Psychosomatics 47:504-512, November-December
doi: 10.1176/appi.psy.47.6.504
© 2006 Academy of Psychosomatic Medicine
Desire for Hastened Death Among Patients With Advanced AIDS
Barry Rosenfeld, Ph.D.,
William Breitbart, M.D.,
Christopher Gibson, Ph.D.,
Michael Kramer, Ph.D.,
Alexis Tomarken, M.S.W.,
Christian Nelson, Ph.D.,
Hayley Pessin, Ph.D.,
Julie Esch, R.N.,
Michele Galietta, Ph.D.,
Nerina Garcia, M.A.,
John Brechtl, M.D., and
Michael Schuster, M.D.
Received June 18, 2005; revised November 15, 2005; accepted November 30, 2005. From Fordham University, Bronx, NY (BR). Address correspondence to Barry Rosenfeld, Ph.D., Dept. of Psychology, Fordham University, 441 E. Fordham Rd, Bronx, NY 10458. e-mail: rosenfeld{at}fordham.edu
|
ABSTRACT
|
The recent debate over legalization of physician-assisted suicide has fueled interest in understanding factors that lead medically ill patients to seek a hastened death. The authors investigated the prevalence and predictors of desire for hastened death in 372 patients with advanced AIDS who were newly admitted to a palliative-care facility. Clinician-rated and self-report measures of desire for hastened death, depression, hopelessness, spiritual well-being, social support, pain, and physical symptom burden were administered to assess the factors that correspond to a high desire for death. The prevalence ranged from 4.6% to 8.3%, significantly lower than in previous studies of patients with advanced or terminal cancer. Multivariate models revealed significant and unique effects for both hopelessness and depression, with these variables accounting for a large proportion of the variance in each model. Authors discuss the implications of these findings for palliative care practice and the assisted-suicide debate.
|
INTRODUCTION
|
One of the most important and controversial healthcare policy issues to emerge in recent years has been the debate regarding legalization of physician-assisted suicide (PAS). In the United States, legalized PAS began in 1997 in the state of Oregon, although many other states have debated this possibility before and since.1 In Europe, euthanasia and PAS were formally legalized in the Netherlands in 2001 and in Belgium the following year, although the practices had been effectively decriminalized in the Netherlands for many years.2 Both proponents and opponents of PAS/euthanasia have highlighted the importance of psychosocial issues such as depression and hopelessness in these debates. Opponents of legalization have argued, for example, that depression plays a large role in driving patients to seek a hastened death and that such patients should be routinely referred for mental-health treatment rather than receive help to end their life.3 Proponents, on the other hand, argue that decisions to hasten death are often "rational" and that depression plays a relatively minor role in requests for PAS.4 Obviously, how one conceptualizes the role of depression in terminal illness has important implications for palliative-care practice (i.e., whether requests for PAS lead to mental-health intervention or a prescription for a lethal medication).
Because actual requests for assisted suicide (which is only legal in Oregon) or euthanasia (which is not legal anywhere in the United States) are relatively rare5 and may be mediated by a number of idiosyncratic factors, such as religious beliefs or family responsibilities, social scientists have increasingly focused on studying the desire for hastened death as an alternative method of identifying patients who are likely to request PAS/euthanasia as well as other methods of hastening death (i.e., suicide without physician assistance, termination of life-sustaining interventions).1 The first measure of desire for hastened death was developed by Harvey Chochinov and his colleagues.6 They developed a clinician-rated scale, the Desire for Death Rating Scale (DDRS), that was based on a series of standardized questions. However, the limited range of possible scores on this scale (a single 6-point rating) and the limited breadth of criteria upon which DDRS ratings were based led our research group to develop a self-report inventory designed to assess desire for hastened death. The Schedule of Attitudes toward Hastened Death (SAHD) was initially developed on patients with AIDS and cancer,7,8 but has subsequently been extended to patients with amyotrophic lateral sclerosis (ALS), as well.9 These scales have greatly enhanced the ability of researchers to study factors associated with desire for hastened death, but, to-date, have typically relied on relatively small samples that include few patients with a high desire for death.
