.3% of the patients had a high desire for death while an additional 5% of patients had a strong desire for death. Approximately 78% of the sample had a SAHD total score of 3

Discussion

Feelings of depression, hopelessness and anxiety are common in individuals who approach the terminal phase of an illness [17]. Whereas many patients manage to avoid feeling distressed as they approach death, others have a great sense of despair during their final weeks or months of life. End-of-life despair could manifest itself as a general feeling of hopelessness or in the extreme might develop into a desire for hastened death or thoughts of suicide [17]. This study sought to examine

References (25)

H.M. Chochinov et al.
Dignity in the terminally ill: a cross-sectional, cohort study
Lancet
(2002)
A. Gamsa
Is emotional disturbance a precipitator or a consequence of chronic pain?
Pain
(1990)
M.E. Gaskin et al.
Negative affect and the experience of chronic pain
J Psychosom Res
(1992)
T. Morita et al.
Desire for death and requests to hasten death of Japanese terminally ill cancer patients receiving specialized inpatient palliative care
J Pain Symptom Manage
(2004)
J.E. Emanuel
Euthanasia and physician-assisted suicide: a review of the empirical data from the United-States
Arch Intern Med
(2002)
W. Breitbart et al.
Depression, hopelessness, and the desire for hastened death in terminally ill patients with cancer
JAMA
(2000)
B. Kelly et al.
Factors associated with the wish to hasten death: a study of patients with terminal illness
Psychol Med
(2003)
J.H. Brown et al.
Is it normal for terminally ill patients to desire death?
Am J Psychiatry
(1986)
H.M. Chochinov et al.
Desire for death in the terminally ill
Am J Psychiatry
(1995)
J.L. Werth et al.
Psychosocial issues near the end of life
Aging Ment Health
(2002)

I. Lawrie et al.

How do palliative medicine physicians assess and manage depression

Palliat Med

(2004)

W.J. Lancee et al.

The impact of pain and impaired role performance on distress in persons with cancer

Can J Psychiatry

(1994)

Cited by (51)

