NEW YORK, December 13, 2000 — Understanding why a terminally-ill patient wishes to die has become a focus for improving end of life care as well as a crucial part of the physician-assisted suicide debate. In identifying the factors that contribute to a patient's desire for hastened death, the psychological factors of depression and hopelessness have been discovered to be as important, if not more important, than physical pain in influencing a patient's wish to die. The study of 92 terminally ill cancer patients by William S. Breitbart, MD and colleagues at Memorial Sloan-Kettering Cancer Center and Calvary Hospital was reported today in the Journal of the American Medical Association.
"If a terminally ill cancer patient meets the criteria for a clinical diagnosis of depression, or scores highly on a measure of hopelessness, this is highly predictive of a desire for hastened death," said Dr. Breitbart, the study's first author and chief of psychiatry at Memorial Sloan-Kettering Cancer Center. "If patients have clinical depression as well as hopelessness, the likelihood of desire for hastened death increases dramatically. There was not one patient in the study who wished to die that did not fall into the 'clinically depressed/high hopelessness' group."
Past studies have been divided on what exactly influences the desire for a hastened death in the terminally ill. Some research showed depression to be the key, while other work pointed to hopelessness as the predominant factor. Using the 20-question Schedule of Attitudes Toward Hastened Death (a new assessment tool developed by Dr. Breitbart and colleagues), this study of terminally ill patients found that both hopelessness and depression were linked to the desire for hastened death. This was true both independently of each other in unique fashion, as well as synergistically.
"It is important to remember that most terminally ill cancer patients are not depressed, are not hopeless, and do not want to die sooner than necessary," said Dr. Breitbart. Of the 92 patients surveyed for the study at Calvary Hospital, a hospital and hospice center located in the Bronx, less than 30 percent were clinically depressed and 20 percent were categorized as hopeless. Of the entire sample, only 17 percent expressed a high desire for hastened death. One implication of the group's findings is that if patients at a state-of-the-art facility like Calvary suffer from depression and hopelessness, then patients at facilities that do not have trained psychologists or psychiatrists on staff may suffer from these mental burdens even more.
"Terminally ill cancer patients may receive comprehensive physical care including pain management during a hospitalization, but clinicians rarely address patients' psychological needs in adequate ways, a crucial step in minimizing their desire for death ", said Dr. Breitbart. "We have demonstrated the need to include psychiatric and psychosocial services as an essential part of end-of-life and palliative care."
The study in JAMA is the result of a pilot project at Calvary Hospital conducted in late 1998 and early 1999. Based on their findings, Dr. Breitbart and colleagues were awarded a four-year, $1.6 million grant from the National Institutes of Health which will be used to study what happens to the desire to die when depressed terminally ill cancer patients are treated with antidepressants.
Memorial Sloan-Kettering Cancer Center is the world's oldest and largest institution devoted to prevention, patient care, research and education in cancer. Our scientists and clinicians generate innovative approaches to better understand, diagnose and treat cancer. Our specialists are leaders in biomedical research and in translating the latest research to advance the standard of cancer care worldwide.
Journal
JAMA