About one of 10 terminally ill patients said they seriously considered using physician-assisted suicide (PAS) or euthanasia to end their own lives, and just a fraction of these attempted to act on their thoughts, according to a study published today in the Journal of the American Medical Association (JAMA). The findings point out that despite the highly charged public debate surrounding PAS and euthanasia, the majority of dying patients would not consider this option for themselves. The study also showed significant instability in patients' attitudes: about half of those who had initially considered euthanasia or PAS had changed their mind in a follow-up interview. The research is the first major assessment of terminally ill patients' attitudes about assisted suicide and euthanasia The study indicates that interest in euthanasia and PAS among dying patients is more often related to psychological distress than physical symptoms. The factors most strongly associated with serious consideration of PAS and euthanasia were depression, feelings of being unappreciated, and substantial needs for help with basic activities such as dressing, eating, homemaking, and transportation. Shortness of breath, not pain, was the physical symptom most closely linked to first thoughts of euthanasia or PAS. "Improving end-of-life care has often been framed as a question of permitting either physician-assisted suicide or euthanasia. But these issues are largely irrelevant and distract us from attending to the real issues of the dying: depression and meeting patients' needs for all kinds of help in their everyday lives," said Ezekiel J. Emanuel, M.D., Ph.D., the lead investigator for the study and chair of the Department of Bioethics at the National Institutes of Health. While three of five dying patients reported support for euthanasia or PAS in a hypothetical situation, 10.5 percent said they seriously considered ending their own lives by euthanasia or PAS. Fewer than 6 percent said they had seriously discussed euthanasia or PAS for themselves or hoarded drugs with the intent of committing suicide. One patient in the study unsuccessfully attempted suicide, and one patient died by euthanasia or PAS. The authors note that patients' personal considerations of euthanasia or PAS appear to be quite unstable. Half of those who had initially considered euthanasia or PAS for themselves changed their minds at a follow-up interview, while an almost equal number of patients who had not considered these measures in the first interview did so in a follow-up interview. Terminally ill patients who began thinking about euthanasia or PAS for themselves at follow-up were significantly more likely to have symptoms of depression and to experience shortness of breath. Yet new thoughts of suicide were not more likely among patients with worsening pain or physical functioning. The authors warn that physicians who receive requests for euthanasia or PAS should recognize their volatility and not take such requests as settled views. When physicians are confronted by a request for euthanasia or PAS, they should attend to the possibility of depression and other psychological stressors. Although numerous studies have examined physicians' views regarding euthanasia and PAS, relatively few have investigated patients' attitudes. In this study, 988 terminally ill adults and their primary caregivers were interviewed twice between March 1996 and March 1997. Patients and caregivers in the study came from five randomly selected urban areas and one rural county: Birmingham, Alabama; Brooklyn, New York; Mesa County, Colorado; St. Louis, Missouri; Tucson, Arizona, and Worcester, Massachusetts. Physician-assisted suicide refers to a patient ending his or her own life with the help of a physician. Euthanasia refers to another person ending a patient's life at the patient's request. The JAMA study is one in a series funded by the Commonwealth Fund and the Nathan Cummings Foundation in an unprecedented effort to expand the nation's understanding of the dying experience and find ways to improve it. The Commonwealth-Cummings Project on the End of Life is directed by Dr. Emanuel and Linda L. Emanuel, M.D., director of the Interdisciplinary Program in Professionalism and Human Rights at Northwestern University Medical School, Chicago. Future Commonwealth-Cummings studies will explore issues such as the impact of managed care on terminally ill patients, pain management among the dying, and the inner life and spirituality of dying patients. The Commonwealth Fund, based in New York, helps Americans live healthy and productive lives. Its national program areas are improving health insurance coverage and access to care and improving the quality of health care services. The Nathan Cummings Foundation, also of New York, is rooted in the Jewish tradition and committed to democratic values, including fairness, diversity, and community. The Foundation works to improve the quality of life at its beginning and at its end by supporting humane, patient-centered care that provides comfort and caring, as well as cure.
