1998

Suicide, euthanasia and AIDS.
Mishara-BL
Crisis. 1998; 19(2): 87-96

This article critically reviews research on suicide, AIDS, and HIV seropositivity. Studies indicate that men with a diagnosis of AIDS or HIV seropositivity have up to 36 times greater risk of suicide than men without the diagnosis. Yet few studies controlled for independent risk factors such as premorbid or comorbid psychiatric syndromes. Also, control groups may not be appropriate, little data are available on women, and explanations of suicidal dynamics are mostly speculative. After a look at the research on the desire for euthanasia and assisted suicide with other illnesses, the author suggests alternative hypotheses concerning suicidality, the desire for euthanasia, and AIDS.


Breaking (through) the law--coming out of the silence: nursing, HIV/AIDS and euthanasia.
Crock-EA
AIDS-Care. 1998 Jun; 10 Suppl 2: S137-45

This paper provides a nursing perspective on ethical, legal, professional and practical issues faced by nurses working in HIV/AIDS care in relation to euthanasia/assisted suicide. Nurses who care for PLWHA (People Living with HIV/AIDS) have been conspicuously silent in the recent debates about euthanasia in Australia. Many factors prevent nurses from openly acknowledging their participation in assisted suicide/euthanasia and contributing to important debates about this topic. Their commitment to client confidentiality and the illegality of the practices are clearly significant factors which inhibit nurses from speaking freely. In addition, however, nurses' well-documented precarious legal position (Johnstone, 1994-alpha) and their subordinate status within the health care system make their public silence almost inevitable. Naming and challenging the factors which contribute to nurses silence, this paper draws on the experiences of nurses who have cared for PLWHA who have requested assistance in dying. It identifies practical, ethical and legal issues and dilemmas which can arise for nurses who may be involved in these practices, highlighting their special skills, relationships with clients, responsibilities and the complexity of their role; it also elucidates, however, the serious professional and personal risks nurses face given the legal and legislative status quo. This paper suggests that nurses may play a central, though covert, role in assisted suicide/euthanasia in HIV/AIDS care, rendering it imperative that their perspectives be included in the debates about the legalization of assisted suicide/euthanasia. Moreover, the paper identifies and challenges some severe impediments nurses must confront and address if they are to be able to contribute fully to this debate and to those which may arise in the future.


End-of-life issues: a survey of English-speaking Canadian nurses in AIDS care
Young-MG; Ogden-RD
J-Assoc-Nurses-AIDS-Care. 1998 Mar-Apr; 9(2): 18-25

This anonymous postal survey explored attitudes and experiences concerning end-of-life decisions. Respondents were English-speaking members of the Canadian Association for Nurses in AIDS Care (CANAC) and other nurses identified as working primarily in HIV/AIDS settings. Seventy-three percent believed that the law should be changed to allow physicians to practice voluntary euthanasia (VE) and assisted suicide (AS). Fifty-three percent indicated that nurses should be allowed to practice VE and AS. Although VE and AS are illegal, fewer than one in five nurses would report a colleague whom they knew to be involved in such acts. More than one in five nurses have received requests from patients to hasten their deaths by VE. Nearly 98% believe that the nursing profession should be involved in policy development concerning VE and AS, and nearly 78% believe that nurses should be involved in the decision-making process with patients if such acts were legal. Given that ethical codes for Canadian nurses promote client self-determination and that nurses are the largest group of care providers for the terminally ill, the profession must promote discussion and research if it is to take a leadership role with respect to end-of-life issues.


Cases of euthanasia and physician assisted suicide among AIDS patients reported to the Public Prosecutor in North Holland.
Onwuteaka-Philipsen-BD; van-der-Wal-G
Public-Health. 1998 Jan; 112(1): 53-6

BACKGROUND: Euthanasia is performed relatively frequently among AIDS patients. OBJECTIVE: To examine the relationship between euthanasia and physician assisted suicide (EAS) and AIDS. METHODS: A descriptive retrospective study in which data was collected from all cases of EAS which were reported to the Public Prosecutor in North Holland between 1984 and 1993. RESULTS: In 7% of the reported cases of EAS the patient had AIDS, and in most of these cases the physician involved was a general practitioner. Both the percentage of AIDS among the cases of EAS and the percentage of EAS among all deaths due to AIDS increased over the years. In 1992, 23% of all deaths due AIDS were reported as cases of EAS. CONCLUSIONS: It seems, in recent years, that EAS has been performed on at least one out of three AIDS patients, which is a far greater percentage than found among other patients.


