Contrary to what some may think, it's not because they are depressed, worried about being a financial burden or lack social support, the researchers say.
Dr. Linda Ganzini and colleagues from three Portland health organizations sent questionnaires to all hospice social workers and nurses who work with terminally ill hospice patients in Oregon, the only state with an assisted suicide law. They asked the 179 who responded to such requests to tell them why the patient asked for it.The desire to determine how they died was the most important reason cited, the researchers report in tomorrow's issue of The New England Journal of Medicine.
"The nurses and social workers rated depression, poor social support and being a financial burden as least important," says Ganzini, director of the Palliative Care Fellowship at the Portland VA Medical Center. The findings refute studies conducted outside of Oregon that have found depression increases the likelihood of terminally ill patients' preference for hastening death.
Other important reasons for requesting physician-assisted suicide, according to the survey, were a desire to die at home, the belief that continuing to live was pointless, and being ready to let go.
In all, 397 hospice social workers or nurses returned the surveys and 179 had cared for a patient who requested assisted suicide. Of those, 172 reported more details on one or more patients who had requested it.
The researchers then zeroed in on the nurses. A total of 122 nurses reported that a patient had asked for a lethal prescription. Of those, the nurses reported that 82 patients actually received it, and 55 died by assisted suicide.
"Because it was likely that the hospice social workers would have given information about the same patients, we only reported on the [experiences of the] hospice nurses," Ganzini explains.
The new findings, Ganzini says, duplicate what she found in a physician survey she did two years ago. In that study, doctors cited loss of independence, poor quality of life and the need to maintain control as the driving forces behind patients' requests for assisted suicide.
Janet Neigh, executive director of the Hospice Association of America, calls the new study very interesting and says the findings are borne out by her own observations.
Whether terminally ill patients request suicide or not, she says, maintaining control is important to most of them, and hospice workers recognize that need.
They often advise loved ones to "pay attention to what the terminally ill patient is asking for. What's important to him?" she says.
"Don't ignore small requests," Neigh adds, explaining that often a patient is exercising a need for control, no matter how inconsequential the request may seem to the healthy. Perhaps a patient asks to sit in the sunshine, she says, or requests only a certain color flower be in her room. She urges loved ones to respond to such requests when possible.
When you are seriously ill, she notes, "your area of control shrinks." When patients hang on or reclaim control, "it helps them maintain their sense of independence and personal dignity."
Not all of the hospice workers surveyed were in favor of Oregon's Death with Dignity Act, enacted in 1997. Fifty-nine percent supported it, 26 percent opposed it and 14 percent were neutral; only one respondent would have actively opposed a patient's choice of assisted suicide.
Since the assisted suicide law was passed, 91 Oregon residents have used it, according to the Compassion in Dying Federation.
However, the law has foes outside state lines.
U.S. Attorney General John Ashcroft tried to override the law, issuing a directive that said assisting a suicide is not a legitimate medical practice, and doctors who do so violate the Controlled Substance Act. But a U.S. District Judge ruled that Ashcroft's directive exceeded the authority of his office and issued a permanent injunction. In September, the Justice Department will appeal the case to the 9th U.S. Circuit Court of Appeals.
Meanwhile, Ganzini hopes next to focus on the patients themselves.
"The study that needs to be done is to talk to patients who are in the process of trying to decide [whether to request physician-assisted suicide]," she says.
She also hopes to research the effect of physician-assisted suicide on family members.
"We know suicide has a devastating effect. But what about assisted suicide?" she asks.
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