Whether anorexic patients should be able to refuse treatment when this refusal potentially has a fatal outcome is a vexed topic. A recent proposal for a new category of “terminal anorexia” suggests criteria when a move to palliative care or even physician-assisted suicide might be justified. The author argues that this proposed diagnosis presents a false sense of certainty of the illness trajectory by conceptualizing anorexia in analogy with physical disorders and stressing the effects of starvation. Furthermore, this conceptualization is in conflict with the claim that individuals who meet the diagnostic criteria for terminal anorexia have decision-making capacity. It should therefore be rejected.

Patient’s needs and rights are the key to delivering state-of-the-art modern nursing care. It is especially challenging to provide proper nursing care for patients who are reaching the end of life (EOL). In Chinese culture nursing practice, the perception and expectations of these EOL patients are not well known. This article explores the feelings and wishes of 16 terminally ill Chinese cancer patients who are going through the dying process. An open-ended questionnaire with eight items was used to interview 16 terminally ill Chinese cancer patients, and was then analyzed by a combined approach employing grounded theory and interpretive phenomenological analysis. Four dimensions were explored: first, patient’s attitudes towards death, such as accepting the fact calmly, striving to survive, and the desire for control; second, the care desired during the dying process, including avoiding excessive treatment and dying with dignity; third, the degree of the patient’s acceptance of death; and fourth, the consequences of death. This cognitive study offers a fundamental understanding of perceptions of death of terminally ill cancer patients from the Chinese culture. Their attitude toward death was complex. They did not prefer aggressive treatment and most of them had given a great deal of thought to their death.

Montana recently joined Oregon and Washington as the only states in the nation to legalize the choice among terminally ill adults to hasten death by self-administering a lethal dose of drugs prescribed by a physician. Unlike Oregon and Washington, however, Montana's legalization of physician aid in dying (PAID) resulted not from public consideration of a statewide initiative, but from the judicial resolution of a lawsuit, Baxter v. Montana. As originally conceived, a trial judge reasoned that the unenumerated right to PAID is embraced by enumerated state constitutional rights to privacy and dignity. On appeal, Montana's supreme court jettisoned this construct, and, in its place, fashioned a legal home for PAID out of state homicide, consent defense, and end-of-life statutes. Central to this court's statutory rendering is the finding that state law, allowing terminally ill Montanans sustained by life support to withdraw such treatment and die, discriminates against terminally ill Montanans not sustained by life support who seek death; these classes are similar, the justices reckoned, entitling both to choose death. This analysis examines Montana's courting of PAID, offering textual examination of state trial and appellate court opinions, an accounting of legal strategies advanced in amici curiae briefs, and commentary about the problems and prospects with Baxter's holding. I argue, ultimately, that the equality principles statutorily conceived in Baxter (1) could be parroted in the vast majority of states that both criminalize assisted suicide and enumerate constitutional equal protection guarantees, and (2) could replace sub silentio the equal protection paradigm applied to “physician-assisted suicide” by the United States Supreme Court in its landmark Vacco v. Quill ruling.

This paper discusses how the concepts of hope and hopelessness can affect therapeutic interventions when working with people affected by cancer. The concepts of hope and hopelessness are considered within the therapeutic relationship and the biomedical model. This explores whether there is a difference between hope and denial and considers how culture, religion, and spirituality influence an individual's interpretation of hope. For some people living with a cancer diagnosis, the word ‘hope’ can become a burden. They can feel a pressure to present as strong, positive, and hopeful in the face of extremely confronting situations. Therapists need to give patients time and space to explore their feelings of hopelessness without rushing them to a place of hope for which they are not ready. Case examples are provided and the author reflects upon her own family therapy practice working in an acute health care facility. This stresses the importance of critical reflection, supervision, and peer support.

Objective: A meta-summary of the qualitative literature on spiritual perspectives of adults who are at the end of life was undertaken to summarily analyze the research to date and identify areas for future research on the relationship of spirituality with physical, functional, and psychosocial outcomes in the health care setting.

Methods: Included were all English language reports from 1966 to the present catalogued in PubMed, Medline, PsycInfo, and CINAHL, identifiable as qualitative investigations of the spiritual perspectives of adults at the end of life. The final sample includes 11 articles, collectively representing data from 217 adults.

Results: The preponderance of participants had a diagnosis of cancer; those with HIV/AIDS, cardiovascular disease, and ALS were also represented. Approximately half the studies were conducted in the United States; others were performed in Australia, Finland, Scotland, and Taiwan. Following a process of theme extraction and abstraction, thematic patterns emerged and effect sizes were calculated. A spectrum of spirituality at the end of life encompassing spiritual despair (alienation, loss of self, dissonance), spiritual work (forgiveness, self-exploration, search for balance), and spiritual well-being (connection, self-actualization, consonance) emerged.

Significance: The findings from this meta-summary confirm the fundamental importance of spirituality at the end of life and highlight the shifts in spiritual health that are possible when a terminally ill person is able to do the necessary spiritual work. Existing end-of-life frameworks neglect spiritual work and consequently may be deficient in guiding research. The area of spiritual work is fertile ground for further investigation, especially interventions aimed at improving spiritual health and general quality of life among the dying.

Objective: Understanding the construct of hopelessness in the context of a life-threatening or terminal illness is a complex and challenging undertaking. The objective of this study was to examine the construct of hopelessness in patients with advanced AIDS by examining the structure of the Beck Hopelessness Scale in this specific population.

Methods: For the past three decades, the primary measure used to study hopelessness in a variety of populations has been the Beck Hopelessness Scale. Several factor analytic studies have been published using this scale, with studies of nonclinical samples typically describing a two-factor model (optimism and pessimism), whereas clinical samples have consistently generated a third factor (lack of motivation to make changes). We used confirmatory factor analysis to analyze two data sets in patients with AIDS.

Results: Confirmatory factor analysis of the Beck Hopelessness Scale in two samples of patients with far advanced AIDS revealed a clear superiority for a three-factor model.

Significance of results: The Beck Hopelessness Scale has unique characteristics when applied to a terminally ill population. The implications of these results for studies of terminal illness are discussed.

Objective: To report on the case of a terminally ill patient who expresses suicidal ideation.

Methods: As this case demonstrates, suicidality at end-of-life poses numerous challenges for the palliative care team. In this case, a 49-year-old man with locally extensive head and neck cancer refused all life-prolonging treatment and expressed a desire to hasten his own death. Other issues, such as chemical dependency and lack of social supports, complicated his care.

Results: Suicidality lessened as continuity of care, with ongoing assessments and interventions, addressed sources of suffering and built relationships with health care professionals.

Significance of results: This case highlights the observation that desire for hastened death fluctuates for patients at end-of-life and may be influenced by factors under the control of the palliative care team.

Without a well-functioning, prehospital, do-not-resuscitate (DNR) system in place, emergency medical service (EMS) providers must resuscitate all patients who access the system, regardless of the patients' wishes and regardless of what makes ethical or economic sense. In lieu of valid documentation, it is not appropriate to withhold resuscitative measures in this critical, time-dependent situation. In order to help EMS systems implement functional prehospital DNR protocols, this paper reviews the state-of-the-art of prehospital DNR including the issues to consider when designing such a system and a discussion of the features of some of the existing systems. This review includes: 1) the basis and requirements of a DNR system; 2) legal and physical forms for DNR orders; 3) eligibility for DNR status; 4) reversal of DNR orders; and 5) inappropriate use of EMS systems for DNR patients. Finally, a more general discussion of overall resource utilization in prehospital resuscitations is presented to emphasize that implementing prehospital DNR systems is only one piece of a larger issue.