Suicidal behaviours, euthanasia and AIDS.
Starace-F; Sherr-L
AIDS. 1998 Mar 5; 12(4): 339-4

1997

Physician-assisted suicide and patients with human immunodeficiency virus disease
Slome-LR; Mitchell-TF; Charlebois-E; Benevedes-JM; Abrams-DI
N-Engl-J-Med. 1997 Feb 6; 336(6): 417-21

BACKGROUND:
Data are limited on the attitudes and practices of physicians regarding assisting the suicide of patients with human immunodeficiency virus (HIV) disease.
METHODS:
Between November 1994 and January 1995, we used an anonymous, self-administered questionnaire to survey all 228 physicians in the Community Consortium, an association of providers of health care to patients infected with HIV in the San Francisco Bay area. The responses were compared with those in a 1990 survey of consortium physicians. Physician-assisted suicide was defined as "a physician providing a sufficient dose of narcotics to enable a patient to kill himself." Respondents were to "assume that the patient is a mentally competent, severely ill individual facing imminent death." RESULTS: One hundred eighteen of the questionnaires were evaluated. Respondents reported a mean of 7.9 "direct" and 13.7 "indirect" requests from patients for assistance. In responses based on a case vignette, 48 percent of the physicians said they would be likely or very likely to grant the request of a patient with the acquired immunodeficiency syndrome (AIDS) for assistance in a suicide, as compared with 28 percent of the respondents in 1990. Asked to estimate the number of times they had granted the request of a patient with AIDS for assistance in committing suicide, 53 percent said they had done so at least once (mean number of times, 4.2; median, 1.0; range, 0 to 100). In a multivariate analysis, factors positively associated with having, in fact, assisted a suicide were having had a higher number of patients with AIDS who had died, a higher number of indirect requests from patients for assistance, a stated gay, lesbian, or bisexual orientation on the part of the physician, and a higher "intention to assist" score (as calculated from the physician's responses to the case vignette). CONCLUSIONS:
Within a group of physicians caring for patients with HIV disease, the acceptance of assisted suicide increased between 1990 and 1995. A majority of respondentsin 1995 said they had granted a request for assisted suicide from a patient with AIDS at least once.


Physician-assisted suicide and patients with HIV disease
McKeogh-M
N-Engl-J-Med. 1997 Jul 3; 337(1): 56

1996

Euthanasia and physician-assisted suicide in homosexual men with AIDS
Bindels-PJ; Krol-A; van-Ameijden-E; Mulder-Folkerts-DK; van-den-Hoek-JA; van-Griensven-GP; Coutinho-RA
Lancet. 1996 Feb 24; 347(9000): 499-504

BACKGROUND: In the Netherlands a nationwide study has shown that, in 38% of deaths, there have been medical decisions concerning the end of life (MDEL); 2.1% of all deaths were brought about by euthanasia or physician- assisted suicide (PAS). We investigated the incidence of MDEL in homosexual men with AIDS, suspecting that it might be higher, and studied the effect of euthanasia/PAS on survival time. METHODS: The patients were 131 male homosexual participants in a cohort study in Amsterdam, diagnosed between 1985 and 1992 as having AIDS; all had died before Jan 1, 1995. Clinical and laboratory data and information on mode of death were obtained from their physicians and by review of hospital records. Those who died by euthanasia/PAS or in whom there had been other MDEL were then compared with those who died naturally. FINDINGS: 29 men (22%) had died by euthanasia/PAS and in 17 (13%) another MDEL had been made; thus, more than one-third of these men had made medical decisions concerning the end of life. The greatest difference between the groups was in age at time of diagnosis-72% aged 40 or more in the euthanasia/PAS group compared with 38% in the natural death group. The likelihood (relative risk) of euthanasia/PAS increased with duration of survival after AIDS diagnosis. Comparison of the groups in terms of three laboratory markers (CD4+ and CD8+ cells and phytohaemagglutinin responses) in the two years before death, and estimates of these markers at the time of death, did not indicate any substantial shortening of life by euthanasia/PAS; in the judgment of the physicians, most of these patients would have died naturally within one month. INTERPRETATION: A possible reason for the high incidence of MDEL in this cohort was a good knowledge of the characteristics of AIDS acquired through long-term awareness of HIV infection. The higher rate of euthanasia in those with long survival from AIDS diagnosis could reflect either additional suffering or the greater opportunity to discuss this option with friends and hysicians. Our findings indicate that euthanasia and other MDEL did little to shorten life; rather, they were an extreme form of palliation, applied in the terminal phase of a lethal disease.