Despite the importance of the assisted-suicide debate and the increasing availability of methods for studying desire for hastened death, only a handful of researchers have attempted to systematically study this phenomenon. Chochinov and colleagues6 studied 200 terminally ill cancer patients and found that depression was the strongest predictor of desire for hastened death in his sample. Using the DDRS, they classified 8.5% of their sample as having a "serious and pervasive" desire for death. Ten of the 17 patients with a high desire for death also met criteria for a diagnosis of major depressive disorder. Social support and pain were also significantly correlated with desire for death, but these variables did not contribute to the prediction of desire for death after depression was considered. In another study of terminally ill cancer patients, Breitbart and colleagues10 found, on the basis of the SAHD, that both depression and hopelessness were strong correlates of desire for hastened death. Both depression and hopelessness provided unique and substantial contributions in a multivariate prediction model that also included social support and physical functioning ability. Pain and physical symptoms, on the other hand, did not provide a significant contribution to the model predicting desire for hastened death. Other studies of desire for hastened death have observed roughly comparable results, with hopelessness and depression emerging as the strongest correlates of desire for hastened death; but these studies have not incorporated multivariate models, typically because of the modest sample sizes.7,9,11
Although much of the interest in end-of-life decisions arose in response to the growing HIV/AIDS epidemic, very little research on interest in assisted suicide or desire for death has focused on patients with AIDS. Breitbart, Rosenfeld, and Passik studied interest in physician-assisted suicide among ambulatory patients with AIDS, asking patients whether they would "consider" assisted suicide if it were legalized.12 They found that depression and psychological distress were the strongest predictors of interest in PAS, whereas physical symptoms, pain, and physical functioning ability were not predictive. In a subsequent study, describing the validation of the SAHD in a sample of patients with AIDS, Rosenfeld et al. found that depression was significantly correlated with SAHD scores, although this sample largely comprised ambulatory patients, and the modest sample size did not permit multivariate analyses.7
The present study seeks to expand and improve upon the existing literature by analyzing desire for hastened death, making use of both clinician-rated and self-report measures in a large sample of patients with advanced HIV/AIDS. This methodology permits multivariate modeling of desire for hastened death, as well an analysis of differences, should they exist, between self-reported and clinician-rated measures of desire for hastened death.
|
METHOD
|
Participants
Patients with advanced AIDS were recruited from three sites (two skilled-nursing facilities and one medical center) in New York City, all of which provide palliative and supportive care for patients with advanced AIDS. Recruitment took place from January of 1999 through December 2002. All patients who met Centers for Disease Control criteria for an AIDS diagnosis and were admitted for palliative care to one of the study facilities were eligible for study participation, provided they met the following inclusion/exclusion criteria: English-speaking, over 18 years old, no history or current symptoms of a psychotic mental disorder, and sufficiently cognitively intact to provide meaningful informed consent (discussed below). Although patients with a current substance abuse disorder were not excluded from participation, each of the study sites required abstinence from illegal drugs/alcohol.
During the 4-year study period, 1,374 patients were admitted to the study institutions, excluding patients who were discharged and subsequently re-admitted (see Figure 1). Of these 1,374 new admissions, 672 patients were available for cognitive screening (48.9%). The remaining patients could not be interviewed because they did not speak English, had died or were discharged from the hospital before they could be contacted, were too ill to be interviewed, or met other exclusionary criteria (e.g., psychosis). Of the 672 patients who were available for cognitive screening, 106 (15.8%) refused to participate in the screening procedure and were therefore not eligible for study participation. Of the 566 patients who were administered the cognitive screening battery, 139 (24.6%) were sufficiently impaired as to be unable to participate (i.e., earned a Mini-Mental State Exam [MMSE] score below 20), and an additional 43 patients (10.1% of the 427 who passed the screening battery) refused to participate in the research study, typically citing illness and fatigue or a lack of interest in research as the reason for their refusal. An additional 12 patients who consented to participate in the study were unable to complete the majority of the assessment battery, leaving a total of 372 patients for whom complete or substantial data were available.