To what extent are psychological variables considered in the study of risk and protective factors for suicidal thoughts and behaviours in individuals with cancer? A systematic review of 70 years of research
2024, Clinical Psychology Review
Psychological variables substantially shape the risk of suicidal thoughts and behaviours (STBs). However, it is unclear to what extent they are considered in individuals with cancer. We synthesized the quantitative research landscape concerning psychological risk/protective factors of STBs in the (psycho-) oncological context.
This pre-registered review (PROSPERO-ID CRD42022331484) systematically searched the databases PubMed/Medline, CINAHL, PsycInfo, Cochrane Library, and Web of Science (as well as the grey literature and preprints). Risk of bias (RoB) was estimated using the ROBINS-I tool.
Of 11,159 retrieved records, 319 studies were eligible for inclusion. Of those, 163 (51.1%) had investigated psychological factors (affective: n = 155; social: n = 65; cognitive: n = 63; personality/individual differences: n = 37; life events: n = 6), in a combined 3,561,741 participants. The most common STBs were suicidal ideation (n = 107) or death wishes (n = 20) rather than behaviour (suicide deaths: n = 26; attempts: n = 14). Most studies had a serious RoB. Thus, a large body of research investigated STBs in cancer patients/survivors, but it rarely aligned with the theoretical or clinical developments in suicide research. We propose a conceptual model of STBs in cancer delineating moderation and mediation effects to advance the integration of the fields, and to inform future research and practice.
Determination of the refractory nature of terminal suffering by palliative care unit physicians?
2022, Medecine Palliative
Un acte de sédation peut être indiqué en cas de souffrance réfractaire en situation palliative. Il est défini comme la recherche par des moyens médicamenteux d’une diminution de la vigilance pouvant aller jusqu’à la perte de conscience. Les pratiques sédatives sont proportionnées ou profondes, à durée déterminée ou continue maintenue jusqu’au décès tel qu’encadrées par la loi Claeys-Leonetti. L’outil SEDAPALL établit une typologie de l’intention de ces sédations à leur initiation. La démarche clinique pour déterminer le caractère réfractaire d’une souffrance qui peut conduire à retenir une indication à une sédation profonde a été étudiée auprès de 16 médecins exerçant dans différentes Unités de Soins Palliatifs de Nouvelle Aquitaine à partir d’entretiens semi directifs. En résultats, le caractère réfractaire est relié à un vécu insupportable par le patient, et à l’absence de soulagement. Cette souffrance est dite multidimensionnelle, physique, psychologique, existentielle et socio familiale. Parmi ces différentes composantes, la souffrance existentielle est estimée la plus difficile à évaluer et la souffrance socio-familiale est la moins bien caractérisée. Le caractère réfractaire est dit déterminé par des évaluations répétées, en pluridisciplinarité. La procédure collégiale est utilisée par onze médecins. Les médecins exerçant depuis longtemps en USP et ceux formés à l’éthique semblent adopter une démarche plus formalisée. Les pratiques des médecins ne déclarant aucune démarche systématisée témoignent néanmoins de l’appropriation des recommandations de l’HAS.
Refractory suffering in a palliative situation may lead to perform a sedation. International policies define palliative sedation as the search of a decreased vigilance by medicinal means, which can go as far as a loss of consciousness. French guidelines distinguish sedative practices as either proportionate or deep and maintained until death as defined by the Claeys-Leonetti law. The SEDAPALL tool establishes a typology of the palliative sedation practices based on the deepness and duration initially expected by the caregivers. Based on semi-directive interviews of 16 physicians of palliative care units (PCU) in the New Aquitaine region, this study describes the clinical approach to determine the refractory nature of a suffering that may lead to a deep sedation as defined by SEDAPALL tool. According to the physicians, the suffering refractoriness is related to the patient's unbearable experience and the absence of relief. They describe this suffering as multidimensional, including physical, psychological, existential and socio-familial components. Among them, they considered the existential suffering as the most difficult to evaluate, and the socio-familial suffering as the least well defined. They propose to determine the refractory character based on repeated evaluations using a multidisciplinary approach. Two third of physicians perform a collegial procedure. Physicians who had been practising for a long time in a PCU and those trained in ethics seemed to adopt a more formalized approach. However, the other use similar practices showing a relative appropriation of the HAS recommendations by all participating practitioners.
The right to die and assisted suicide: Review and critical analysis
2022, Encephale
En France, dans le contexte de révision des lois de bioéthique, le débat public fait surgir la question de la possibilité de demander une aide médicale à mourir. Ce travail se propose : de faire un état des lieux du cadre réglementaire et des pratiques, dans cinq pays ayant légiféré, la Suisse, les Pays-Bas, la Belgique, le Luxembourg et l’état de l’Oregon (USA) ; de réaliser une analyse critique du rôle du psychiatre et de l’intérêt d’entretiens psychiatriques lors d’une demande d’aide à mourir (DAM).
Trois mots clefs apparaissent fréquemment avec une forte ambiguïté sémantique dans la question du droit à mourir : euthanasie ; assistance au suicide ; suicide assisté. À partir de ces derniers, nous avons interrogé les bases de données Pubmed et Cairn, ainsi que divers sites officiels des pays concernés, entre janvier 1997, date d’entrée en vigueur de la première législation dans l’état d’Oregon, et janvier 2020. Au total, 127 références ont été obtenues et ont toutes été analysées. Soixante contributions originales en ont été extraites et résument, à elles seules, l’ensemble des questions d’intérêt.
La législation de la DAM et les conditions concrètes de sa mise en pratique diffèrent largement entre les pays. C’est essentiellement la validité des critères formels qui est considérée ; par ailleurs, la qualification des médecins, habilités à valider la demande, varie grandement et un réel entretien psychiatrique, explorant les motivations profondes de la personne, est très rarement mis en œuvre.
Dans l’intérêt du patient, nous insistons sur la nécessité d’entretiens psychiatriques avec toute personne formulant une demande d’aide médicale à mourir. Cette demande doit s’appréhender, au-delà d’un savoir technique et scientifique, sur le terrain du colloque singulier, afin de permettre une contextualisation de la demande dans la dialectique du patient.
In the context of the present re-examination of the French bioethical laws by the National Advisory Ethics Committee (“Comité consultatif national d’éthique”: CCNE), a recent survey indicated a request of the public opinion to obtain a medical aid in end of life and a so-called “assisted suicide”. This led psychiatrists to re-consider their role and deontological position which usually led them to consider a request for an assistance in suicide as – a priori – a pathological demand, occurring within a suicidal crisis. The present article intends to: 1) describe the laws and practices of countries which allow medically assisted end of life help procedures; 2) clarify the definitions of “assisted suicide”, “assistance to suicide” and “euthanasia”; 3) consider available epidemiological data and the roles given to doctors and, more specifically psychiatrists, in these procedures; 4) analyse the rationale behind these demands. These considerations should enable French psychiatrists to clarify their position when facing requests for a medical aid in dying.
