10. An End in Sight: Factors in Aging & Dying Flashcards
10 Health Tips?
- Control is everything in the end, but so is acceptance.
- Death may be a lot less scary once you get there.
- There’s no right way to grieve.
- Be wise, and find some meaning…
What is Death? + premature death
Irreversible loss of circulation and respiration or irreversible loss of brain function (whole brain [cerebral hemispheres and brain stem]; or brain stem alone).
A death is premature if it occurs before the age of 70 or 75.
What is Death, Psychologically speaking?
Death is the “possibility of the impossibility of any existence at all”
- Difficult concept to grasp, we cannot imagine not existing.
Death - Variations by Disease?
The course and length of illness vary greatly from one disease to another.
-> This means that the dying process is quite variable.
Palliative Care?
Care intended to reduce pain and discomfort and improve quality of life in patients with chronic/terminal illness; standard form of care in nursing homes, regardless of prognosis.
- Often initially applied alongside curative care.
Hospice Palliative Care?
Hospice care begins when curative care ends. Proves relief of suffering from terminal illness.
Designed to provide warm, personal comfort at the end of life; begins after the treatment of the disease is stopped.
- Pain is managed and invasive treatments are discontinued.
- Psychological comfort & increasing social support are key goals.
- May extend beyond a person’s death to assist in bereavement.
Hospice Care?
May occur in palliative care units of hospitals, freestanding hospices, or in homes (home-based hospice services).
Only 16% to 30% of Canadians who die currently have access to or receive hospice palliative and end-of-life care services.
Home Care?
Accompanied by improved personal control and availability of support, but can be problematic for family members.
When asked, most Canadians would prefer to die at home in the presence of loved ones.
But nearly 60% of Canadian deaths occur in
hospitals though that number is decreasing.
Research on Palliative Care
Temel et al. (2010) examined 151 patients with newly diagnosed metastatic lung cancer.
- Randomized patients into 2 groups: early palliative care integrated with standard oncologic care vs. standard oncologic care alone.
- Palliative care involved at least monthly meetings with a palliative care specialist up until death. Meetings involved evaluations of physical and psychological symptoms, care planning, decision-making, and coordinating care based on individual needs.
- Researchers assessed quality of life and mood at baseline and 12 weeks following study entry.
Mood Symptoms:
Those who reccived early palilitative care had significant lower depression, anxiety and mood disorders.
Survival Rates:
Median survival was longer among patients receiving early palliative care (11.6 months vs. 8.9 months, P=0.02).
Palliative care has been associated with… +$$$
- Lower pain.
- Improved quality of life.
- Lower anxiety and depression.
- Reduction in disease symptomology.
- Prolonged survival.
There is also evidence that terminal patients who receive palliative/hospice care have significantly lower healthcare costs than those who do not.
- Curative care is far more experince, futual inverventions such as surgerices.
Goals in End-of-Life Care
Avery Weisman’s goals for medical staff working with dying patients:
Informed consent: offer knowledge, encourage involvement
Safe conduct: act as helpful guides for patient
Significant survival: help patient make most of time
Anticipatory grief: aid patient and family with sense of loss (debated, might actully make things more difficult)
Timely and ‘appropriate death’: patient should be allowed to die when and how they want, as much as possible.
Help the patient achieve death with dignity.
Disparities in End-of-Life Care?
Racialized individuals have lower use of palliative care services, experience worse symptom control, and are less likely to have
end-of-life wishes documented or respected.
Indigenous cultural needs and traditions related to death and dying often go unaccommodated in Canadian hospitals.
End-of-life care is often more difficult for medical staff and formal care providers.
Why? (4)
- Emotionally draining.
- Unpleasant custodial work.
- Not curative care.
- Less interesting/stimulating.
There is evidence that working with
dying patients increases burnout. But some studies have shown that palliative/hospice care nurses are less burned out than other nurses.
What would you expect?
- Empahy provides meaning and is a protective facotor.
- Greater difficult early on, and people learn how to adapt to it.
- Facing the fact of mortailty, can make people appciate their own life.
Medically Assisted Dying vs.
Euthanasia defintion?
A physician knowingly and intentionally provides a person with the knowledge or means (or both) required to end their life, including counselling about lethal doses of
drugs, prescribing such lethal doses
of drugs, or supplying the drugs.
vs.
euthanasia deliberately ending a person’s life to relieve suffering.
What does the
word dignity mean
to you? And to
“die” with
Bill C 14 was passed in 2016, permitting?
‘medical assistance in dying’ (MAiD) for mentally competent adults who have a serious and incurable illness or disability; are in an advanced state of irreversible decline; and face a “reasonably foreseeable” death
* written request in presence of 2 independent witnesses
* minimum 10-day ‘reflection period’ in most cases
* must be making decision voluntarily, given opportunity to withdraw
Bill C-7 was passed in 2021 , expanding access to MAID by removing?
The requirement that death be “reasonably foreseeable.“
- accompanied by 2 safeguards for non foreseeable deaths: 90-day waiting period and consultation with additional physician (expert in area).
