Stephen J.LurieMD, PhD, Senior EditorIndividualAuthorJody W.ZylkeMD, Contributing EditorIndividualAuthor
To the Editor: Dr Emanuel and colleagues1 report that among terminally ill patients, those with depression, substantial caregiving needs, and pain were more likely to consider euthanasia or physician-assisted suicide (PAS). These 3 factors are commonly reversible using specific approaches such as psychiatric2 and palliative care.3 Patients who are terminally ill often experience frustration, humiliation, or feelings of betrayal, leading to anger that may be unexpressed or unconscious. For some patients, lack of appropriate medical care leads to despair and hopelessness,4 and the patient's anger may assume the most efficacious form in which to be heard by caregivers and proxies: the demand for euthanasia or PAS. This approach is sometimes the only way for a patient to change treatment and care strategies. Rather than an autonomous wish, the expression of a desire for death by a terminally ill patient should be seen as a plea to change the context of his or her life, to oblige proxies and caregivers to pay more attention, and to assert his or her authority. Perhaps this is why the results of surveys about end-of-life decisions are affected by whether the questions are framed in terms of hypothetical situations vs the reality of patients' feelings when confronted with a terminal illness. Moreover, even when terminally ill patients genuinely wish to die, some results show that the intervention of proxies and caregivers may decrease the desire for euthanasia.2 Desire for death must be considered first as a symptom, not as a clear and autonomous wish that must be respected.
Pochard F, Azoulay E, Grassin M. Assessing Requests for Euthanasia From Terminally Ill Patients. JAMA. 2001;285(6):734-735. doi:10-1001/pubs.JAMA-ISSN-0098-7484-285-6-jlt0214