|
Advertisement |
|
|
||
 |
|
|||||
|
|||||
|
 |
||||||
|
||||||
|
||||||
|
Originally published as JCO Early Release 10.1200/JCO.2005.06.001 on August 22 2005 © 2005 American Society of Clinical Oncology.
Depression, Euthanasia, and Improving End-of-Life CareDepartment of Clinical Bioethics, The Clinical Center, National Institutes of Health, Bethesda, MD Why would a patient request euthanasia or physician-assisted suicide (PAS)? To many the answer seems obvious—excruciating, unremitting pain: As a result [of medical progress], Americans are living longer, and when they finally succumb to illness, lingering longer, either in great pain or in a stuporous, semi-comatose condition that results from the infusion of vast amounts of pain killing medications...The now recognized right to refuse or terminate treatment and the emergent right to receive medical assistance in hastening one's death are inevitable consequences of [these] changes.1 The statute that we propose is designed to provide the option of physician-assisted suicide to competent patients who either have a terminal illness or are suffering from relievable and unbearable distress, due to bodily illness, that is so great that they prefer death.2 The avoidance of severe physical pain (connected with death) would have to comprise an essential part of any successful claim [for a right to physician-assisted suicide].3 It seems that many people imagine the circumstances that might drive them to want to "end it all," and excruciating pain comes to mind. This picture of terminally ill patients writhing in uncontrolled or even uncontrollable pain requesting euthanasia or PAS has dominated all discussions about whether euthanasia or PAS is ethical and should be legalized. Despite being widespread and well accepted, there is woefully little evidence supporting this image. Beginning in 1996, data accumulated suggesting that pain was not a key factor motivating terminally ill patients' interest in euthanasia or PAS. For instance, one study of cancer patients found that pain was significantly associated with finding euthanasia and PAS unacceptable (odds ratio [OR], 2.3).4 Another study of 378 HIV/AIDS patients reported that "interest in physician-assisted suicide was not related to severity of pain, pain-related functional impairment, [or] physical symptoms."5 Similarly, data on the first group of 15 patients in Oregon who requested legal PAS—of whom 13 (87%) had cancer—indicated that only one (7%) had severe pain, whereas among matched decedents who did not request PAS, 35% had inadequate pain control.6 Since 1998, 208 people have died by PAS in Oregon; worry about pain was a motivating factor—but not necessarily the primary concern—in only 22% of cases.7 Review of the seven patients who died by euthanasia for the brief time it was legal in the Northern Territory in Australia showed that all were cancer patients and none had uncontrolled pain; three of the patients had no pain at all, and for the other four, pain was well controlled.8 If not pain, then what motivates patient interest in euthanasia or PAS? Accumulating data support what might be called the depression thesis. Most, if not all, studies that have examined this question reveal that psychological distress, including depression and hopelessness, are significantly associated with patients' interest in hastening their own death through euthanasia and/or PAS.4,5,8-14 In 1996, a survey of cancer patients, not all of whom were terminally ill, showed those who were depressed "were significantly more likely to have discussed euthanasia [for themselves], hoarded drugs, or to have bought or read Final Exit (the Hemlock Society suicide manual)."4 Similarly, a survey of 988 patients determined to be terminally ill by their physician revealed that patients with depressive symptoms were more likely to have demonstrated a personal interest in euthanasia or PAS.11 Researchers in Oregon have found that among patients with amyotrophic lateral sclerosis, hopelessness was strongly associated with wanting a lethal prescription to take immediately or for future use.12 In Australia, of the seven patients who died by euthanasia, only three did not have depressive symptoms: one was suicidal, one was depressed but not receiving treatment, one was depressed and receiving antidepressants, and one had a history of depression and suicidal thoughts.8 It is against this background that van der Lee et al15 conducted their study of 138 terminally ill cancer patients. These Dutch researchers are refreshingly frank about their initial hypothesis; namely, that the data supporting the depression thesis are wrong, possibly because most of the studies occurred in countries where euthanasia and PAS were either illegal or socially disparaged. Their prior clinical experience suggested