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Evaluation and Management in Terminal Care

Susan D. Block, MD; J. Andrew Billings, MD

Arch Intern Med. 1994;154(18):2039-2047.

Abstract
Terminally ill patients often hope that death will come quickly. They may broach this wish with their physicians, and even request assistance in hastening death. Thoughts about accelerating death usually do not reflect a sustained desire for suicide or euthanasia, but have other important meanings that require exploration. When patients ask for death to be hastened, the following areas should be explored: the adequacy of symptom control; difficulties in the patient's relationships with family, friends, and health workers; psychological disturbances, especially grief, depression, anxiety, organic mental disorders, and personality disorders; and the patient's personal orientation to the meaning of life and suffering. Appreciation of the clinical determinants and meanings of requests to hasten death can broaden therapeutic options. In all cases, patient requests for accelerated death require ongoing discussion and active efforts to palliate physical and psychological distress. In those infrequent instances when a patient with persistent, irremediable suffering seeks a prompt and comfortable death, the physician must confront the moral, legal, and professional ramifications of his or her response. Rarely, acceding to the patient's request for hastening death may be the least terrible therapeutic alternative.

(Arch Intern Med. 1994;154:2039-2047)

Author Affiliations
From the Massachusetts Mental Health Center and the Consolidated Department of Psychiatry, Harvard Medical School and the Teaching Programs of the Department of Ambulatory Care and Prevention, Harvard Medical School and Harvard Community Health Plan (Dr Block), and the Departments of Medicine, Massachusetts General Hospital and the Adult Medicine Unit, Massachusetts General Hospital-Chelsea Memorial Health Center, the Trinity Hospice of Greater Boston, Olsten Kimberly Quality-Care Hospice, and Harvard Medical School (Dr Billings), Boston, Mass.

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