Psychiatric dimensions of palliative medicine

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Chochinov, Harvey Max
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The euthanasia and physician assisted suicide debate has largely focused on moral and legal considerations. Questions pertaining to the mental state of terminally ill patients who request that their death be hastened, have received considerably less attention. The intent of this thesis is to address that apparent gap in the literature. Empirically based data of this kind may help guide health care providers confronted by these difficult clinical situations, as well as inform the process of creating public policy pertaining to these issues. This thesis summarizes a program of research, which I initiated and have continued to guide over the course of the last seven years. It details a series of publications and works in progress, all of which have evolved in the context of this research initiative. These empirically based studies address several critical issues that have a direct bearing on the issue of euthanasia and physician assisted suicide. They include the following: (1) establishing the prevalence of clinical depression amongst the terminally ill, (2) examining the prevalence of a 'desire for death' in this patient population and its relationship to depression, pain and perception of social support, (3) reporting on screening approaches to help identify clinical depression in terminally ill patients, (4) addressing the extent to which 'hopelessness' is a reliable risk factor in predicting suicidal ideation in patients with advanced disease, (5) exploring the temporal stability of a dying patients 'will to live' and its determinants and (6) investigating the relationship between prognostic awareness and psychological adaptation. These studies, funded and supported by the Manitoba Cancer Treatment and Research Foundation, the Manitoba Mental Health Research Foundation, the Manitoba Health Research Foundation, the National Cancer Institute of Canada and Project on Death in America, the Open Society Institute, are presented and summarized. The connections between the various studies, the rationale for choosing the research questions, the methods employed, and laying out the natural evolution of each successive study within the overall program has been provided. This thesis concludes by reflecting on the implications of this body of work regarding: (1) the clinical issues, (2) the public policy considerations and (3) the direction of future research in this area. A clearer understanding of these matters can only lead to an improvement in care for patients approaching the end of life.