Procedures
All patients admitted to the study sites were first administered a brief cognitive screening measure as a routine part of the admission protocol (the MMSE).13 Patients who earned scores of 20 or above on the MMSE were considered sufficiently cognitively intact to be eligible for study participation, provided they met the inclusion/exclusion criteria described above. Eligible patients were offered study participation within the first week of admission, provided with a brief description of the risks and benefits of the study, and, if willing to participate, were asked to read and sign a written statement of informed consent. Patients who consented to participate were then administered a series of clinician-rated and self-report instruments (described below), with the self-report instruments being administered orally by a trained research assistant in order to minimize patient burden and fatigue or other medical/cognitive limitations (e.g., vision problems, limited reading ability). Most assessments were completed in a single interview, although, on some occasions, the assessments had to be conducted over two separate sessions (typically separated by 1 or 2 days). A subset of the assessments (roughly 10%) were conducted jointly, by two investigators, in order to determine interrater reliability (described below). The study was approved by the Institutional Review Boards of Memorial Sloan-Kettering Cancer Center, Fordham University, and each of the three participating study institutions where patient accrual occurred. After completion of the study, all participants were given $10 as compensation for their time.
Two measures of desire for hastened death were administered, the Schedule of Attitudes toward Hastened Death (SAHD)7 and the Desire-for-Death Rating Scale (DDRS).6 Also, we administered the Structured Clinical Interview for DSM-IV (SCID),14 the Hamilton Rating Scale for Depression (Ham-D),15 the Beck Hopelessness Scale (BHS),16 the Duke–UNC Functional Social Support Questionnaire (FSSQ),17 the FACIT Spiritual Well-Being Scale (SWB),18 the Brief Pain Inventory (BPI),19 the Memorial Symptom Assessment Scale (MSAS),20 the Karnofsky Performance Rating Scale (KPRS),21 and an abbreviated version of the McGill Quality-of-Life Questionnaire (M–QOL).22 Patients were classified as having suicidal ideation on the basis of their responses to the Ham-D item regarding thoughts of suicide; those patients who acknowledged suicidal ideation (a score  2) were classified as having suicidal ideation and distinguished from patients who felt that life was not worth living but did not have thoughts of death or suicide. Also, in order to maintain the independence of self-report and clinician ratings, as well as between ratings of depression and desire for hastened death, self-report inventories such as the SAHD and BHS were administered after the clinician-rated measures (e.g., the SCID and DDRS) had already been completed. Demographic and medical data were elicited from subjects and from hospital charts. Patients diagnosed with major depression (on the basis of SCID interviews) were referred to the institution’s psychiatrist for further evaluation and treatment.
Statistical Analysis
We used frequency analyses to describe sample characteristics, including the prevalence of depression and patterns of desire for hastened death, as well as the relationship between these variables. The dependent variable, desire for hastened death, was analyzed in two ways, once from clinician ratings (the DDRS) and once from responses to the self-report inventory (the SAHD). For descriptive purposes, we analyzed these variables separately; however, for most analyses, these two variables were combined such that patients who revealed a high desire for hastened death on either of the two measures were classified as having "high" desire for death, whereas patients who obtained low scores on both measures were classified as "low" in desire for hastened death. This method of combining the variables was selected in order to optimize our "sensitivity" to desire for hastened death and minimize the possibility that assessment method (clinical or self-report) would influence the pattern of results. We used correlational analyses (point-biserial correlation coefficients) to identify predictors of desire for hastened death. Variables that were significantly associated with desire for death in correlational analyses (p<0.05) were subsequently entered into a stepwise logistic-regression model in order to identify the most parsimonious set of variables that predicted desire for hastened death.
