Factors That Influence Consideration of Hastening Death among People with Life-Threatening Illnesses

Policymakers, ethicists, health care professionals, and the courts continue to examine the issue of assisted suicide and whether individuals with life-threatening illnesses should have the legal right to hasten their deaths. The debate began in Oregon where the Death with Dignity Act (Oregon Death with Dignity Act, 1994), which allows physicians to prescribe lethal drugs to patients who request death as long as patients can administer the drugs themselves, was passed. However, the issue of assistance in dying is the focus of legal initiatives in other states, and interest in the issue has grown in recent years. Despite perceptions that consideration of hastening death is uncommon among people at the end of life, this may not be the case. Researchers have documented that requests for assisted suicide are not rare, and in one study, 12 percent of physicians reported that they had received a request for physician-assisted suicide (PAS) in the past year (Back, Wallace, Starks, & Perlman, 1996). Despite the importance of the issue, the debate over whether a right to die exists has excluded an in-depth analysis of why people would want to hasten death. An understanding of the factors that may affect such a decision must be examined as both legislative initiatives in support of PAS and efforts to improve the care of people who are dying continue. Because of the value debates, ethical dilemmas, and emotions associated with this issue, it is of critical importance to dispassionately address this issue from a research perspective. Without empirical data, the risk of policy development based on emotion that excludes the voices of those affected by such legislation is a possibility that must be considered. Despite the strong presence of social work in the care of people at the end of life, little mention of hastening death is made in the social work literature. Social workers have written about death and dying but have only recently begun to examine the impact that patient requests for assistance in dying may have on social work practice. In 1997 NASW issued a policy statement on client self-determination and end-of-life decisions--a first step in the provision of guidelines for social workers who work with clients who may consider hastening death (NASW, 1997). Regardless of whether policies support or restrict the practice of assisted suicide, those who work with terminally ill patients must seek to understand the factors that might contribute to such a request. If social workers and other health care providers can gain an understanding of this complex issue, more appropriate assessments and interventions for care at the end of life can be developed. Although the ethical issues associated with hastening death are of importance to social work practice, this article focuses on the role of unrelieved symptoms or problems (physical or psychosocial issues or conditions that are the direct or indirect result of a life-threatening illness) and their possible effect on the decision-making process of those who may consider hastening death. THE EFFECT OF UNRELIEVED SYMPTOMS AND PROBLEMS The existing literature suggests that both physical and psychosocial issues may contribute to an individual's consideration to hasten his or her death. Researchers have asserted that discussions about hastening death have neglected the role unrelieved symptoms may play in the decision-making process (Coyle, Adelhart, Folery, & Portenoy, 1990). "In the absence of such considerations, and the data necessary to evaluate them, it is possible that physician-assisted suicide and euthanasia will be requested by patients and discussed as a realistic option by clinicians, without the realization that appropriate efforts to manage symptoms and provide support to families may radically alter the issue" (Coyle et al., p. 91). Pain The effect of physical pain on issues related to hastening death has received some attention in the empirical literature. …