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Research ArticleRegular Articles

End-of-Life Mental Health Assessments for Older Aged, Medically Ill Persons With Expressed Desire to Die

Linda E. Weinberger, Shoba Sreenivasan and Thomas Garrick
Journal of the American Academy of Psychiatry and the Law Online September 2014, 42 (3) 350-361;
Linda E. Weinberger
Dr. Weinberger is Professor of Clinical Psychiatry and the Behavioral Sciences, Keck School of Medicine, University of Southern California, and Chief Psychologist, USC Institute of Psychiatry, Law, and Behavioral Science, Los Angeles, CA. Dr. Sreenivasan is Clinical Professor of Psychiatry and the Behavioral Sciences, Keck School of Medicine, University of Southern California, and Director, Forensic Outreach Services, Greater Los Angeles VA Medical Center, Los Angeles, CA. Dr. Garrick is Professor of Psychiatry, Geffen School of Medicine, University of California, Los Angeles and Chief of General Hospital Psychiatry, Greater Los Angeles VA Medical Center, Los Angeles, CA.
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Shoba Sreenivasan
Dr. Weinberger is Professor of Clinical Psychiatry and the Behavioral Sciences, Keck School of Medicine, University of Southern California, and Chief Psychologist, USC Institute of Psychiatry, Law, and Behavioral Science, Los Angeles, CA. Dr. Sreenivasan is Clinical Professor of Psychiatry and the Behavioral Sciences, Keck School of Medicine, University of Southern California, and Director, Forensic Outreach Services, Greater Los Angeles VA Medical Center, Los Angeles, CA. Dr. Garrick is Professor of Psychiatry, Geffen School of Medicine, University of California, Los Angeles and Chief of General Hospital Psychiatry, Greater Los Angeles VA Medical Center, Los Angeles, CA.
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Thomas Garrick
Dr. Weinberger is Professor of Clinical Psychiatry and the Behavioral Sciences, Keck School of Medicine, University of Southern California, and Chief Psychologist, USC Institute of Psychiatry, Law, and Behavioral Science, Los Angeles, CA. Dr. Sreenivasan is Clinical Professor of Psychiatry and the Behavioral Sciences, Keck School of Medicine, University of Southern California, and Director, Forensic Outreach Services, Greater Los Angeles VA Medical Center, Los Angeles, CA. Dr. Garrick is Professor of Psychiatry, Geffen School of Medicine, University of California, Los Angeles and Chief of General Hospital Psychiatry, Greater Los Angeles VA Medical Center, Los Angeles, CA.
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    Table 1

    Suicides of 166 Persons 65 Years of Age or Older in Los Angeles County in 2000

    Aged 65–74 (n = 61) n (%)Aged 75–84 (n = 82) n (%)Aged 85 and older (n = 23) n (%)
    Sex
        Male49 (80.3)71 (86.6)18 (78.3)
        Female12 (19.7)11 (13.4)5 (21.7)
    Race
        White41 (67.2)60 (73.2)17 (73.9)
        Black6 (9.8)2 (2.4)1 (4.3)
        Hispanic8 (13.1)9 (11.0)2 (8.7)
        Asian/Pacific islander6 (9.8)11 (13.4)3 (13.0)
    Marital status
        Married23 (37.7)38 (46.3)7 (30.4)
        Divorced18 (29.5)8 (9.8)2 (8.7)
        Widowed11 (18.0)20 (24.4)14 (60.9)
        Single/separated8 (13.1)14 (17.1)0 (0.0)
        Unknown1 (1.6)2 (2.4)0 (0.0)
    Means of death
        Gunshot to head32 (52.5)41 (50.0)8 (34.8)
        Gunshot to body2 (3.2)7 (8.6)4 (17.4)
        Hanging10 (16.4)11 (13.4)3 (13.0)
        Overdose8 (13.1)7 (8.5)4 (17.4)
        Fall2 (3.2)4 (4.9)1 (4.3)
        Other7 (11.5)12 (14.6)3 (13.0)
    Presence of alcohol in body*
        Yes5 (8.2)5 (6.1)3 (13.0)
        No56 (91.8)77 (93.9)20 (87.0)
    Place of death
        Home alone21 (34.4)36 (43.9)13 (56.5)
        Alone in garage7 (11.5)9 (11.0)1 (4.3)
        Alone in home but person in another room16 (26.2)17 (20.7)6 (26.1)
        Other location17 (27.9)20 (24.4)3 (13.0)
    Mental state†
        Depression56 (91.8)73 (89.0)23 (100)
        Dementia1 (1.6)1 (1.2)0 (0.0)
        Agitation2 (3.3)2 (2.4)0 (0.0)
        Alcohol intoxication2 (3.3)2 (2.4)0 (0.0)
        Psychosis0 (0.0)1 (1.2)0 (0.0)
        Unknown3 (4.9)6 (7.3)0 (0.0)
    Presence of physical illness*
        Yes45 (73.8)69 (84.1)18 (78.3)
        No1 (1.6)1 (1.2)1 (4.3)
        Unknown15 (24.6)12 (14.6)4 (17.4)
    Medical history†
        Cancer16 (26.2)22 (26.8)5 (21.7)
        Cardiovascular10 (16.4)14 (17.1)6 (26.1)
        COPD4 (6.6)8 (9.8)3 (13.0)
        Stroke4 (6.6)7 (8.5)3 (13.0)
    In medical or mental health treatment*
        Yes47 (77.0)67 (81.7)15 (65.2)
        No1 (1.6)3 (3.7)3 (13.0)
        Unknown13 (21.3)12 (14.6)5 (21.7)
    Stressor at time of suicide†
        Physical health42 (68.9)62 (75.6)19 (82.6)
        Mental health37 (60.7)46 (56.1)12 (52.2)
        Loss of family member or significant other6 (9.8)12 (14.6)4 (17.4)
        Loss of friend2 (3.3)0 (0.0)1 (4.3)
        Financial problems6 (9.8)1 (1.2)0 (0.0)
        Legal problems2 (3.3)2 (2.4)1 (4.3)
        Family problems4 (6.6)5 (6.1)1 (4.3)
        Forced retirement2 (3.3)1 (1.2)0 (0.0)
        Feeling like a burden0 (0.0)6 (7.3)4 (17.4)
    • COPD, chronic obstructive pulmonary disorder.