Interest in physician-assisted suicide among ambulatory HIV-infected patients
Breitbart-W; Rosenfeld-BD; Passik-SD
Am-J-Psychiatry. 1996 Feb; 153(2): 238-42

OBJECTIVE: This study surveyed HIV-infected patients' attitudes toward physician-assisted suicide and examined the relationship between interest in physician-assisted suicide and physical and psychosocial variables. METHOD: Three hundred seventy-eight ambulatory HIV-infected patients, 90% of whom met the criteria of the Centers for Disease Control for AIDS, were recruited from several sites in New York City. Self-report measures were used to assess pain, physical symptoms, psychological distress, depression, and social supports. Attitudes toward, and interest in, physician-assisted suicide were assessed through responses to a questionnaire. RESULTS: Sixty-three percent of the patients supported policies favoring physician-assisted suicide, and 55% acknowledged considering physician-assisted suicide as an option for themselves. The strongest predictors of interest in physician-assisted suicide were high scores on measures of psychological distress (depression, hopelessness, suicidal ideation, overall psychological distress) and experience with terminal illness in a family member or friend. Other strong predictors were Caucasian race, infrequent or no attendance at religious services, and perceived low level of social supports. Interest in physician-assisted suicide was not related to severity of pain, pain-related functional impairment, physical symptoms, or extent of HIV disease. CONCLUSIONS: HIV-infected patients supported policies favoring physician-assisted suicide at rates comparable to those in the general public. Patients' interest in physician-assisted suicide appeared to be more a function of psychological distress and social factors than physical factors. These findings highlight the importance of psychiatric and psychosocial assessment and intervention in the care of patients who express interest in or request physician-assisted suicide.

1995


Euthanasia and HIV disease: how can physicians respond?
Voigt-RF
J-Palliat-Care. 1995 Summer; 11(2): 38-41

By accepting the role of caregiver, the physician can do much to decrease the fear surrounding death. By providing an opportunity for a patient to discuss his ideas and feelings about his own death, physicians can better prepare their patients and themselves for the inevitable. None of us can reverse the dying process. By accepting the fact of death and by reframing our goals to provide care that promotes comfort and dignity, the act of watching our patients die becomes not only bearable but also serene.


AIDS and euthanasia.
Green-G
AIDS-Care. 1995; 7 Suppl 2: S169-73

This paper estimates the proportion of people with HIV who have considered asking assistance to end their lives and explores their motivations and plans of action to hasten death. 16/57 (28%) people with HIV have considered asking for assistance to hasten death, significantly more than seronegative controls (4/67) (3%) (p < 0.001). In follow-up interviews with seropositive respondents the figure increased to 19/57 (33%). The main motivations are fear of being dependent and losing dignity and control in the final stages of the disease. These results are discussed in the light of current legislation about euthanasia and recent evidence that about one-half of NHS doctors would be prepared to comply with requests for euthanasia were it legal to do so.


AIDS, euthanasia and grief.
van-den-Boom-F
AIDS-Care. 1995; 7 Suppl 2: 5175-85

Almost 50% of people with AIDS in the Netherlands make the necessary arrangements for a possible death by the administration of thanatic drugs. In approximately 50% of those who arranged for it, euthanasia is performed. Euthanasia is a well-considered decision. By means of euthanasia people with AIDS want to prevent unbearable suffering and a degrading existence. Those who have arranged for euthanasia were proven to have adapted to the disease better than those who had not. No relationship was found between ending life by means of euthanasia and complicated grief in survivors. However, if the euthanasia process itself was complicated, the risk of complicated grief increased.


Euthanasia, assisted suicide and AIDS.
Laane-HM
AIDS-Care. 1995; 7 Suppl 2: S163-7

Euthanasia is the termination of the life of a patient by a doctor at the request of the patient. Over the past 15 years AIDS has become the most common cause of death among men aged 20-50 years in Amsterdam. It follows from this that in Amsterdam euthanasia and assisted suicide among PWAs is seen relatively frequently, considerably more frequently than among patients with other diseases. This paper examines the existing data on suicide and euthanasia in relation to HIV. The calculated overall incidence of euthanasia/assisted suicide among PWAs in Amsterdam is about 26%. Reasons for the procedure, drugs used and outcomes are discussed, with specific reference to the Dutch context within which these occur.