Patient requests to hasten death. Evaluation and management in terminal care

Terminally ill patients often hope that death will come quickly. They may broach this wish with their physicians, and even request assistance in hastening death. Thoughts about accelerating death usually do not reflect a sustained desire for suicide or euthanasia, but have other important meanings that require exploration. When patients ask for death to be hastened, the following areas should be explored: the adequacy of symptom control; difficulties in the patient's relationships with family, friends, and health workers; psychological disturbances, especially grief, depression, anxiety, organic mental disorders, and personality disorders; and the patient's personal orientation to the meaning of life and suffering. Appreciation of the clinical determinants and meanings of requests to hasten death can broaden therapeutic options. In all cases, patient requests for accelerated death require ongoing discussion and active efforts to palliate physical and psychological distress. In those infrequent instances when a patient with persistent, irremediable suffering seeks a prompt and comfortable death, the physician must confront the moral, legal, and professional ramifications of his or her response. Rarely, acceding to the patient's request for hastening death may be the least terrible therapeutic alternative.