Interrater reliability was established by use of intraclass correlation coefficients (ICC)23 for continuous variables (e.g., Ham-D, DDRS, and KPRS ratings) and kappa coefficients for categorical ratings (e.g., diagnosis of depression based on SCID interviews).23 Reliability estimates were uniformly high for each of the clinician-rated variables. The kappa coefficient for the diagnosis of depression based on the SCID was 0.93 (N=29; p<0.0001). Ratings of depression based on the Ham-D and ratings of desire for hastened death based on the DDRS were also quite consistent across raters, with an ICC of 0.94 (N=42; p<0.0001) for Ham-D ratings and 0.92 (N=42; p<0.0001) for DDRS ratings. Reliability for estimates of physical functioning (based on the KPRS) were somewhat lower, but still adequate: ICC=0.71 (N=37; p<0.0001).
|
RESULTS
|
Sample Characteristics
As noted above, complete (or nearly complete) assessments were available for 372 patients (see Table 1), including 280 men (75.3%) and 92 women (24.7%). The average age of participants was 44.4 years (standard deviation [SD]: 9.4; range: 23–75 years), and they reported an average of 11.9 (SD: 2.9) years of education. More than half of the sample were African American (N=214; 57.5%); 72 participants were Caucasian (19.4%), and 83 (22.3%) were Hispanic/Latino. Catholics comprised more than one-third of the sample (N=138; 37.5%), with another 136 reporting other Christian faiths (largely Protestant and Baptist: 36.4%). The most common source of HIV infection was reported to be sexual contact (N=208; 56.7%), although intravenous (IV) drug use was noted by 25.9% (N=95), and 16.6% (N=61) reported multiple risk factors (typically sexual contact and IV drug use). All participants carried a diagnosis of AIDS, and the median CD4 cell count was 68; 75% of the sample had CD4 cell counts below 200 at the time of study participation. Median viral load was 16,850. Frequent or severe pain was reported by 60% of the sample, and 35% of patients (N=132) described their pain "at its worst" as severe (>7 on a 0–10 scale).
Prevalence of Depression and Desire for Death
One hundred study participants (26.9%) met DSM-IV criteria for a major depressive episode (MDE); the average Ham-D rating of depression severity was 12.4 (SD: 7.8). The rate of desire for hastened death ranged from 4.6% to 6.5%, depending on the measure utilized. The average number of SAHD items endorsed was 2.9 (SD: 3.3) items, and 17 participants (4.6%) endorsed 10 or more SAHD items, indicating a high desire for hastened death. The mean DDRS rating was 0.7 (SD: 1.1), and 24 (6.5%) received a score 3. When these measures were combined, 31 individuals (8.3%) were classified as having high desire for hastened death.
Not surprisingly, SAHD and DDRS ratings were highly correlated with each other: r=0.60; p<0.0001. Interestingly, the rate of desire for hastened death (based on SAHD scores) observed in the present study was significantly lower than that observed in a previous study of terminally ill cancer patients.10 In our previous study, roughly 17% of terminally ill cancer patients endorsed 10 or more items on the SAHD, versus only 4.6% of patients with AIDS in the present study:  2[1]=22.27; p<0.0001. The mean number of SAHD items also differed significantly across these two samples, as cancer patients endorsed an average of 4.6 items, versus 2.9 for AIDS patients: t[461]=4.09; p<0.0001. On the other hand, a diagnosis of MDE was significantly more common among the present sample (26.9%; N=100) than in our previous study of cancer patients (16.9%; N=15; 2[1]=3.86; p=0.049).
Correlates of Desire for Hastened Death
The strongest associations with desire for hastened death were found for hopelessness, severity of depressive symptoms, and spiritual well-being (see Table 2). Hopelessness was most highly correlated with desire for death: (r=0.49; p<0.0001), followed by depression severity (Ham-D score) and spiritual well-being (SWB): r=0.44 and r=0.42, respectively; p<0.0001 for both measures. Desire for hastened death was also significantly more common among patients who met criteria for MDE on the basis of SCID interviews: 2=49.73; p<0.0001. Among the 100 patients who met DSM-IV criteria for major depression, 25 (25%) had elevated SAHD or DDRS scores (or both), versus only 2% of nondepressed patients (6 of 272). Measures of social support, quality of life, concerns regarding being a burden to others, and suicidal ideation were also significantly associated with both the SAHD and DDRS (see Table 2).
