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PURPOSE Voluntary stopping of eating and drinking (VSED) is a controversial method to hasten death. Little is known about why and how people come to VSED. This study assessed patients' motives, how patients decide on VSED, and the ways in which they prepare for VSED and involve others. METHODS We conducted a qualitative study in the Netherlands of 29 patients; 24 started VSED and 19 died. Thirteen patients were included before or during VSED and 16 afterward. We interviewed 17 patients, 18 relatives, and 10 professional caregivers. Inductive ideal-type analysis was used to describe typologies. RESULTS Three patient groups emerged. The first group (12 patients) were older people who felt life was completed, for whom control was important. They prepared well for VSED, but could overlook the need for help and the emotional burden their decision could place on relatives. The second group (11 patients) were older care-dependent patients with a poor quality of life. They sometimes started VSED suddenly, and they relied heavily on (informal) caregivers to prepare and execute their plan. The third group (6 patients) were psychiatric patients with a long-standing but fluctuating death wish, most of whom were younger. They often prepared for VSED in secrecy or started VSED unprepared. CONCLUSIONS Patients embarking on a trajectory toward VSED are a very diverse group, with different care needs. Guidance for care during VSED needs to be applicable to all 3 groups. Key words: voluntarily stopping eating and drinking; VSED; palliative care; pain; suffering; death; aged; aged, 80 and over; elderly; geriatrics; psychiatric illness; end of life; physician-assisted suicide; euthanasia; ethics; primary care, INTRODUCTION Physicians around the world are confronted with patients who want to hasten death by voluntary stopping of eating and drinking (VSED). Studies showed that 46% of Dutch general practitioners [...]

This article discusses the concepts of euthanasia, assisted suicide and physician-assisted suicide, under the umbrella term of assisted dying, from a pro-assisted dying perspective. It outlines the key principles underpinning [...]

A TWO-CULTURE PROBLEM BY THE TIME SCIENTIST AND NOVELIST C. P. SNOW GAVE HIS FAMOUS 1959 Rede Lecture, The Two Cultures (Snow 2007 [1959]) memories of the Platonic Academy, the [...]

Living and dying are inextricably associated in nursing homes. It is not unusual for old nursing home residents to express a wish to die. This article examines interwoven patterns of family responses to resident's wish to die. As part of a multi-site ethnographic study of bereavement in long-term care, we analyzed themes in audio-transcribed in-depth qualitative interviews with 20 family members in two religiously and culturally diverse nursing homes. Rooted in the contexts of the nursing home, the family system, and the socio-cultural milieu, three patterns of family responses emerged: avoidance, disconfirmation, and acceptance of the wish to die. The family members' responses reflect their efforts to make meaning of the resident's wish both for the resident and for themselves. Rather than viewing the wish to die as a symptom of mental health problems, they perceive it as reflecting the existential situation of the resident.

The beginnings and ends of life must be defined for social reasons. Scientific methods, rather than social cultural or religious means, will help determine the lines between life and death.

This article provides an overview of the major mental health issues involved in the debate over rational suicide and other forms of hastened death. In doing so, it covers the arguments for including counseling psychologists and other mental health professionals in discussions about hastened death; highlights the relevant empirical research associated with the topic, with special attention given to the studies involving psychologists and areas needing more investigation; and reviews the implications for practice and training and provides direction for those counseling psychologists who are working with persons who may be rational in their decisions to hasten death.

Client self-determination is the key element of NASW's policy statement about social work intervention in end-of-life decisions. However, both self-determination and the common good must be respected in social work practice and policy regarding end-of-life decisions. This article discusses self-determination in end-of-life decision making, ethical decision making and the NASW Code of Ethics, and professional ethics based on a balanced view of both self-determination and the common good. Recommendations for professional practice and social policy are offered. Key words code of ethics common good end-of-life decisions ethics self-determination, Social workers frequently find themselves counseling patients and families regarding end-of-life decisions. The policy statement of the NASW Delegate Assembly states, 'End-of-life decisions are the choices made by a person [...]