that patients who want euthanasia render thoroughly thought-out requests that reflect deep values rather than psychological distress. As they report, contrary to their experience and hypothesis, depressed patients were four times more likely to request euthanasia. Indeed, 44% of depressed patients requested euthanasia; of those who requested euthanasia, about half were depressed. The authors also show that patients' depression was not the consequence of a poorer prognosis. The researchers' strong prior bias against the outcome makes these data all the more convincing. These data should also help to erase the perceived link between pain and interest in euthanasia and PAS, while substantially solidifying the depression thesis. IMPLICATIONS FOR EUTHANASIA AND PAS Much of the public debate during the last 15 years has suggested that euthanasia and PAS are just another type of withdrawal or withholding of life-sustaining treatments.16 However, the empirical data strongly suggest that requests for euthanasia or PAS are less like traditional requests for the withdrawal and withholding of life-sustaining interventions than like plain old suicide. Like terminating life-sustaining treatments, euthanasia and PAS are intended to end a patient's life when it is causing more suffering and do so at the patient's request. However, this does not appear to be what actually occurs in cases of euthanasia or PAS. Instead, requests for these interventions tend to be guided by psychological distress rather than rational choices about a good death. This conclusion should be especially worrisome given that approximately 15% to 25% of cancer patients are depressed,17 and approximately 80% of requests for euthanasia or PAS come from cancer patients. When the depression thesis is juxtaposed with epidemiologic data demonstrating that, in general, suicide is approximately 30% to 50% more likely among cancer patients and that depression is a primary motivation for suicide,18-20 euthanasia and PAS look more like a method of acting on suicidal ideation than a type of termination of medical treatment. IMPLICATIONS BEYOND EUTHANASIA AND PAS Practically, for physicians and especially oncologists, the empirical data emphasize the need to attend to depression, hopelessness, and psychological distress among cancer patients. The study by van der Lee et al15 confirms that 15% to 25% of terminally ill cancer patients probably suffer from depression.17 In general, physicians are poor at suspecting, identifying, and diagnosing depression.21 Indeed, oncologists themselves recognize that diagnosing and treating depression is not one of their better clinical skills. In the American Society of Clinical Oncology–sponsored survey about end-of-life care, only 55% of oncologists reported feeling very competent at managing depression compared with 94% who reported feeling competent at managing pain, 92% who reported feeling competent at managing nausea and vomiting, and 88% who reported feeling competent at managing fever and neutropenia. One reason why physicians do not recognize or aggressively treat depression may be the view that terminally ill patients are bound to be depressed because they are facing the end of their lives. This conclusion is obviously incorrect, considering that 75% to 85% of terminally ill patients are not depressed.17 Furthermore, physicians should recognize that there is a difference between sadness, adjustment disorders, and full depression, and that they should not be too quick to classify patients as having adjustment disorders rather than depression. Finally, the fact that depression may be a natural reaction to a desperate situation does not mean it should not be treated. As one psychiatrist pointed out, the fact that hypotension is the natural reaction to hemorrhage does not mean physicians should not administer fluids, transfusions, and vasopressors. That people are depressed because of their impending death should warrant, rather than preclude, aggressive treatment. Not only do individual oncologists need to suspect, refer, and treat depression more aggressively, but the system needs to do more. The oncology system has responded admirably to pain, making it a fifth vital sign; dispelling prejudice, ignorance, and false claims about its treatment; encouraging more aggressive use of opioids and other pain medications; and developing pain services. We need to be equally proactive about routinely screening for and treating depression and other psychological disorders among cancer patients. Depression could be a sixth vital sign. Oncologists should make the question "How often have you been down-hearted and blue over the last few weeks?" or "Are you depressed?" a routine part of their interview with patients.22,23 Similarly, strong consideration—or a low threshold—for