Predicting the trajectory of will to live in terminally ill patients
Tataryn D & Chochinov HM;
Commented by , 21 Oct 2002
Background
Will to live in the terminally ill appears to fluctuate considerably over short periods of time.
Purpose
To identify whether discernible patterns in the fluctuation of will to live exist in the terminally ill, and to what extent demographic or illness-specific factors predict one’s will to live.
Methods
Participants were 168 patients with cancer admitted to a palliative care unit with a Mini-Mental State Score ³ 21. The Edmonton Symptom Assessment System, a palliative care self-report measure with 100-mm visual analogue scales (VAS), was completed twice daily throughout hospitalization. The scale assesses pain, anxiety, depression, well-being, dyspnea, nausea, activity, drowsiness and appetite; a “will-to-live” VAS was added.
Data was analyzed in 3-steps:
- Each patient’s will-to-live data was summarized into two parameters, slope and intercept, using linear regression. Slope reflects millimetres of change in the will-to-live score per 12-hour period. Intercept is a calculated will-to-live score at time 0 (just prior to admission).
- Analysis of variance with post-hoc comparisons determined intercept-slope clusters.
- Discriminant analysis evaluated degree to which demographic and symptom characteristics predicted cluster membership.
Results
Five intercept-slope clusters emerged:
- sustained high will to live (58%)
- sustained low will to live (3%)
- sustained moderate will to live (11%)
- will-to-live relinquishers (18%)
- will-to-live acquirers (10%).
Seven variables accounted for 69% of the variance in group membership
- anxiety
- shortness of breath
- nausea
- length of survival time from admission
- colon cancer
- having no religion
- living with a spouse
Patients acquiring the will to live had the highest rates of colon cancer and nausea on admission, and were most likely to be living with a spouse. Patients with sustained high will to live had the lowest rates of anxiety and colon cancer, and were more religious. The group with sustained low will to live had the highest levels of anxiety and dyspnea, and the lowest rate of living with a spouse (0%).
Discussion
This study confirms that most terminally ill patients sustain a strong will to live. High initial nausea scores among will-to-live acquirers suggest symptom relief may re-establish a will to live.
Low anxiety and high religiosity characterized the sustained high will to live group, whereas the sustained low will to live group had the highest levels of anxiety, dyspnea and none were living with a spouse. This latter highly symptomatic group with presumed lower social support shares these variables with terminally ill patients interested in physician-assisted suicide.
This comparison highlights the importance of care aimed at alleviating physical, emotional, psychosocial and spiritual suffering in the terminally ill, which sadly appears to be the exception rather than the rule.
For example, while 75% of Canadians die in hospital or long-term care facilities, only an estimated 5% receive such an integrated care approach (1). The paucity of palliative care education in medical schools and continuing education programs further illustrates this systemic problem (2).
The vigorous debate about physician-assisted suicide (3) underscores the need to further our understanding of the transient construct – “will to live” - in the terminally ill.
Although the authors have made a significant contribution to the end-of-life literature, the cohort of older individuals (mean age 68), all with a terminal cancer, limits the study’s generalizability to younger or other terminally ill populations (e.g. AIDS).
References
- Subcommittee of the Standing Senate Committee on Social Affairs, Science and Technology. Quality end of life care: the right of every Canadian. Ottawa: The Senate of Canada, 2000
- Chochinov HM. The Senate report on end-of-life care: the ball is in our court. Canadian Medical Association Journal 2001; 164: 794-795
- Angell M. The Supreme Court and physician-assisted suicide – the ultimate right. New England Journal of Medicine 1997; 336: 50-53