The influence of cognitive impairment on desire for hastened death among terminally ill AIDS patients

Understanding the relationship between cognitive impairment and desire for hastened death has important implications for palliative care practice and the debate over the legalization of physician-assisted suicide. The presence of cognitive impairment may significantly influence terminally ill patient\u27s attitudes towards hastened death. As cognitive abilities become compromised, patients may have more difficulty making decisions and finding alternative solutions besides death to improve their situation. This loss of cognitive abilities may result in a direct decrease in the patient\u27s quality or enjoyment of life. The awareness of cognitive deficits may contribute to a patient\u27s sense of deterioration and increase emotional distress levels. The primary objectives of this study were: (1) to examine the relationship between cognitive impairment and desire for death directly in a terminally ill AIDS population, (2) to further characterize the specific aspects of cognitive functioning that impact desire for death among terminally ill patients with AIDS, and (3) to examine the relationships among desire for death, cognitive functioning, and other relevant physical and psychological symptoms associated with advanced disease. The sample included 128 terminally ill patients with AIDS receiving palliative care in a long-term care facility. Participants completed a clinical assessment that included a self-report measure of desire for hastened death, the Schedule of Attitudes toward Hastened Death (SAHD), a self-report measure of desire for hastened death in the medically ill, and the HIV-Dementia Scale (HIV-DS), Mini-Mental Status Exam (MMSE), and the Dementia Rating Scale (DRS), cognitive screening measures designed to detect the presence of cognitive impairment. Results demonstrated that there was a significant association between desire for death and the presence of cognitive impairment as indicated by clinical cutoff scores on the HIV-DS, MMSE, and DRS. The presence of memory impairment, as measured by the DRS subscale, provided an independent and unique contribution to desire for hastened death. Patients\u27 self-reported awareness of and distress around cognitive difficulties was also significantly associated with increased desire for death. Therefore, it can be concluded that the presence of mild to moderate cognitive impairment and the awareness of these deficits were related to terminally ill patients with AIDS\u27 desire for hastened death

Hopelessness at the end of life: An analysis of the Beck Hopelessness Scale

Objectives. We sought to investigate the utility of the Beck Hopelessness Scale (HS) in a sample of terminally ill cancer patients by examining the scale properties. Moreover, we sought to identify and remove potentially problematic items in order to ascertain a “purer” index of hopelessness for this population. Design. A cross-sectional study of 200 hospice inpatients with a life expectancy of less than 6 months. The HS, as well as several other distress measures, were administered to patients at bedside by trained clinicians. Methods. An item analysis of the HS was conducted, looking specifically at item endorsement and item-total correlations. Three abbreviated versions (3-item 7-item, 13-item) were developed based on certain denoted item-total correlation cut-offs. Reliability and validity of the original 20-item HS was then compared to that of the newly developed abbreviated version. Results. All scales were found to be reliable and valid measures of hopelessness. The three abbreviated versions were more highly correlated with the distress measures than the original version, and the 7-item and 13-item subscales outperformed the original HS in the prediction of suicidal ideation and desire for hastened death. Conclusion. The data suggest that the HS may be improved, when applied to a terminally ill sample, by the elimination of problematic items. The development of a shorter, purer measure of hopelessness for this population is crucial given the need to reduce the burden placed on those who participate in end-of-life studies, and the important role of hopelessness in the prediction of suicide and desire for hastened death

The role of cognitive impairment in desire for hastened death

To examine the relationship between cognitive impairment and desire for death in patients with advanced AIDS we evaluated 128 patients with advanced AIDS consecutively admitted to three long-term care facilities. Participants completed a clinical assessment that included a self-report measure of desire for hastened death in the medically ill (Schedule of Attitudes toward Hastened Death), three measures of cognitive functioning designed to screen for cognitive impairment (Dementia Rating Scale, Mini-Mental State Exam, HIV Dementia Scale), and other measures of physical and psychological functioning. Participants who were classified as cognitively impaired obtained significantly higher scores on the measure of desire for death than did patients without cognitive impairment. This modest association between cognitive impairment and desire for death remained significant even after controlling for the impact of depression on desire for death. Specific aspect of cognitive functioning such as memory and psychomotor coordination appeared to be more salient than executive functioning or abstract reasoning. Cognitive impairment appears to have a modest, but significant impact on patients’ desire for hastened death. Aggressive treatment of cognitive symptoms in the terminally ill is necessary in order to disentangle the various factors that may drive end-of-life treatment decisions

Decision-making capacity in elderly, terminally ill patients with cancer

Despite the importance and complexity of evaluating decision-making capacity at the end of life, little research has focused on terminally ill patients’ decision-making ability. The purpose of this study was to explore the decisionmaking capacity of elderly, terminally ill patients and the psychological and physical factors that affect decision making. Decision-making capacity and cognitive abilities were assessed using four measures: the Hopkins Competency Assessment Kit, the Bechara Gambling Task, the Concept Assessment Kit, and the Mini Mental Status Exam. In addition, symptoms of depression, level of physical functioning, and extent of physical symptoms were evaluated in order to identify correlates of decisionmaking ability. Two samples were compared: elderly, terminally ill patients with cancer (n¼43) and elderly, physically healthy adults living in supportive community residence (n¼35). Results revealed significantly poorer decision-making abilities among the terminal ill sample compared with healthy comparisons, but no association between demographic variables (e.g., age, race, or education) or clinical variables (depression or physical symptoms) and decision making. Implications for evaluating decision-making capacity are addressed