On the other hand, few demographic variables were associated with desire for hastened death, as no significant associations were observed for age, gender, years of education, transmission risk factor, religious affiliation, or religiosity as measured by patient self-perception and frequency of attending religious services (see Table 2). Patients with a history of psychiatric treatment, on the other hand, were significantly more likely to have high desire for hastened death: 2[1]=6.95; N=372; p=0.008. Patients who had signed a Do-Not-Resuscitate (DNR) order were also significantly more likely to be classified as having a high desire for hastened death as indicated by the SAHD or DDRS: 2[1]=5.59; N=372; p=0.02.
Most medical variables studied were also unrelated to desire for hastened death (see Table 2). For example, neither CD4+ cell count nor viral-load measurements were associated with desire for hastened death. Likewise, neither physical functioning ability (as measured by the KPRS) nor the presence of severe pain was associated with desire for hastened death, although the latter variable approached significance: 2[1]=3.70; N=372; p=0.054. On the other hand, number of physical symptoms and overall symptom distress (as measured by the MSAS) and pain-related functional limitations were significantly associated with desire for hastened death (Table 2).
Multivariate Prediction of Desire for Hastened Death
We used stepwise logistic regression to identify the variables significantly associated with desire for hastened death. All variables that were significant (p<0.05) in univariate analyses were considered as potential predictors, using a forward-selection method. Despite the large number of variables that were significantly associated with desire for hastened death, only depression and hopelessness provided significant, unique contributions to this prediction model. The overall model was statistically significant, Wald 2[2]=49.66; p<0.0001. Both depression (Ham-D score) and hopelessness (BHS scores) provided large, significant contributions to this model: Wald 2[2]=21.17; p<0.0001 for depression; Wald 2[2]=24.86; p<0.0001. There were no other variables that contributed significantly to the prediction of desire for hastened death after depression and hopelessness were entered into this model. These two variables correctly classified 93.4% of cases.
In order to better understand the interrelationships between depression, hopelessness, and desire for hastened death, we classified patients into either high or low hopelessness, based on the number of BHS items endorsed. Patients who endorsed >8 BHS items were classified as "hopeless" and were contrasted with patients who endorsed  8 symptoms.
Figure 1 depicts the relationship between hopelessness, a diagnosis of MDE (on the basis of the SCID), and desire for hastened death. The majority of our sample were neither "depressed" nor "hopeless" (237 of 372, or 63.7%), and only one of these 237 individuals had a high desire for hastened death (0.4%). Of the 57 patients (15.3% of the total sample) diagnosed with an MDE but who did not have high hopelessness (8 of the 20 BHS items), five (8.8%) had a high desire for hastened death. Conversely, 35 individuals (9.4%) had a high level of hopelessness but did not meet criteria for an MDE, and 5 had a high desire for hastened death (14.3%). However, when both depression and hopelessness were present, 20 of 43 individuals (46.5%) had a high desire for hastened death.
|
DISCUSSION
|
This study represents the first systematic examination of desire for hastened death among patients with advanced AIDS and the largest study to-date of desire for hastened death. Our results generated a number of findings on this topic that support and extend the growing literature suggesting a powerful influence of both depression and hopelessness in predicting desire for hastened death.
Also, our study produced a number of surprising findings. Perhaps most noteworthy was the relatively low rate of desire for hastened death among our sample; less than 10% of our sample showed elevated levels on one of the two measures of desire for hastened death (4.6% on the SAHD and 6.5% on the DDRS; 8.3% were elevated on one or the other). This rate stands in contrast to previous studies of cancer patients, where substantially higher rates of desire for hastened death have been observed, ranging from 8.5% to 16%.6,10,25
Perhaps even more striking, our study observed a significantly higher rate of clinical depression in patients with AIDS than did these previous studies of cancer patients, despite the lower frequency of elevated desire for hastened death. We found 27% of our sample to meet criteria for a major depressive disorder, as compared with 12%–17% of cancer patients in previous studies.6,10 However, the magnitude of association between a clinical diagnosis of depression and desire for hastened death was substantially stronger in our sample of patients with AIDS than was found in studies of cancer patients. We found that around 80% of patients with high desire for hastened death met criteria for a diagnosis of major depression, versus 47%–58% in studies of cancer patients.