a psychiatric evaluation should be given when a patient expresses interest in euthanasia or PAS. The study by van der Lee et al15 also provides an important reminder about the limits of physicians' clinical experience. As we have learned from cognitive psychology, people unconsciously select and frequently distort what they mentally process; people remember what confirms their prior views and ignore what challenges their views. This is not conscious or overt, but rather involuntary. For this reason, clinical experience does not constitute rigorous scientific data. Informal data gathering through daily experience is likely to lead one astray. Frequently, formal data collection will challenge rather than confirm clinical experience. It is therefore prudent to be skeptical and suspicious of someone who acts solely on clinical experience, rather than relying on formal data collection. Author's Disclosures of Potential Conflicts of Interest The author indicated no potential conflicts of interest. Acknowledgment I thank David Shalowitz for critical comments and insights. REFERENCES 1. Compassion in Dying v State of Washington, 79 F3d 790 (9th Cir 1996) 2. Baron CH, Bergstresser C, Brock DW, et al: Statute: A model stat act to authorize and regulate physician-assisted suicide. Harvard J Legisl 33:1-34, 1996 3. Justice Breyer concurring in Washington v. Glucksberg, 117 (S Ct 2258 1997) 4. Emanuel EJ, Fairclough DL, Daniels ER, et al: Euthanasia and physician-assisted suicide: Attitudes and experiences of oncology patients, oncologists, and the public. Lancet 347:1805-1810, 1996[CrossRef][Medline]
5. Breitbart W, Rosenfeld BD, Passik SD: Interest in physician-assisted suicide among ambulatory HIV-infected patients. Am J Psychiatry 153:238-242, 1996
6. Chin AE, Hedberg K, Higginson GK, et al: Legalized physician-assisted suicide in Oregon: The first year's experience. N Engl J Med 340:577-583, 1999 7. Department of Human Services, State of Oregon: Seventh Annual Report on Oregon's Death With Dignity Act. March 10, 2005. http://www.oregon.gov/DHS/ph/pas/index.shtml 8. Kissane DW, Street A, Nitschke P: Seven deaths in Darwin: Case studies under the right of the terminally ill act, Northern Territory, Australia. Lancet 352:1097-1102, 1998[CrossRef][Medline]
9. Breitbart W, Rosenbeld B, Pessin H, et al: Depression, hopelessness, and desire for hastened death in terminally ill patients with cancer. JAMA 284:2907-2911, 2000
10. Rosenfeld B, Breitbart W, Stein K, et al: Measure desire for death among patients with HIV/AIDS: The schedule of attitudes toward hastened death. Am J Psychiatry 156:94-100, 1999
11. Emanuel EJ, Fairclough DL, Emanuel LL: Attitudes and desires related to euthanasia and physician-assisted suicide among terminally ill patients and their caregivers. JAMA 284:2460-2468, 2000
12. Ganzini L, Johnston WS, McFarland BH, et al: Attitudes of patients with amyotrophic lateral sclerosis and their caregivers toward assisted suicide. N Engl J Med 339:967-973, 1998
13. Wilson KF, Scott JF, Graham ID, et al: Attitudes of terminally ill patients toward euthanasia and physician-assisted suicide. Arch Intern Med 160:2454-2460, 2000 14. Blank K, Robison J, Doherty E, et al: Life sustaining treatment and assisted death choices in depressed older patients. J Am Geriatr Soc 49:153-161, 2001[CrossRef][Medline]
15. Van der Lee ML, van der Bom JG, Swarte NB, et al: Euthanasia and depression: A prospective cohort study among terminally ill cancer patients. J Clin Oncol 23:6607-6612, 2005 16. Brock DW: Voluntary active euthanasia. Hastings Cent Rep 22:10-22, 1992[CrossRef][Medline] 17. Bottomley A: Depression in cancer patients: A literature review. Eur J Cancer Care 7:181-191, 1998 18. Yousaf U, Christensen ML, Engholm G, et al: Suicides among Danish cancer patients 1971-1999. Br J Cancer 92:995-1000, 2005[CrossRef][Medline]
19. Llorente MD, Burke M, Gregory GR, et al: Prostate cancer: A significant risk factor for late-life suicide. Am J Geriatr Psychiatry 13:195-201, 2005
20. Hem E, Loge JH, Haldorsen T, et al: Suicide risk in cancer patients from 1960-1999. J Clin Oncol 22:4209-4216, 2004 21. Eisenberg L: Treating depression and anxiety in primary care: Closing the gap between knowledge and practice. N Engl J Med 326:1080-1084, 1992[Medline] 22. Berwick DM, Murphy JM, Goldman PA, et al: Performance of a five-item mental health screening test. Med Care 29:169-176, 1991[CrossRef][Medline] 23. Chochinov HM, Wilson KG, Enns M, et al: "Are you depressed?" screening for depression in the terminally ill. Am J Psychiatry 154:674-676, 1997[Abstract] Related Article
|
|||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
|
|
|||||||||||
|
|||||||||||
|
|
Copyright © 2005 by the American Society of Clinical Oncology, Online ISSN: 1527-7755. Print ISSN: 0732-183X
|
