Will to live in the terminally ill

Summary

Background

Complex biomedical and psychosocial considerations figure prominently in the debate about euthanasia and assisted suicide. No study to date, however, has examined the extent to which a dying patient's will to live fluctuates as death approaches.

Methods

This study examined patients with cancer in palliative care. Will to live was measured twice daily throughout the hospital stay on a self-report 100 mm visual analogue scale. This scale was incorporated into the Edmonton symptom assessment system, a series of visual analogue scales measuring pain, nausea, shortness of breath, appetite, drowsiness, depression, sense of well-being, anxiety, and activity. Maximum and median fluctuations in will-to-live ratings, separated by 12 h, 24 h, 7 days, and 30 days, were calculated for each patient.

Findings

Of 585 patients admitted to palliative care during the study period (November, 1993, to May, 1995), 168 (29%; aged 31–89 years) met criteria of cognitive and physical fitness and agreed to take part. The pattern of median changes in will-to-live score suggested that will to live was stable (median changes <10 mm on 100 mm scale for all time intervals). By contrast, the average maximum changes in will-to-live score were substantial (12 h 33·1 mm, 24 h 35·8 mm, 7 days 48·8 mm, 30 days 68·0 mm). In a series of stepwise regression models carried out at 12 h, 24 h, and 1–4 weeks after admission, the four main predictor variables of will to live were depression, anxiety, shortness of breath, and sense of well-being, with the prominence of these variables changing over time.

Interpretation

Among dying patients, will to live shows substantial fluctuation, with the explanation for these changes shifting as death approaches.

Introduction

A patient's state of mind is the single most important factor in understanding of a request for physician-hastened death. Euthanasia and physician-assisted suicide raise critical issues about the psychological underpinnings of death-hastening requests. This study is part of a programme of research that has addressed various psychiatric dimensions of palliative care.1, 2, 3, 4 The defining characteristic of this research has been that dying patients have served as the key informants. These studies have helped establish the prevalence of clinical depression among the terminally ill¹ and the extent to which dying patients may endorse a desire for death.² A limitation of the latter study was its largely cross-sectional design, with very little information on whether there are fluctuations in patients' will to live over the course of a terminal disease. Thus, although we now know that occasional or fleeting thoughts of a desire for death are common among the terminally ill and that some of these patients express a genuine desire for death, little is known about how these thoughts may change over the course of time.² Although the stability and determinants of will to live in a palliative-care setting are fundamental issues, they have received surprisingly little critical attention.

No previous studies have specifically examined the issue of will to live per se, but a few have addressed constructs that may serve as its proxy. Some studies, using responses to hypothetical scenarios before and after treatment, have documented the extent to which treatment of depression can favourably influence a patient's endorsment of life-sustaining therapy.5, 6 Other studies have shown a strong association between interest in physician-assisted suicide and depression,2, 4, 7, 8 pain,2, 7, 9, 10, 11 and other distressing symptoms.7, 9, 10, 11, 12, 13 To date, only one small study reported that a desire for death may fluctuate over a brief period in a palliative-care setting.² Our study prospectively addressed the temporal stability of will to live and its correlates in a large cohort of terminally ill patients.