The role of cognitive impairment in desire for hastened death: a study of patients with advanced AIDS

Abstract

To examine the relationship between cognitive impairment and desire for death in patients with advanced AIDS we evaluated 128 patients with advanced AIDS consecutively admitted to three long-term care facilities. Participants completed a clinical assessment that included a self-report measure of desire for hastened death in the medically ill (Schedule of Attitudes toward Hastened Death), three measures of cognitive functioning designed to screen for cognitive impairment (Dementia Rating Scale, Mini-Mental State Exam, HIV Dementia Scale), and other measures of physical and psychological functioning. Participants who were classified as cognitively impaired obtained significantly higher scores on the measure of desire for death than did patients without cognitive impairment. This modest association between cognitive impairment and desire for death remained significant even after controlling for the impact of depression on desire for death. Specific aspect of cognitive functioning such as memory and psychomotor coordination appeared to be more salient than executive functioning or abstract reasoning. Cognitive impairment appears to have a modest, but significant impact on patients’ desire for hastened death. Aggressive treatment of cognitive symptoms in the terminally ill is necessary in order to disentangle the various factors that may drive end-of-life treatment decisions.

Introduction

Understanding why terminally ill patients might desire a more rapid death or request physician-assisted suicide has become an important element of both palliative care and public policy. A growing body of research has focused on identifying factors that influence desire for hastened death or interest in assisted suicide in medical patients, although most of these studies have been limited both in scope and methodological rigor [1]. Nevertheless, this literature has begun to elucidate many correlates of desire for hastened death, as a few consistent findings have emerged. The most consistent correlates of desire for hastened death have been psychosocial influences such as depression, hopelessness, and social support [2], [3], [4], [5], [6].

Many symptoms of cognitive impairment may impede rational decision making such as difficulty thinking, cognitive disturbances, fearfulness, suspiciousness, and impulsivity. In addition, cognitive impairment may exacerbate a patient’s sense of helplessness and loss of control, possibly fueling a desire for hastened death or thoughts of suicide [7], [8], [9]. Yet despite the potential influence of cognitive impairment on desire for hastened death, no research to date has examined the possible contributing role of cognitive impairment. However, a handful of studies have explored the impact of cognitive impairment on decision-making and preferences for life-sustaining treatment (i.e., CPR, artificial nutrition), aspects of end-of-life decision-making that are clearly relevant to desire for hastened death [10], [11], [12], [13]. However, these studies have been limited by reliance on small samples, hypothetical scenarios, and simplistic measures of cognitive functioning. In addition, the results have been contradictory, as two studies have not observed a relationship between cognitive functioning and treatment choices [10], [11] and two demonstrated a correlation between cognitive impairment (i.e., lower MMSE scores) and a desire for life-sustaining interventions [12], [13]. Fazel and colleagues argued that cognitive impairment may limit a patient’s ability to understand the consequences or the potential benefits of treatment alternatives, leading to impulsive, deferential, or overly aggressive decisions [13].

Several studies have also addressed the impact of cognitive impairment on suicidal ideation in elderly and medically ill individuals. Some authors have suggested that even mild cognitive impairment is associated with suicidal ideation and requests for hastened death in medical patients [9], [14], [15], [16]. For example, Mendonca and Holden [15], [16] found that a combination of cognitive impairment and affective symptoms were the strongest predictors of severity of suicidal ideation in psychiatric patients. HIV-associated dementia has been suggested as a particularly strong risk factor for suicide because of the frequent impulsive behavior and emotional lability that accompanies this syndrome [7].

Understanding the impact of cognitive impairment on terminally ill patients’ desire for hastened death is particularly important given the high frequency of cognitive impairment among terminally ill populations in general and diseases like HIV/AIDS in particular [8], [17], [18]. As cognitive abilities such as abstract reasoning, problem solving, and memory become compromised, patients may have more difficulty making decisions and finding ways to improve their situation. In addition, the loss of cognitive abilities may directly impede one’s quality or enjoyment of life. Finally, an awareness of cognitive deficits may contribute to a patient’s sense of deterioration and increase their emotional distress. Given the likelihood that cognitive impairment may impact attitudes toward end-of-life care, we sought to examine the role of cognitive functioning in desire for hastened death among patients with advanced AIDS.