[Older people who are 'weary of life': their expectations for the future and perceived hopelessness]. / Ouderen die 'klaar met leven' zijn: Toekomstverwachtingen en ervaren uitzichtloosheid.

There has been a debate for over a decade in The Netherlands about whether physicians should be allowed to provide assistance with suicide to older people who are 'weary of life'. Actual knowledge about these older people is missing in this debate. The purpose of this article is to explore and discuss the expectations older people who are 'weary of life' have of their future, and to what extent they perceive their suffering as hopeless. In this qualitative study, 31 older people who were 'weary of life' were interviewed. The results of this study show that most respondents who were 'weary of life' did not plan to end their life within a short time frame. The burden to their loved ones played a large role in their decision in addition to the awareness of still having reasons to live. Most respondents tried not to think too much about the future, and hoped death would come soon. Most respondents could not name a condition that would diminish their wish to die, that they also found desirable and feasible. The results of this study suggest that people who develop thoughts about death do so when they give up finding solutions to improve their situation.

Understanding why older people develop a wish to die: a qualitative interview study.

BACKGROUND: Quantitative studies in several European countries showed that 10-20% of older people have or have had a wish to die. AIMS: To improve our understanding of why some older people develop a wish to die. METHODS: In-depth interviews with people with a wish to die (n = 31) were carried out. Through open coding and inductive analysis, we developed a conceptual framework to describe the development of death wishes. Respondents were selected from two cohort studies. RESULTS: The wish to die had either been triggered suddenly after traumatic life events or had developed gradually after a life full of adversity, as a consequence of aging or illness, or after recurring depression. The respondents were in a situation they considered unacceptable, yet they felt they had no control to change their situation and thus progressively "gave up" trying. Recurring themes included being widowed, feeling lonely, being a victim, being dependent, and wanting to be useful. Developing thoughts about death as a positive thing or a release from problems seemed to them like a way to reclaim control. CONCLUSIONS: People who wish to die originally develop thoughts about death as a positive solution to life events or to an adverse situation, and eventually reach a balance of the wish to live and to die.

Wishes to die in older people: a quantitative study of prevalence and associated factors.

BACKGROUND: Death thoughts and wishes occur frequently among older people. In different European countries estimates of 10%-20% have been found. AIMS: To determine the prevalence and associated factors of death thoughts and wishes among older people in The Netherlands. METHODS: In The Netherlands 1794 people (58-98 years) were interviewed in 2005/2006 (Longitudinal Aging Study Amsterdam). RESULTS: 81.3% reported never having death thoughts/wishes; 15.3% reported having had such thoughts/wishes; 3.4% reported currently having a wish to die and/or a weakened wish to continue living. Of those with a current wish to die, 67% had depressive symptoms (vs. 32% of people with death thoughts/wishes ever and 9% of people who never had had death thoughts/wishes), and 20% suffered from a depressive disorder (vs. 5% if death thoughts/wishes ever; 0.3% if never death thoughts/wishes). In a multivariate analysis, a current wish to die was associated with having depressive symptoms, a depressive disorder, lower perceived mastery, financial problems, loneliness, small network, involuntary urine loss, being divorced, and having a speech impediment. CONCLUSIONS: Practical implications for health-care professionals are that they should be aware that in certain situations older people are more likely to develop a wish to die, and that a wish to die does not necessarily mean that someone has a depressive disorder. Nevertheless, it should serve as a trigger to investigate and to treat depression if present.

Physicians' labelling of end-of-life practices: a hypothetical case study.

OBJECTIVES: To investigate why physicians label end-of-life acts as either 'euthanasia/ending of life' or 'alleviation of symptoms/palliative or terminal sedation', and to study the association of such labelling with intended reporting of these acts. METHODS: Questionnaires were sent to a random, stratified sample of 2100 Dutch physicians (response: 55%). They were asked to label six hypothetical end-of-life cases: three 'standard' cases and three cases randomly selected (out of 47), that varied according to (1) type of medication, (2) physician's intention, (3) type of patient request, (4) patient's life expectancy and (5) time until death. We identified the extent to which characteristics of cases are associated with physician's labelling, with multilevel multivariable logistic regression. RESULTS: The characteristics that contributed most to labelling cases as 'euthanasia/ending of life' were the administration of muscle relaxants (99% of these cases were labelled as 'euthanasia/ending of life') or disproportional morphine (63% of these cases were labelled accordingly). Other important factors were an intention to hasten death (54%) and a life expectancy of several months (46%). Physicians were much more willing to report cases labelled as 'euthanasia' (87%) or 'ending of life' (56%) than other cases. CONCLUSIONS: Similar cases are not uniformly labelled. However, a physicians' label is strongly associated with their willingness to report their acts. Differences in how physicians label similar acts impede complete societal control. Further education and debate could enhance the level of agreement about what is physician-assisted dying, and thus should be reported, and what not.

