Correspondence
Nurses' and Social Workers' Experience with Patients Who Requested Assistance with Suicide
N Engl J Med 2002; 347:2082-2083December 19, 2002
- Article
To the Editor:
Ganzini et al. (Aug. 22 issue)1 surveyed nurses and social workers regarding their perceptions of patients' motivations for requesting lethal doses of medication. Apparently, the authors believe that their data are not subject to the bias of physicians who prescribe lethal doses, who may be “subject to an inherent conflict of interest and . . . may have failed to recognize depression or explore existential and social issues sufficiently.” It could be argued, however, that nurses and social workers are subject to the same bias. Certainly, nurses who provide such lethal doses would like to think that their practice is consistent with statutory requirements — namely, that their patients' requests are not overly motivated by such factors as depression and uncontrolled pain. Nurses thus have some of the same inherent conflicts of interest as physicians do. Moreover, even nurses who have not provided lethal doses of medication have an interest in thinking that patients in their practice setting receive care that is consistent with the law. These considerations may thus bias nurses' responses to the study questionnaire.
1 ReferencesDaniel Polowetzky, A.C.R.N.
Visiting Nurse Service of New York, New York, NY 10001
dpolowetzky@nyc.rr. com 1
Ganzini L ,Harvath TA ,Jackson A ,Goy ER ,Miller LL ,Delorit MA . Experiences of Oregon nurses and social workers with hospice patients who requested assistance with suicide. N Engl J Med 2002;347:582-588
Full Text | Web of Science | Medline
To the Editor:
Ganzini et al. present results suggesting that hospice staff members believe that depression was among the least important reasons why patients requested physician-assisted suicide. Staff members also reported that patients requesting physician-assisted suicide had a level of depression that was similar to that of other hospice patients. These results contradict evidence from direct, standardized assessments showing that terminally ill patients who request physician-assisted suicide have higher levels of depression.1
There are several serious methodologic problems in this study. The results are based on retrospective reports by staff members on patients who requested physician-assisted suicide as compared with other hospice patients who did not; they covered a four-year period. This long period covered by the retrospective reports and the task of comparing the reports with global impressions of other hospice patients are subject to many biases. Clinicians often inadequately identify depression,2 and recall of depression was based on unstandardized assessments. Psychological research suggests that such retrospective questions are answered by construction, not recall, based on the subjective viewpoints of participants.3 Confirmation bias4 is also likely to have led staff members to recall patients' characteristics according to their personal beliefs. We recommend a comparison between the ratings by staff members and the self-reported attitudes about physician-assisted suicide in order to partially address this issue of personal bias in recall.
4 ReferencesWilliam E. Haley, Ph.D.
Susan C. McMillan, Ph.D., A.R.N.P.
Ronald S. Schonwetter, M.D.
University of South Florida, Tampa, FL 336201
Emanuel EJ . Euthanasia and physician-assisted suicide: a review of the empirical data from the United States. Arch Intern Med 2002;162:142-152
CrossRef | Web of Science | Medline2
Block SD . Assessing and managing depression in the terminally ill patient. Ann Intern Med 2000;132:209-218
Web of Science | Medline3
Ross M . Relation of implicit theories to the construction of personal histories. Psychol Rev 1989;96:341-357
CrossRef | Web of Science4
Nickerson RS . Confirmation bias: a ubiquitous phenomenon in many guises. Rev Gen Psychol 1998;2:175-220
CrossRef
Author/Editor Response
The authors reply:
To the Editor: We agree that “nurses who provide such lethal doses” might be subject to the same conflicts of interest as physicians. Nurses, however, have no role under the Oregon Death with Dignity Act in providing lethal medications. Most hospices in Oregon either discourage or prohibit employees from being present when the lethal medication is ingested. Other studies support the belief that nurses, when offered anonymity as was offered in our study, are willing to provide information regarding illegal experiences with euthanasia.1
There are currently no studies using standardized assessments that demonstrate a relation between depression and requests for assisted suicide. The studies referenced by Haley et al. report that between 10 percent and 56 percent of terminally ill patients have a general interest in physician-assisted death and that depression is associated with a general interest, but whether these patients made actual requests is unknown.2 In Oregon, 1 in 1000 deaths is from assisted suicide, including 4 in 1000 deaths of patients with cancer.3 These figures suggest that only 1 in 100 patients expressing a general interest in assisted suicide dies by it. Among those interested in assisted suicide, there are no data to suggest that depression is a risk factor for receiving a lethal prescription. It is possible that very ill and depressed patients may be at a disadvantage in marshaling the focus and determination needed to obtain these prescriptions.4
Nurses' reports about the reasons for these requests were unrelated to their support of or opposition to the Oregon Death with Dignity Act, except that those who opposed the law rated dying at home as a less important reason than those who supported it (P=0.002). Nurses' ratings of the importance of depression for patients requesting a lethal prescription were not associated with nurses' support of or opposition to the law (P=0.24).
Clinicians who lack expertise in mental health do overlook depression. We reported that hospice social workers, who have expertise in evaluating mood disorders in dying patients, rated depression as the least important reason for the request for assisted suicide. Otherwise, as we noted in the article, we agree that the degree to which the nurses' responses accurately represent the patients' views is unknown, and studies of persons in Oregon who request assistance with suicide are needed to validate the importance of all these reasons.
4 ReferencesLinda Ganzini, M.D.
Oregon Health and Science University, Portland, OR 97201
ganzinil@ohsu.edu Ann Jackson, M.B.A.
Oregon Hospice Association, Portland, OR 97296Elizabeth R. Goy, Ph.D.
Oregon Health and Science University, Portland, OR 972011
Asch DA . The role of critical care nurses in euthanasia and assisted suicide. N Engl J Med 1996;334:1374-1379
Full Text | Web of Science | Medline2
Emanuel EJ . Euthanasia and physician-assisted suicide: a review of the empirical data from the United States. Arch Intern Med 2002;162:142-152
CrossRef | Web of Science | Medline3
Sullivan AD ,Hedberg K ,Hopkins D . Legalized physician-assisted suicide in Oregon, 1998-2001. N Engl J Med 2001;344:605-607
Full Text | Web of Science | Medline4
Ganzini L, Dobscha SK, Heintz RT, Press N. Oregon physicians' perceptions of patients who request assisted suicide and their families. J Palliative Med (in press).