The lower rate of desire for hastened death found in our sample of patients with advanced AIDS, as compared with previous studies of terminally ill cancer patients, may reflect a number of differences in both the populations and the methods. First, the cancer patients studied by other researchers were clearly terminally ill, typically having a life expectancy of less than 3 months. On the other hand, our sample of patients with advanced AIDS were quite ill, having been admitted to a palliative-care facility for patients with AIDS, but were not necessarily imminently dying (i.e., they had a more uncertain and potentially longer life expectancy). There are also noteworthy differences between the population of patients diagnosed with cancer and AIDS, including a greater proportion of ethnic minority patients, lower socioeconomic status, lower levels of education, and younger age in our sample. Many of these variables have been associated with desire for hastened death and interest in assisted suicide in past research. For example, ethnic minority patients, poorer, and less educated patients are less likely to support legalization of PAS and are less likely to utilize death-hastening interventions.1
Despite differences in rates of depression and desire for hastened death, the powerful relationships between depression, hopelessness, and desire for hastened death mirror the results of our previous research with terminally ill cancer patients. Although a handful of studies have questioned the importance of depression in driving patients’ desire for hastened death, suggesting that hopelessness overshadows the role of depression, our data offer a different perspective.26,27 As in our previous study of terminally ill cancer patients, we found a unique role for both depression and hopelessness in predicting desire for hastened death among patients with AIDS (Figure 2), although hopelessness did appear slightly more powerful in some analyses. This finding, that both depression and hopelessness provide a unique contribution to understanding desire for hastened death, may reflect the relatively stronger methodology utilized in the present study, as we applied two state-of-the-art measures of desire for hastened death, structured clinical interviews for diagnosing major depression, and reliable and valid measures of depressive symptom severity and hopelessness.
Interpretation of other correlates of desire for hastened death, which were not significant in our multivariate model, is somewhat less straightforward. One plausible explanation is that depression and hopelessness mediate the relationships between variables such as social support, physical symptom distress, and physical functioning. Although the impact of physical symptom distress, pain, and social support on depression has been well established, these variables do not appear to directly affect desire for hastened death once mediating variables such as depression and hopelessness have been considered. Alternatively, these mediating relationships may be more pronounced in patients with AIDS, whereas studies of cancer patients have often found an independent contribution for physical-symptom variables.6,10,11 Likewise, we found no associations between gender or transmission risk factor and desire for hastened death. Although the former may have been affected by the relatively modest number of women sampled, we cannot exclude the possibility that these results reflect unique characteristics of the HIV-infected population. Further research to understand the nature of these interrelationships and different patterns of associations among different populations is necessary in order to better understand the mechanisms by which depression and hopelessness affect the desire for hastened death.
Understanding the relationship between depression and hopelessness is also clearly complex. Although hopelessness is often considered as simply a symptom of depression, researchers have increasingly identified this construct as an important and distinct phenomenon. Moreover, the construct of hopelessness may be quite different in patients with a terminal illness, as compared with physically healthy-but-depressed samples upon which the construct (and the measure, the Beck Hopelessness Scale) was initially developed.28 Our research demonstrates that although these variables are clearly related, they are also distinct, as demonstrated by the unique and non-overlapping contributions of each variable to the prediction of desire for hastened death.
Despite the importance of these findings, associations between hopelessness, depression, and desire for hastened death shed little light on the appropriateness of assisted-suicide policies. Although much of the impetus behind studying desire for hastened death was driven by the emergence of the assisted-suicide debate, these findings do not address the "rationality" of desire for hastened death when it occurs. Moreover, arguments against legalized assisted suicide are often premised, at least in part, on the assumption that depression and hopelessness are treatable, even among patients with advanced medical illness. Whether this assumption is true, however, cannot be determined from these data. Likewise, although it is certainly possible that severe depression can compromise decision-making ability so profoundly as to render an individual incompetent to make treatment decisions, the diagnosis of depression does not necessarily correspond to impaired decision-making. Further research is clearly necessary to determine the link between depression and hopelessness and legal policies surrounding assisted suicide.
