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Modules:

  • Introduction
  • 1. Advance Care Planning
  • 2. Communicating Bad News
  • 3. Whole Patient Assessment
  • 4. Pain Management
  • 5. Assisted Suicide Debate
  • 6. Anxiety, Delirium
  • 7. Goals of Care
  • 8. Sudden Illness
  • 9. Medical Futility
  • 10. Common Symptoms
  • 11. Withholding Treatment
  • 12. Last Hours of Living
  • 13. Cultural Issues
  • 14. Religion, Spirituality
  • 15. Legal Issues
  • 16. Social and Psychological
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    Back to Module 5: Physician-Assisted Suicide Debate
    A Six Step Protocol

    Step 2: Determine the Root causes Step 3: Affirm Your Commitment to Care for the Patient

    Step 2: Determine the Root Causes

    Assessing the Underlying Causes of a Request for Physician-Assisted Suicide: A Brief Overview

    • A request for PAS may indicate a failure to address the full scope of a patient’s needs
    • Focus on all 4 dimensions of suffering:
      • Physical
      • Psychological
      • Social
      • Spiritual suffering
      • As well as practical concerns
    • Among all the psychological and physical possibilities, give particular consideration to the possibility of clinical depression or anxiety as research indicates correlation between requests and their presence
    • When evaluating psychological and social issues, explore the patient’s fears about his or her future

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    Assess for Clinical Depression

    • Clinical depression:
      • Occurs frequently
      • Is both under-diagnosed and under-treated
      • Can be a source of intense mental suffering
      • Can be a barrier to completing life closure and achieving a "good death"
    • Diagnosis of depression is challenging in patients with advanced illness
      • The physical symptoms typically associated with depression (e.g., changes in appetite, weight, energy level, libido, or sleeping) frequently occur in these patients as a result of their illness

      • Studies have shown that the screening question, "Do you feel depressed most of the time?" is highly sensitive and specific in the medically ill

      • Also be alert to feelings of pervasive helplessness, hopelessness, and worthlessness. These feelings are not normal. Do not assume they are situational and leave them unattended (see Module 6: Anxiety, Delirium, Depression)
    • Treatment choices depend on time available
      • Fast-acting psychostimulants

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    Psychosocial Suffering, Practical Concerns

    • Emotional and coping responses to life-threatening illness may include:
      • A strong sense of shame
      • Feelings of not being wanted
      • Inability to cope
    • Adjustment to the losses that occur with advanced illness may be difficult:
      • Loss of previous function
      • Loss of independence
      • Loss of control
      • Loss of self-image
    • Each change may lead to tensions within relationships that further increase isolation and misery
    • Worries about practical matters can create considerable distress
      • Who caregivers will be
      • How domestic chores will be tended to
      • Who will care for dependents, pets
    • If support is not forthcoming or is insufficient, suffering may ensue or increase

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    Physical Suffering

    • A host of physical issues may accompany advanced illness, including:
    • Their presence, particularly if they are unmanaged for long periods, may markedly increase suffering

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    Spiritual Suffering

    • The prospect of dying may evoke seemingly unresolvable existential concerns that are then experienced as suffering
    • As illness advances and disability increases, the patients may come to question their sense of:
      • Meaning
      • Value
      • Purpose in life
    • Patients may experience a sense of abandonment or punishment by God, which can result in:
      • Erosion of faith and religious beliefs
      • Anger

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    Common Fears

    • In addition to current concerns, many patients are fearful about what the future will be like
    • They may worry about issues such as:
      • Pain and other symptoms
      • Loss of control or independence
      • Abandonment
      • Loneliness
      • Indignity
      • Loss of self-image
      • Being a burden to others
    • While their thoughts may be unrealistic in the setting of quality care, understand that many have witnessed suboptimal care in others that fuels their fears and fantasies
    • Direct questions may be adequate to assess a patient’s fears
      • When personal values and goals of care are being discussed, clarify the things the person most wants to avoid

      • This may help to preempt unrealistic fears
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