Four European countries (Switzerland, the Netherlands, Belgium, Luxemburg) and Oregon (the first US state to introduce legislation) were considered, since they accumulated and published a large amount of experiences and data about “assisted suicide” and medical help in dying. In total, 127 articles were selected, mainly from PubMed and Cairn databases, published between 1997 and 2020. These articles deal with legal considerations, epidemiological data, ethical and sociological considerations.
Laws and practices differ notably according to the state/country. In Belgium, the Netherlands and Luxemburg, as in Oregon, the medical help in dying has been de-criminalized, as long as certain legal criteria are met. In Switzerland, where no specific law exists in the penal code, non-governmental associations have benefited from the legal vacuum and organized the practice of “assisted suicide” for “altruistic motives”. In the scientific and legal literature, the terms used to describe and define the medical help in dying upon request differ greatly. In France, the National Advisory Ethics Committee defines euthanasia (“euthanasie”), assisted suicide (“suicide assisté”) and suicide assistance (“assistance au suicide”). Available epidemiological data, whatever the country considered, indicate that requests for a medical aid in dying are expressed mainly by patients aged over 60 years and suffering from cancer. Psychiatric diseases account for only 1% to 3%. Most often, systematic assessment by a psychiatrist is neither requested nor made, when the demand does not occur during a primary psychiatric illness. In the case of an existing primary psychiatric pathology, a psychiatrist assesses the case against formal legal predefined criteria. This latter practice was only recently introduced, after some feedback and after legal actions had been brought to Court. When the underlying motivations of the request are considered, it appears that, even in the absence of an evolving psychiatric condition, several psychological or psychopathological reasons prevail such as spirituality, attachment style, social isolation, despair, depression… which should greatly benefit psychiatric exploration, investigation and expertise.
In some countries, the request for medically assisted help in dying has become a legal and social reality. In France, where the public debate is still open, it should be emphasized that a psychiatric assessment and interview should be systematically provided to any person requesting medical assistance to die or commit suicide. It is the commitment of psychiatrists to understand the implicit demands and unexpressed motives underlying this request which have strong links with the unique life-events and emotional experiences of the person. The psychiatrist has a unique role in the contextualization of such a request.
The wish to hasten death: Definition, determinants, issues and perspectives
2021, Bulletin du Cancer
En service de soins palliatifs, il n’est pas rare que des personnes atteintes par la maladie grave souhaitent hâter leur mort. Ces souhaits représentent des défis considérables pour les professionnels de santé. Ainsi, cette revue a pour objectif d’étayer les professionnels de santé dans leur compréhension et appréhension du souhait des patients de hâter leur mort. Pour se faire, nous présenterons la définition de ce souhait, puis nous l’explorerons à partir de ses trois composantes principales : les intentions, les motivations et les interactions. Le fil conducteur de cette revue réside dans l’interrogation suivante : comment accompagner au mieux l’homme qui fait face à la mort ?
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?
Palliative care education and its effectiveness: a systematic review
2021, Public Health
Citation Excerpt :
Apart from physical symptom management, there are two PCE programs45,49 that touched on the topic of depression for the dying. Research has identified that end-of-life patients often experience feelings of hopelessness with symptoms of anxiety and depression, leading to suicidal ideation in the worst cases.69,70 This limitation of the PCE programs warrants future research into this area.
Palliative care education (PCE) is an important public health approach to palliative care and is crucial to improving its utilisation. The present study aims to develop a comprehensive understanding of PCE and its effectiveness.
A systematic review approach, including narrative synthesis, was used to review qualitative and quantitative studies published in the English language between January 1969 and January 2019, focussing on PCE programs.
Thirty-nine research studies were included in the systematic review. The target audience of the included studies were mostly healthcare professionals, followed by family caregivers. Definitions of death and palliative care, symptom management and communication were leading themes in the reviewed PCE programs. The educational resources used in PCE programs were mainly self-developed teaching materials, with some programs utilising eLearning resources. The included PCE programs were effective in improving knowledge, attitude and confidence in palliative care and the satisfaction of participant learning experience.
PCE is a useful tool to improve knowledge of, confidence in and attitudes towards palliative care amongst healthcare professionals and carers. To make palliative care a public health issue, PCE should be expanded to the public and policy-makers.
Dyspnea in Hospice and Palliative Medicine
2020, Physician Assistant Clinics
Citation Excerpt :
Although the predominant pathologies contributing to dyspnea remain cardiopulmonary in origin, patients nearing end of life report increasing dyspneic symptoms regardless of a cardiopulmonary cause, which is thought to be attributed to the generalized muscle fatigue, weakness, and debility noted in the dying process.2 Research has shown a correlation between anxiety, panic disorders, and panic attacks with respiratory changes including hyperventilation and increased desire of patients to hasten death in the dying patient.10,11 In these patients with preexisting psychological components, they experience dyspnea at a more severe level compared with those without.10

View all citing articles on Scopus

¹: Tel.: +1 718 817 3794; fax: +1 718 817 3699.

²: Tel.: +30210 7707669; fax: +30210 7488437.

³: Tel.: +30210 7286137; fax: +30210 7488437.

View full text

Laws, Ethics, and PsychiatryDesire for death near the end of life: the role of depression, anxiety and pain

Abstract

Objective

Methods

Results

Conclusions

Introduction

Section snippets

Patients and methods

Procedures and measurements

Statistical analysis

Results

Discussion

Lancet

Pain

J Psychosom Res

J Pain Symptom Manage

Euthanasia and physician-assisted suicide: a review of the empirical data from the United-States

Arch Intern Med

Depression, hopelessness, and the desire for hastened death in terminally ill patients with cancer

JAMA

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

Psychol Med

Is it normal for terminally ill patients to desire death?

Am J Psychiatry

Desire for death in the terminally ill

Am J Psychiatry

Psychosocial issues near the end of life

Aging Ment Health

How do palliative medicine physicians assess and manage depression

Palliat Med

The impact of pain and impaired role performance on distress in persons with cancer

Can J Psychiatry

Laws, Ethics, and Psychiatry
Desire for death near the end of life: the role of depression, anxiety and pain