Finally, despite our finding that desire for hastened death is relatively infrequent in patients with advanced AIDS, identifying those patients with a high desire for hastened death is critical. Identification of such individuals provides an opportunity for palliative care and for AIDS practitioners to intervene with medical and mental health treatment, addressing those factors that might drive depression and hopelessness, as well as addressing these psychological symptoms directly. Clinical interventions designed to address end-of-life despair may have an important impact on subsequent requests for euthanasia and assisted suicide, and have the potential to dramatically improve psychological well-being in the face of life-threatening illness.
|
ACKNOWLEDGMENTS
|
We express our appreciation to a number of individuals who helped facilitate this research, including Monique Kaim, Ph.D., Patty Cafferty, R.N., and the hundreds of patients with advanced AIDS who gave their time and insights into the conduct of this study.
This research was supported by a grant from the National Institute of Mental Health (R01-MH 57629; W. Breitbart, P.I.). Dr. Breitbart was also supported by the Soros Foundation, Project on Death in America Faculty Scholars Program. These funding sources had no involvement in the conduct and interpretation of this study, although the comments of several anonymous reviewers were integrated into the initial study design. There are no known conflicts of interest related to this research for any of the study authors.
|
REFERENCES
|
- Rosenfeld B: Assisted Suicide and The Right to Die: The Interface of Social Science, Public Policy, and Medical Ethics. Washington, DC, American Psychological Association Press, 2004
- Griffiths J, Bood A, Weyers H: Euthanasia and Law in The Netherlands. Amsterdam, The Netherlands, Amsterdam University Press, 1998
- Foley K, Hendin H: The Case Against Assisted Suicide. Baltimore, MD, The Johns Hopkins University Press, 2002
- Quill TE, Cassel CK, Meier DE: Care of the hopelessly ill: proposed clinical criteria for physician-assisted suicide. N Engl J Med 1993; 327:1380–1384
- Oregon Health Division, 4th Annual Report on Oregon’s Death With Dignity Act. Portland, OR, Oregon Health Division, 2002
- Chochinov HMC, Wilson KG, Enns M, et al: Desire for death in the terminally ill. Am J Psychiatry 1995; 152:1185–1191[Abstract/Free Full Text]
- Rosenfeld B, Breitbart W, Stein K, et al: Measuring desire for death among the medically ill: The Schedule of Attitudes toward Hastened Death. Am J Psychiatry 1999; 156:94–100[Abstract/Free Full Text]
- Rosenfeld B, Breitbart W, Galietta M, et al: The Schedule of Attitudes toward Hastened Death: measuring desire for death in terminally ill cancer patients. Cancer 2000; 88:2868–2875[CrossRef][Medline]
- Rabkin JG, Wagner GJ, Del Bene M: Resilience and distress among amyotrophic lateral sclerosis patients and caregivers. Psychosom Med 2000; 62:271–279[Abstract/Free Full Text]
- Breitbart W, Rosenfeld B, Pessin H, et al: Depression, hopelessness, and desire for death in terminally ill cancer patients. JAMA 2000; 284:2907–2911[Abstract/Free Full Text]
- Wilson KG, Scott JF, Graham ID, et al: Attitudes of terminally ill patients toward euthanasia and physician-assisted suicide. Arch Intern Med 2000; 160:2454–2460[Abstract/Free Full Text]
- Breitbart W, Rosenfeld B, Passik SD: Interest in physician-assisted suicide among ambulatory HIV-infected patients. Am J Psychiatry 1996; 153:238–242[Abstract/Free Full Text]