- expands access to those whose sole condition is mental illness.*
*Eligibility delayed again to March 17, 2027.
According to the Fourth Annual Report on Medical Assistance in Dying in Canada, in 2022?
There were 13,241 cases of MAID reported in Canada, accounting for 4.1% of all deaths in Canada.
There was a 31% increase in MAID cases over 2021 (covid).
- Evidence of increasing interest in most provinces and territories.
- Cancer (over 60%), neurological disorders, respiratory diseases most common.
3.5% of total MAID cases were non-foreseeable deaths (neurological conditions were most common for this group).
What are some of the concerns and criticisms of physician-assisted suicide/medically assisted dying?(6)
- Incompatibility with care provider’s ethics (95% of doctors willingly approve requests of MAiD).
- Errors in diagnoses or prognoses, very rare!
- Coercion by family members or physicians, numerous safe guards in place.
- Suicide contagion effect, nocorrelation between MAiD and non-assisted suicide -> the ohter way around people who would die by suicide now have another option.
- Disproportionate impacts on vulnerable groups, so far no evidence for this.
- Impact on the bereaved.
Disproportionate Impacts?
Battin et al. (2007) analyzed rates of assisted dying in Oregon
and the Netherlands.
Found no evidence of heightened risk for vulnerable populations:
- the elderly; women; racial or ethnic minorities
- the poor, the uninsured (Oregon only)
- people with low educational status
- the physically disabled or chronically ill
- people with psychiatric illnesses including depression
The only group with a heightened risk: people with AIDS.
Could Poverty Play a Role?
There are concerns about people in poverty resorting to MAID due to their challenging circumstances.
But…
But an early Ontario study concluded that “MAiD is unlikely to be driven by social or economic vulnerability”.
MAiD was more likely to be taken up by higher
income Canadians.
Another study found that patients with lower socioeconomic status (SES) were less likely to receive medical assistance in dying. They are experincing barriers to MAid, just like other barriers in the healthcare system.
MAiD - Impact on the Bereaved? + exception
People bereaved by assisted dying tend to have similar or lower scores on measures of disordered grief, mental illness, and
posttraumatic stress compared to those who die naturally.
One study found that loved ones of terminal cancer patients who died with medical assistance had less intense grief
response and lower posttraumatic stress.
Expetions, when the bereaved are not informed of the process -> percieved control
Reasons for Choosing Death?
A 2019 Toronto study found that 64% of patients surveyed cited….
… functional decline or inability to participate in meaningful activities as the main factor motivating their MAiD request.
Reasons for Choosing Death?
Reasons patients gave when requesting assisted dying in Oregon have
been consistent in reports for 20 years.
- 90% reported a decreasing ability to participate in activities that made life enjoyable.
- 90% reported loss of autonomy.
- 65% reported loss of dignity.
Physical Illness & Suicide
Ahmedani et al. (2017) examined 2674 individuals who died by suicide between 2000 and 2013.
Compared the incidence of disease/illness to the incidence of disease/illness in a population of living people.
Results?
17 conditions (including migraines, back pain, diabetes, heart disease, COPD, cancer) were associated with increased risk of
suicide (i.e., more prevalent in the suicide group).
Highest risk of suicide was determined for Traumatic brain injuries, sleep disorders and HIV/AIDS.
Reminder: physical illness already leads to suicide.
Is Depression a Factor?
Chochinov et al. (1995) surveyed 200 palliative care patients with cancer in Winnipeg hospitals.
Results?
46 patients had a serious desire to die; 52% of these individuals met the diagnostic criteria for anxiety or depression.
compared to only 20% of those without a serious desire to die suggesting that depression may be a factor in wishing for death.
The depression might be driving the desire to die.
In the media…
Should a person with severe (treatment
resistant) depression be eligible for assisted suicide?
In Canada, they will be eligible in 2024; are currently eligible in other countries.
“It’s very difficult for people to intuitively understand what suffering is involved in something that is not ‘quote-unquote’
physiological. … Depression is just, ‘You know what? Get your act together.’ And I think that’s very unfortunate.”
-> tend to minimize and invalidate depression
Stages of Dying? + The principal coping mechanism + imporant to note…
(Elisabeth Kübler Ross, 1969)
(model not based on emperical approach, only her personal observations)
Denial
- Lack of belief or acceptance.
Anger
- Expressed towards those who are closest.
Bargaining
- Negotiation for more time or longer life.
Depression
- Despair over the recognition of mortality.
Acceptance
- Mortality and future embraced.
The principal coping mechanism people use during the terminal phase is denial.
Death Acceptance, defintion?
A ‘giving in’ and realizing of the inevitability of death; often neither happy nor sad sometimes void of feelings. May involve “letting go” and detaching oneself from events and things we used to value.
No longer in denial; neither depressed nor angry.
Value shift, notice and appciate the small things -> similar to post traumatic growth.
Complexities of Denial
In a qualitative study, Copp & Field (2002) found that…
Denial and acceptance were interdependent and fluctuating coping strategies used by hospice patients.
They are not opposing, but they can co-occur and are realtead.
