Will to Live in the Terminally Ill
Will to Live in the Terminally Ill
abstract & commentary
Synopsis: These findings raise important implications for the ongoing debate regarding the legalization of physician-assisted suicide and pose a challenge to the medical community to pay vigorous attention to symptom control in the care of dying patients.
Source: Chochinov HM, et al. Lancet 1999;354:816-819.
Chochinov and colleagues examined the extent to which will to live may fluctuate among terminally ill cancer patients as death approaches. Of 585 patients admitted to a Palliative Care Unit in Winnipeg, Manitoba, Canada, 168 met enrollment criteria of a MMSE score of 21 or higher and a sufficiently strong physical condition to participate in the study at several points in time. Chochinov et al used the Edmonton System Assessment System, a self-report instrument that consists of a series of visual analogue scales designed to measure the following symptoms among inpatients in a palliative care unit: pain, anxiety, depression, sense of well-being, dyspnea, drowsiness, nausea, activity, and appetite. A will-to-live visual analogue scale was added with "complete will to live" and "no will live to live," respectively reflected as the lowest and highest marks on the scale. Maximum and median differences in will to live were calculated for each individual over consecutive 12-hour, 24-hour, 7-day, and 30-day intervals. Several multiple regression models were constructed to evaluate the relationship between will to live and various common symptoms of distress at 12 hours, 24 hours, 1 week, 2 weeks, 3 weeks, and 4 weeks since entry into the study. The pattern of median changes in will to live over the various time intervals was stable. However, the maximum fluctuation in each individual patient’s will-to-live score showed wide variation even between very short time intervals. Analysis of the multiple regression models revealed that while psychological variables (anxiety, depression) were predictors of will to live at the earlier points in time, as the patients came closer to death physical symptoms (dyspnea) replaced the psychological factors as mediators in the patient’s desire to live.
Comment by Alan Carver, MD
The substantial fluctuations among the individuals in this study suggested to Chochinov et al that will to live among terminally ill cancer patients is highly unstable. While other studies1,2 have demonstrated an association between support for physician-assisted suicide and depression and pain, this is the first investigation of will to live over time in a significant number of terminally ill patients. These findings raise important implications for the ongoing debate regarding the legalization of physician-assisted suicide and pose a challenge to the medical community to pay vigorous attention to symptom control in the care of dying patients. (Dr. Carver is a Pain and Palliative Care Fellow in the Department of Neurology at Memorial Sloan-Kettering Cancer Center.)
References
1. Chochinov HM, et al. Am J Psychiatry 1995;152: 185-191.
2. Foley KM. J Pain Symptom Manage 1991;6:289-297.
Analysis of the multiple regression models revealed that as the patients came closer to death, physical symptoms replaced the psychological factors as mediators in the patient’s desire to live.
a. True
b. False
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