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Theresa A. Harvath, PhD, RN, CNSLois L. Miller, PhD, RNKathryn A. Smith, MS, RNLisa D. Clark, MS, RNAnn Jackson, MBALinda Ganzini, MD, MPH• In 1997, Oregon enacted the OregonDeath With Dignity Act, which legalizedphysician-assisted suicide. This article reportson a qualitative study of the ethical and clinicaldilemmas experienced by hospice nursesand social workers when they encounterpatients who wish to hasten death throughphysician-assisted suicide. The biggestdilemma arises from the conflict between twoimportant hospice values: honoring patientautonomy versus promoting a deathexperience in which personal and spiritualtransformation are possible. Hospiceprofessionals report conflict between theiradvocacy for patients and for the familymembers who sometimes opposephysician-assisted suicide. Conversely, whenpatients choose to hasten death by voluntarilyrefusing all food and fluids, many of thesedilemmas dissipate. As more patients requestcontrol of the circumstances of their deaths,a better understanding of the complex issuesregarding hastening death is needed forpatients, families, and the health professionalswho provide care during this difficult transition.K

Objective: To study the health care experiences and palliative care needs of patients with ALS in their final month of life. Methods: Caregivers of decedent patients with ALS completed a single survey focused on the final month of life. They reported the patients’ physical and emotional symptoms, preferences for end-of-life care, completion of advance directives, and preparation for death. The caregiver reported which life-sustaining treatments were administered, withheld, or withdrawn; whether the patient was enrolled in hospice; and their own satisfaction with the patient’s medical care. Results: Fifty caregivers completed the survey. Caregivers reported that the most common symptoms in the last month of life included difficulty communicating (62%), dyspnea (56%), insomnia (42%), and discomfort other than pain (48%). Pain was both frequent and severe. One-third of caregivers were dissatisfied with some aspect of symptom management. Caregivers reported an advance directive was completed by 88% of patients and the patients’ goals of care were honored by 88% of health care practitioners. Two-thirds of patients were enrolled in hospice. Compared to nonhospice patients, hospice patients were significantly more likely to: 1) die in their preferred location; 2) die outside the hospital; and 3) receive morphine. Most caregivers reported that their loved one was at peace, and prepared for and was accepting of death. Conclusions: Caregivers report that many patients with ALS still experience distressing physical symptoms in the last month of life, despite enrollment in hospice. Most patients with ALS, however, anticipate and plan for their deaths and have their wishes respected.

PurposeThe personal health care of medical students is an important but neglected issue in medical education. Preliminary work suggests that medical student-patients experience special barriers to health care services and report problematic care-seeking practices that merit further inquiry.M

In a controlled study, the authors determined the risk of developing major mental illness after catastrophic financial loss. Seventy-two adults who lost their retirement savings in a bank fraud were interviewed using the Diagnostic Interview Schedule. Major depression by DSM-III criteria was present in 29% of the victims during the first 20 months after their loss as compared with 2% of 66 age, gender, and residential area-matched control subjects (p less than .0001). Generalized anxiety disorder as defined by DSM-III criteria was experienced by 27% of victims after the loss as compared with 10% of control subjects (p = .03). After the loss, victims had lower subjective health ratings, more functional somatic complaints, and higher tranquilizer usage than control subjects. There was no difference between depressed and nondepressed in types of coping responses or use of social supports and confidants. Only four of 21 victims who suffered major depression sought help from a mental health professional. We conclude that catastrophic financial loss may result in the onset of major depressive disorder and generalized anxiety disorder.

Mortality associated with Parkinson disease (PD) is two to five times that of age- and sex-matched controls, and PD is 14 among the leading 15 causes of death in the United States.1-3 Most PD texts from the last decade contain no information on the final months of life with PD.4-6 Quality end-of-life care for patients with PD is impeded by scant information about the prevalence and severity of disabling psychological and physical symptoms and decision making about goals of care. ### Methods. We interviewed 47 family caregivers of patients with idiopathic PD evaluated at the Oregon Health and Science University and Portland Veterans Affairs Medical Center, who died from 6 to 53 months before the interview. Caregivers rated patient physical and psychological symptoms in severity, frequency, and degree to which the symptom bothered or distressed the patient in the final month of life, reported the use of health care proxies and health care services, overall goals of medical care, and degree to which patients’ wishes were respected. …