Greater physician contact with seriously ill patients does not appear to improve the quality of care these patients receive during their final days. A two-part trial involved observations of the treatment of seriously ill patients by their doctors, followed by a second phase in which another group of doctors was given more information about the likelihood of survival of their patients. In the second phase, a specially trained nurse communicated with patient, family and physician in order to ensure that the patients' wishes about resuscitation and certain types of life support were known in advance. In the first phase, only 47% of doctors were aware of their patients desire to avoid CPR, and 46% of do-not-resuscitate orders were written within two days of the patient's death. Patients spent an average of 10 days in intensive care, and for half of those that were conscious during their final days, family members said they were in at least moderate pain. None of the outcomes improved in the second phase, suggesting that broader, societal changes will need to take place before physicians recognize the need to improve their care of the seriously ill., Objectives. - To improve end-of-life decision making and reduce the frequency of a mechanically supported, painful, and prolonged process of dying. Design. - A 2-year prospective observational study (phase I) with 4301 patients followed by a 2-year controlled clinical trial (phase II) with 4804 patients and their physicians randomized by specialty group to the intervention group (n=2652) or control group (n=2152). Setting. - Five teaching hospitals in the United States. Patients. - A total of 9105 adults hospitalized with one or more of nine life-threatening diagnoses; an overall 6-month mortality rate of 47%. Intervention. - Physicians in the intervention group received estimates of the likelihood of 6-month survival for every day up to 6 months, outcomes of cardiopulmonary resuscitation (CPR), and functional disability at 2 months. A specially trained nurse had multiple contacts with the patient, family, physician, and hospital staff to elicit preferences, improve understanding of outcomes, encourage attention to pain control, and facilitate advance care planning and patient-physician communication. Results. - The phase I observation documented shortcomings in communication, frequency of aggressive treatment, and the characteristics of hospital death: only 47% of physicians knew when their patients preferred to avoid CPR; 46% of do-not-resuscitate (DNR) orders were written within 2 days of death; 38% of patients who died spent at least 10 days in an intensive care unit (ICU); and for 50% of conscious patients who died in the hospital, family members reported moderate to severe pain at least half the time. During the phase II intervention, patients experienced no improvement in patient-physician communication (eg, 37% of control patients and 40% of intervention patients discussed CPR preferences) or in the five targeted outcomes, ie, incidence or timing of written DNR orders (adjusted ratio, 1.02; 95% confidence interval [CI], 0.90 to 1.15), physicians' knowledge of their patients' preferences not to be resuscitated (adjusted ratio, 1.22; 95% CI, 0.99 to 1.49), number of days spent in an ICU, receiving mechanical ventilation, or comatose before death (adjusted ratio, 0.97; 95% CI, 0.87 to 1.07), or level of reported pain (adjusted ratio, 1.15; 95% CI, 1.00 to 1.33). The intervention also did not reduce use of hospital resources (adjusted ratio, 1.05; 95% CI, 0.99 to 1.12). Conclusions. - The phase I observation of SUPPORT confirmed substantial shortcomings in care for seriously ill hospitalized adults. The phase II intervention failed to improve care or patient outcomes. Enhancing opportunities for more patient-physician communication, although advocated as the major method for improving patient outcomes, may be inadequate to change established practices. To improve the experience of seriously ill and dying patients, greater individual and societal commitment and more proactive and forceful measures may be needed. (JAMA. 1995;274:1591-1598)

Ethical dilemmas are inherent in health care decision making. The Patient Self-Determination Act of 1990 provides health care facilities with guidelines to address patients' advance directives. Family members who are charged with the responsibility to implement their loved ones' wishes often feel emotional conflicts because of the many difficulties that arise from making life and death decisions for another person. The PRACTICE model discussed in this article allows health care practitioners to think about ethical issues in a structured and systematic way. Social workers have a vital role to play in facilitating the implementation of patients' advance directives by working with the patient in creating clear and accurate directives, by supporting the family in allowing these directives to be carried out, and by working with the treatment team to resolve ethical dilemmas., As health care professionals, social workers advocate for comprehensive and thorough care for all patients. What should we do when the patient refuses treatment? when the patient wants less than [...]

The movement to institutionalize a patient's right to die gained ground following the New Jersey Supreme Court's decision on the Karen Quinlan case. The ethics of the different varieties of passive and active euthanasia are discussed., Anyone who followed the daily news in the mid-1970s probably recalls the Karen Quinlan case. As the result of ingesting a potent combination of alcohol and barbiturates, 21-year-old Karen lapsed [...]

Death is a theme of central importance in all cultures, but the manner in which it is interpreted varies from society to society. Even so, traditional cultures, including Christian, Hindu and Jain religious traditions, exhibited a positive attitude to death and did not look upon it in a dualistic framework of good vs bad, or desirable vs undesirable. Nor was pessimism the dominant mood in their thinking about death itself. A fundamental paradigm shift occurred in the West in the eighteenth century when death was desacralized and transformed into a secular event amenable to human manipulation. From those early beginnings, dying and death have been thoroughly medicalized and brought under the purview of high technology in the twentieth century. Once death is seen as a problem for professional management, the hospital displaces the home, and specialists with different kinds and degrees of expertise take over from the family. Everyday speech and the religious idiom yield place to medical jargon. The subject (an ageing, sick or dying person) becomes the object of this make-believe yet real world. As the object of others' professional control, he or she loses the freedom of self-assessment, expression and choice. Or, he or she may be expected to choose when no longer able to do so. Thus, not only freedom but dignity also is lost, and lawyers join doctors in crisis manipulation and perpetuation. Although the modern medical culture has originated in the West, it has gradually spread to all parts of the world, subjugating other kinds of medical knowledge and other attitudes to dying and death. This is regrettable because traditional cultures may provide alternative perspectives, which, if taken seriously, may help correct some of the excesses of modern attitudes, introduce a measure of humaneness to the practice of medicine and surgery, and restore some freedom and dignity to the old, the sick and the dying. The argument is not in support of religious revivalism, but in favour of the values of cultural and individual autonomy and familial responsibility, combined in one holistic paradigm in which death, considered a normal aspect of living, is encompassed by life, and thus not its simple opposite. Prolongation of life, even when technically feasible, may fail to provide an acceptable level of quality of life and, therefore, of dignity.