Patients’ Perceptions of Physician-Assisted Suicide
ABSTRACT & COMMENTARY
Synopsis: Physician-assisted suicide is a controversial topic that is commonly discussed among oncologists. In a large survey of terminally ill patients conducted by Emanuel and colleagues, attitudes about this intervention were examined. The majority of patients were in favor of the availability of this option for those with unrelenting pain but only a small percentage considered it for themselves. Of those who did, depression and hopelessness were more common features than pain.
Source: Emanuel EJ, et al. JAMA 2000;284:2460-2468.
Physician-assisted suicide is a controversial topic and individual oncologists have, no doubt, thought about the issue and formulated their own opinion. In this report, the attitudes of terminally ill patients (most of whom have cancer) and their caregivers were systematically recorded. A cohort of 988 terminally ill patients from six geographically disparate areas within the United States and 893 patient-designated primary caregivers were surveyed twice between March 1996 and July 1997. Of the patients, 60.2% supported euthanasia or physician-assisted suicide in a hypothetical situation, but only 10.6% reported seriously considering it for themselves. Factors associated with being less likely to consider this were the feeling of being appreciated (odds ratio [OR], 0.65, 95%; confidence interval [CI] 0.52-0.82), being 65 years or older (OR, 0.52; CI 0.34-0.82), and being African-American (OR, 0.39; CI, 0.18-0.84). In contrast, factors associated with considering euthanasia or physician-assisted suicide were depressive symptoms (OR, 5.29; CI, 1.21-23.2), substantial caregiver needs (OR, 1.09; CI, 1.01-1.17), and pain (OR, 1.26; CI, 1.02-1.56). At the follow-up interview, half of the terminally-ill patients who had considered euthanasia or physician-assisted suicide for himself or herself had changed their minds, while an equal number began considering these interventions. At this time, patients with depressive symptoms (OR, 5.29; CI, 1.21-23.2) or dyspnea (OR, 1.68; CI, 1.26-2.22) were more likely to change their minds to consider euthanasia or physician-assisted suicide. Of note, of the 256 patients who died during the period of the study, one died by physician-assisted suicide, one had unsuccessfully attempted suicide, and one had repeatedly requested for her life to be ended but the family and the physician refused.
COMMENT by William B. Ershler, MD
Although there have been several reports about physicians attitudes on this topic, including those of oncologists,1 there are only a few reports focusing on the patient’s concerns and desires. Those that are published2-4 have revealed that depression, particularly the sense of hopelessness rather than pain, is the primary factor motivating patients to consider euthanasia or physician-assisted suicide. The current study adds to our understanding because it only included patients with terminal illnesses (a feature not present in the earlier reports) and it included follow-up interviews to determine the sturdiness of these attitudes. Although there are inherent limitations on studies such as this, including referral bias, concerns about confidentiality, etc., Emanuel et al were careful in their approach and the findings are likely to reflect the attitudes of those patients with a limited life expectancy.
These findings suggest that most patients support the notion of physician-assisted suicide for other patients with unremitting pain, but only 10% considered it for themselves and less than 4% had discussed this with a physician. This is considerably lower than would have been predicted from other studies in which individuals were given hypothetical scenarios including terminal illness.5
It appears that the most important determinants of interest in physician-assisted suicide relate more to psychological rather than physical symptoms. In addition, this study indicated that those patients who believed they were a burden to their family and caregivers were most likely to consider physician-assisted suicide. Thus, as Emanuel et al point out, there is a distinction between what this cohort and other published reports2-4 have found regarding the reason people find euthanasia and physician-assisted suicide acceptable (predominantly pain), and the main motivating factor for patients (depression). However, this study points out that patients’ personal considerations of euthanasia and physician-assisted suicide appear unstable because about one-half the terminally ill patients interested in these interventions changed their minds and terminally ill patients who had not previously considered them developed an interest over several months. Again, depression seemed to be a motivating factor in this developed interest. Emanuel et al rightfully point out that this instability of consideration on the topic suggests that the waiting period before a patient is given the prescription for physician-assisted suicide mandated in Oregon and included in many proposals for legislation is an important safeguard.
References
1. Emanuel EJ, et al. Ann Intern Med 2000;133:527-532.
2. Chin AE, et al. N Engl J Med 1999;340:577-583.
3. Sullivan AD, et al. N Engl J Med 2000;342:598-604.
4. Emanuel EJ, et al. Lancet 1996;347:1805-1810.
5. Ganzini L, et al. N Engl J Med 1998;339:967-973.
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