The wish to hasten death: Reflections from practice and research.

Abstract

The debate over whether or not to allow physician-assisted suicide (PAS) or euthanasia is one that is periodically reopened in Western society. This debate tends to arise as the result of a specific case, a difficult situation involving a patient whose prognosis leads him or her to regard death as the best way out. The experience of those countries or states that have developed legislation on this matter shows that controversy remains. Furthermore, when addressing this issue, the origin of the problem is often overlooked. After all, the possibility of such a ‘‘way out’’ would not arise were there not people who contemplated hastening their own death. Yet how much do we know about the wish to hasten death (WTHD) in patients with advanced illness? Is it common? What are the motives which may trigger such a complex phenomenon? A recent systematic review highlights the lack of precise terminology for referring to this phenomenon. Any attempt to capture a genuine WTHD needs to distinguish between the following situations: (a) a vague wish to die, (b) a wish to hasten one’s death (whether sporadic or enduring), (c) the explicit expression of the WTHD, and (d) as the final stage on this continuum, planning suicide or requesting an assisted death or euthanasia. In practice, however, many of the clinical articles identified in the abovementioned systematic review used the term WTHD (or similar) in an indistinct way, mixing patients from across the continuum, and even at times including those who merely expressed an acceptance of death. An interpretative synthesis of qualitative studies on the WTHD concluded that the WTHD seems to be a reactive phenomenon, a response to multidimensional suffering, and not merely one aspect of the despair that may accompany this suffering. In these patients, the expression of a wish to die may have multiple meanings, and it does not necessarily imply a genuine WTHD. These different meanings can be grouped into six broad categories: the WTHD in response to physical/psychological/spiritual suffering, loss of self (which would encompass the loss of bodily functions, control, and meaning in life), fear of the dying process, the wish to live but not in this way, the WTHD as a way of ending one’s suffering, and the WTHD as a form of control over one’s life. According to the explanatory model developed in that study, there are various factors that can lead to the emergence of such a wish, including the presence of generalized distress, the loss of selfhood (losses of different kinds brought about by the illness), and the fear of both the dying process and of death itself. A combination of these factors can lead to overwhelming emotional distress in patients,