|
Advertisement |
|
|
||
 |
|
|||||
|
|||||
|
 |
||||||
|
||||||
|
||||||
|
Journal of Clinical Oncology, Vol 24, No 19 (July 1), 2006: pp. 3211-3212 © 2006 American Society of Clinical Oncology. DOI: 10.1200/JCO.2006.06.3396
What About the Family When a Terminally Ill Cancer Patient Makes a Request for Euthanasia?Klinik und Poliklinik für Strahlentherapie und Radioonkologie, Regensburg, Germany
Klinik und Poliklinik für Innere Medizin II, Schwerpunkt Psychosomatik, Universität Regensburg, Regensburg, Germany
Klinik und Poliklinik für Strahlentherapie und Radioonkologie, Regensburg, Germany To the Editor: van der Lee and her colleagues recently wrote an interesting clinical article that was published in the Journal of Clinical Oncology.1 Their work deals with euthanasia and depression. A positive correlation between depression and an increased likelihood of requesting euthanasia could be found among cancer patients with an estimated life expectancy of less than 3 months. We would like to address some additional aspects of this issue, which need further discussion. The hypothesis of van der Lee et al reads as follows: Patients requesting euthanasia might be less depressed than patients who do not request it. To test this hypothesis, the researchers undertook a prospective cohort study. Their assumption not only contradicts the established clinical literature, but our own clinical intuition as well. van der Lee et al offer two reasons for their hypothesis. First, they believe that the available literature cannot be transferred to the Dutch situation, which they describe as a "well-considered and persistent request for euthanasia in an environment where euthanasia is customary."1 Second, the hypothesis corresponds to their clinical experience. van der Lee et al suggest that there are patients who deny their prognosis and are uncertain about their impending death. Among these individuals, the number of more depressed patients may be higher. Many different factors are known to be associated with an increased request for euthanasia among cancer patients, especially at the end of life. These factors include pain, depression, hopelessness, sadness, fatigue, the fear of death, and the feeling of being a burden on the family.2 At present, it is still unclear as to what the leading factors are for a request for euthanasia and whether a causal relationship exists between such factors. These central questions were not ultimately answered by the article by van der Lee et al. Apart from depression or a depressed mood, other fundamental factors, such as pain, are completely ignored in the study. Furthermore, van der Lee et al can only detect a statistical relationship between depressed mood and the request for euthanasia, but they are not in a position to describe the causal relationship between the two, or whether such a relationship exists at all. Hence, van der Lee et al cannot exclude that factors such as pain, unbearable suffering, or loneliness can cause both the request for euthanasia as well as a depressed mood. We consider it possible in some patients that the request for euthanasia itself, which could be caused by unbearable suffering, could be the cause for a depressed mood. The terms "depressed mood" and "depression" are not identical because, in contrast to a depressed mood, depression is a specific psychiatric diagnosis. Nevertheless, van der Lee et al use these terms as if they are synonymous. Hospital Anxiety and Depression Scale (HADS) is a screening instrument for depression and requires confirmation by a specific instrument such as the Composite International Diagnostic Interview (CIDI-auto) or SCID. HADS is suitable for diagnosing a depressed mood, whereas CIDI-auto is suitable for diagnosing depression in terms of International Classification of Disorders (ICD-10). Only 29 patients (20%) received a CIDI interview, whereas all patients were assessed by the HADS instrument. In the context of the study, the use of the term depression in the article and the article's title are both misleading, because depression was seldom empirically validated. Cancer patients all too often suffer from organic brain syndrome, which must be differentiated from depression, but which van der Lee et al did not consider. Therefore, the term depressed mood as an unspecific notion is much more appropriate for the study discussed. Unfortunately, van der Lee et al did not record the type of psychopharmacological drugs the patients received. Such medication should lower the occurrence of a depressed mood and subsequently also the request for euthanasia if there is a causal relationship. Despite all of these objections, the high proportion of patients with a depressed mood (23%) and their frequently expressed request for euthanasia must be noted, and such an observation requires further consideration. The high rate of a depressed mood in the study was probably based on the selection of hopeless cases, if we follow van der Lee et al's representation and diction. The estimated life expectancy was 3 months or less and the patients, mostly inpatient (83%), were aware of their untreatable cancer. Furthermore, antitumor treatment had been discontinued for an average period of 2.7 months before inclusion. If the cancer was untreatable, what were the reasons for transferring the patients to a specialized university medical center? Here, van der Lee et al owe their readers an explanation. In our clinical experience, the family's exhaustion could have played a prominent role. We show in a recently published article that the family plays a central role in medical decision making, especially in end of life decisions.3 If we keep in mind that medical decision making is a complex interplay between the patient, the family, and the doctor, van der Lee et al confront us with a black box, such that the reader cannot figure out which events took place between inclusion in the study and the final request for euthanasia. The study did not even test whether the depressed mood changed between inclusion and final request. The will to live, and accordingly the wish to die, are far from stable over time and can change from day to day.4 Not only a diseased person, but any other person can also be so depressed that he has the urge to die. Supportive families can help cancer patients make appropriate decisions. Not only do the patients need to accept their imminent death, but also the family members need to come to terms with the impending loss of their relative. Acceptance of death means to maintain support and remain together until death. Otherwise, patients could perceive themselves as being a burden on their families and thus make a request for euthanasia. Neither patients with a depressed mood nor those without a depressed mood seemed to differ on the variable married or cohabiting. However, this description alone is not sufficient to describe the complex socioeconomic circumstances in which patients live. It cannot be excluded that cancer patients were transferred to the university medical centers to start the euthanasia procedure in an environment where euthanasia is customary as van der Lee et al noted initially. If this intention was really an underlying factor from the beginning but was not clearly stated, then this would be an alarming fact. The improvement and maintenance of patient quality of life is the main aim of palliative cancer therapy. On this point van der Lee et al certainly agree with us. Hence, quality of life has to be considered and all measures that palliative care provides have to be utilized before euthanasia is taken into consideration. We therefore sorely missed both quality of life considerations and the optimization of palliative care in this article. It should not be forgotten that palliative care implies both early detection and treatment of a depressed mood. We are convinced that van der Lee and her colleagues have written an important article. Nevertheless, so many questions are left unanswered that we think it is too early to draw any clinical consequences for patient care, especially for cancer patients outside of the Netherlands where euthanasia has not been legalized. However, it could be helpful for oncologists to invest more time in psycho-oncological education to increase the awareness of the depressed mood among their treated patients. If van der Lee et al continue with their research, the role of the family in decision making needs more attention and additional clarification. In addition, they should not lose sight of the optimization of palliative care, which could ultimately even supersede the need for euthanasia. Authors' Disclosures of Potential Conflicts of Interest The authors indicated no potential conflicts of interest. REFERENCES
1. 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 2. Mystakidou K, Parpa E, Katsouda E, et al: The role of physical and psychological symptoms in desire for death: A study of terminally ill cancer patients. Psycho-Oncology 15:355-360, 2006[Medline] 3. Schäfer C, Putnik K, Dietl B et al: Medical decision-making of the patient in the context of the family: Results of a survey. Supp Care Cancer 10.1007/s00520-006-0025-x 4. Chochinov HM, Tataryn D, Clinch JJ, et al: Will to live in the terminally ill. Lancet 354:816-819, 1999[Medline]
Related Reply
|
|||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
|
|
|||||||||||
|
|||||||||||
|
|
Copyright © 2006 by the American Society of Clinical Oncology, Online ISSN: 1527-7755. Print ISSN: 0732-183X
|
