Psychological Factors Outweigh Physical in Patients' Will to Live

These lines from Shakespeare well capture the hopelessness—the existential despair—that sometimes grips terminally ill individuals.

Hopelessness, along with a loss of dignity and anguish over burdening others, appear to be the major factors linked to terminally ill persons' losing their will to live, a new study has found.

The study was headed by Harvey Chochinov, M.D., a professor of psychiatry at the University of Manitoba and the Canada Research Chair in Palliative Care. Results appeared in the February Psychosomatics.

Certainly, the association between depression and a desire for death has been well established. Pain, shortness of breath, hopelessness, and some other factors have been coupled with a yearning for death as well. But no investigation has apparently examined these variables all at once to see which might carry more weight in eroding the will to live.

Chochinov and his colleagues recruited 189 patients receiving end-of-life care at one of two palliative-care units in Winnipeg, Manitoba. All had been diagnosed with end-stage cancer and were expected to live for six months or less. None had dementia or delirium.

Each subject filled out the Symptom Distress Scale, McGill Pain Questionnaire, and Quality of Life Scale.

The first scale measures the degree of distress that a respondent is currently experiencing from nausea, pain, loss of appetite, insomnia, fatigue, bowel pattern, concentration, breathing, and coughing, as well as whether the respondent is experiencing depression, and if so, how severe it is.

The second scale measures a respondent's current pain experiences. The third scale evaluates a respondent's satisfaction with his or her current quality of life. Subjects also answered questions that shed light on whether they were experiencing anxiety, felt like a burden to others, still wanted to live, or felt hopeless.

Finally, the Index of Independence in Activities of Daily Living was used to assess each subject's dependency in terms of bathing, dressing, toileting, continence, transferring, and feeding.

The investigators then used the results obtained with these yardsticks to see whether there was a statistically significant relationship between subjects' will to live and sources of physical distress, social issues, psychological issues, existential issues, and quality of life. They found that there was a relationship in all five categories and on most, but not all, items. For example, there was a significant relationship between the will to live and anxiety, depression, shortness of breath, and nausea frequency, but not between the will to live and pain frequency, pain severity, or nausea severity.

Moreover, the links between the will to live and some factors were stronger than links between others. For example, the associations between the will to live and anxiety and depression were highly statistically significant (p=0.001 and p<0.00001, respectively), whereas they were only statistically significant for loss of appetite and decline in appearance (p<0.04 and p<0.05, respectively).

Finally, the scientists used multiple regression analysis, where confounding influences were controlled, to find out which of the items linked with a will to live were most important. The answer was three existential factors—loss of dignity, feeling like a burden to others, and hopelessness.

In an interview with Psychiatric News, Chochinov said that he was not surprised by these results, because “hopelessness, burden to others, and loss of dignity have been sited in several other studies” and because they have also been linked “with a wish or interest in euthanasia or physician-assisted suicide.”

The results, he added, also suggest that psychiatrists who care for patients toward the end of life should not only diagnose and treat depression, manage pain, and bolster patients' support network wherever possible, but also pay attention to the three key existential issues.

He commented on whether these results have any implications for physician-assisted suicide, which is legal in Oregon and will be at the root of a case before the U.S. Supreme Court this year.

“Clinical studies can only illustrate, and help clinicians understand, what may move a dying patient toward a death-hastening decision. No clinical study, however, can determine whether helping a patient take active measures to end his or her life. .is ever morally justifiable. .or whether the courts are justified in sanctioning actions that would help patients. .hasten their own death.”

“This and other studies by Dr. Chochinov and his colleagues help us move from a narrow focus on psychopathology to a broader understanding of meaning, dignity, and hope at the end of life,” Linda Ganzini, M.D., told Psychiatric News. “These types of studies set the stage for new interventions and more comprehensive services for dying patients.”

Ganzini is a professor of psychiatry at Oregon Health and Science University. She has also studied terminally ill patients in Oregon who have hastened their death (Psychiatric News, January 16, 2004).

The study was financed by the National Cancer Institute of Canada, Canadian Cancer Society, and Canada Research Chair Program.

An abstract of “Understanding the Will to Live in Patients Nearing Death” is posted online at<http://psy.psychiatryonline.org/cgi/content/abstract/46/1/7>.▪