Concept of unbearable suffering in context of ungranted requests for euthanasia: qualitative interviews with patients and physicians.

OBJECTIVE: To obtain in-depth information about the views of patients and physicians on suffering in patients who requested euthanasia in whom the request was not granted or granted but not performed. Design In-depth interviews with a topic list. Setting Patients' homes and physicians' offices. Participants 10 patients who explicitly requested euthanasia but whose request was not granted or performed and eight physicians of these patients; and eight physicians of patients who had requested euthanasia but had died before the request had been granted or performed or had died after the request was refused by the physician or after the patient had withdrawn his or her request. Results Not all patients who requested euthanasia thought their suffering was unbearable, although they had a lasting wish to die. Patients and physicians seemed to agree about this. In cases in which patients said they suffered unbearably there was less agreement about what constitutes unbearable suffering; patients put more emphasis on psychosocial suffering, such as dependence and deterioration, whereas physicians referred more often to physical suffering. In some cases the physician thought that the suffering was not unbearable because the patient's behaviour seemed incompatible with unbearable suffering-for instance, because the patient was still reading books. Conclusions Patients do not always think that their suffering is unbearable, even if they have a lasting wish to die. Physicians seem to have a narrower perspective on unbearable suffering than patients and than case law suggests. In an attempt to solve the problem of different perspectives, physicians should take into account the different aspects of suffering as described in the literature and a framework for assessing the suffering of patients who ask for euthanasia.

[Trends in the agents used for euthanasia and the relationship with the number of notifications]. / Trends in gebruikte middelen bij euthanasie en samenhang met het aantal meldingen.

OBJECTIVE: To provide insight into the relationship between the drugs used for euthanasia and its notification. DESIGN: Retrospective and descriptive. METHODS: By comparing the drugs used for euthanasia according to different components of studies carried out in 1990, 1995 and 2000, insight was obtained into the drugs used in all cases of euthanasia satisfying the definition thereof (death-certificate studies), those cases of euthanasia that, in addition, were defined as such by the physician (physician interviews), and the cases of euthanasia that, in addition, had been reported (reported case studies). RESULTS: In 2001, standard drugs for euthanasia were used in 76% of cases and opioids in 23%. Euthanasia with standard drugs was reported in 73% of cases in 1995, and in 71% of cases in 2000, while euthanasia with opioids was reported in 2% and 1% of cases, respectively. The total percentage of euthanasia reported was higher in 2001 than in 1995 (54% versus 44%), since in 2001 euthanasia was apparently performed more often with standard drugs and less with opioids. CONCLUSION: An increasing proportion of cases of euthanasia is being carried out with the drugs recommended for this purpose. Euthanasia with opioids was rarely reported. Possibly, physicians did not always consider these cases to be euthanasia.

[The role of the physician in requests for physician-assisted suicide in patients who are 'suffering from life': the Dijkhuis Report commissioned by the Royal Dutch Medical Association]. / De rol van de arts bij verzoeken om hulp bij levensbeëindiging van patiënten die 'lijden aan het leven'; het rapport van de commissie-Dijkhuis van de KNMG.

In the Brongersma case, physician-assisted suicide was carried out in an 86-year-old man who was tired of life. The Dutch Supreme Court ruled that physician-assisted suicide may not be carried out if the suffering of the patient is not mainly determined by a medically classifiable disease. The Royal Dutch Medical Association set up a commission headed by J.Dijkhuis to advise them on determining their position in similar cases. This commission proposed a broader medical domain than had been determined by the Supreme Court. The commission was of the opinion that each physician should be able to manage requests for physician-assisted suicide from patients who are 'suffering from life' in terms of treatment that could influence the situation of the patient or his or her experience of it. If the patient continues to request physician-assisted suicide in spite of this, physicians are free to set their own individual limits which may be stricter than those set by the medical profession nationally. It is necessary to acquire scientifically underpinned knowledge of how to manage requests from patients who are 'suffering from life'.