- Folstein MF, Folstein SE, McHugh PR: "Mini-Mental State:" a practical method of grading the cognitive state of patients for the clinician. J Psychiatric Res 1975; 75:189–198
- First MB, Spitzer RL, Gibbon M, et al: Structured Clinical Interview for DSM-IV-TR Axis I Disorders. New York, Biometrics Research, New York State Psychiatric Institute, 2001
- Hamilton M: A rating scale for depression. J Neurol Neurosurg Psychiatry 1960; 23:56–61[Free Full Text]
- Beck AT, Weissman A, Lester D, et al: The measurement of pessimism: The Beck Hopelessness Scale. J Consult Clin Psychol 1974; 42:861–865[CrossRef][Medline]
- Broadhead WE, Gehlbach SH, De Gruy FV, et al: The Duke-UNC Functional Social Support Questionnaire: measurement of social support in family-medicine patients. Med Care 1988; 26:709–723[Medline]
- Brady MJ, Peterman AH, Fitchett G, et al: A case for including spirituality in quality-of-life measurement in oncology. Psycho-oncology 2000; 8:417–428[CrossRef]
- Cleeland CS: Measurement of pain by subjective report, in Issues of Pain Measurement, Vol. 12 (Advances in Pain Research and Therapy). Edited by Chapman CR, Loeser JD. New York, Raven, 1989, pp 391-403
- Portenoy R, Thaler HT, Kornblith AB, et al: The Memorial Symptom Assessment Scale: an instrument for evaluation of symptom prevalence, characteristics, and distress. Eur J Cancer 1994; 30A:1326-1336
- Karnofsky DA, Burchenal JH: The clinical evaluation of chemotherapeutic agents in cancer, in Evaluation of Chemotherapeutic Agents. Edited by MacLeod CM. New York, Columbia University Press, 1949, pp 191-205
- Cohen SR, Mount BF, Strobel MG, et al: The McGill Quality-of-Life Questionnaire: a measure of quality of life appropriate for people with advanced disease. Palliat Med 1975; 9:207–219
- Shrout PE, Fleiss JL: Intraclass correlations: uses in assessing rater reliability. Psychol Bull 1979; 86:420–428[CrossRef][Medline]
- Cohen J: Coefficient of agreement for nominal scales. Ed Psychol Meas 1960; 20:37–46[CrossRef]
- Emanuel EJ, Fairclough DL, Emanuel LL: Attitudes and desires related to euthanasia and physician-assisted suicide among terminally ill patients and their caregivers. JAMA 2000; 284:2460–2468[Abstract/Free Full Text]
- Chochinov HM, Wilson KG, Enns M, et al: Depression, hopelessness, and suicidal ideation in the terminally ill. Psychosomatics 1998; 39:366–370[Abstract/Free Full Text]
- Ganzini L, Johnston W, McFarland BH, et al: Attitudes of patients with amyotrophic lateral sclerosis and their caregivers toward assisted suicide. N Engl J Med 1998; 339:967–973[Abstract/Free Full Text]
- Rosenfeld B, Gibson C, Kramer M, et al: Hopelessness and terminal illness: the construct of hopelessness in patients with advanced AIDS. Palliative and Supportive Care 2004; 2:43–53
This article has been cited by other articles:
|
|
|
|
 
L. Ganzini, E. R. Goy, and S. K. Dobscha
Oregonians' Reasons for Requesting Physician Aid in Dying
Arch Intern Med,
March 9, 2009;
169(5):
489 - 492.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
L. Ganzini, E. R Goy, and S. K Dobscha
Prevalence of depression and anxiety in patients requesting physicians' aid in dying: cross sectional survey
BMJ,
October 7, 2008;
337(oct07_2):
a1682 - a1682.
[Abstract]
[Full Text]
[PDF]
|
|
|
Get information about faster international access.
Privacy Policy
Copyright © 2006
Academy of Psychosomatic Medicine.
All rights reserved.
Home
| Search
| Current Issue
| Past Issues
| Subscribe
| All APPI Journals
| Help
| Contact Us
|
TOP
ABSTRACT
INTRODUCTION