    • ↵* At time of death.

    • ↵† More than one category per person may apply.

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    Table 2

    Data on the Death with Dignity Act for Oregon and Washington

    Oregon 1998–2011 (n = 596) n (%)*Washington 2009–2011 (n = 213) n (%)*
    Sex
        Male308 (51.7)111 (52.1)
        Female288 (48.3)102 (47.9)
    Age, years
        18–346 (1.0)0 (0)
        35–4414 (2.3)3 (1.4)
        45–5444 (7.4)19 (8.9)
        55–64123 (20.6)45 (21.1)
        65–74170 (28.5)67 (31.5)
        75–84168 (28.2)47 (22.1)
        85+71 (11.9)32 (15.0)
    Race(n = 189)†
        White579 (97.6)180 (95.2)
        Hispanic or non-white14 (2.4)9 (4.8)
        Unknown30
    Marital status(n = (189)†
        Married271 (45.7)90 (47.6)
        Widowed134 (22.6)41 (21.7)
        Divorced139 (23.4)42 (22.2)
        Never married49 (8.3)16 (8.5)
        Unknown30
    Underlying Illness
        Cancer480 (80.9)166 (77.9)
        Neurodegenerative disease (including ALS)44 (7.4)22 (10.3)
        Respiratory disease (including COPD)25 (4.2)9 (4.2)
        Heart Disease10 (1.7)10 (4.7)
        HIV/AIDS8 (1.3)Not noted
        Other illnesses26 (4.4)6 (2.8)
        Unknown30
    End-of-life concerns‡n = (592)§(n = 202)‖
        Losing autonomy538 (90.9)183 (90.6)
        Less able to engage in activities that make life enjoyable523 (88.3)179 (88.6)
        Loss of dignity386 (82.7)151 (74.8)
        Losing control of bodily functions318 (53.7)105 (52.0)
        Burden on family, friends/caregivers214 (36.1)78 (38.6)
        Inadequate pain control or concern about it134 (22.6)70 (34.7)
        Financial implications of treatment15 (2.5)8 (4.0)
    Health care provider present when medication ingested(n = 526)¶(n = 157)#
        Prescribing physician or other provider331 (82.1)87 (62.6)
        No provider72 (17.9)52 (37.4)
        Unknown123**18
    At time of death
        Prescribing physician or other provider343 (66.7)Not noted
        No provider171 (33.3)Not noted
        Unknown12††Not noted
    • The totals for some categories are less than the number of people who died in Washington, because not all data had been received or reported at the time the report was written. Data are expressed as n (%), unless otherwise noted. COPD, chronic obstructive pulmonary disorder; ALS, amyotrophic lateral sclerosis.

    • ↵* Unknowns are excluded when calculating percentages.

    • ↵† Data available for 87 of the 94 participants who died in 2011, 61 of the 72 who died in 2010, and 41 of the 47 who died in 2009.

    • ↵‡ Participants may have noted more than one concern; therefore, total percentage may be more than 100% for both Oregon and Washington.

    • ↵§ Data unavailable for 4 participants in 2001.

    • ↵‖ Data available for 91 of the 94 participants who died in 2011, 67 of the 72 who died in 2010, and 44 of the 47 who died in 2009.

    • ↵¶ Data are reported for 2001–2011.

    • ↵# Of those participants who ingested the medication and died, data are available for 70 in 2011, 51 in 2010, and 36 in 2009.

    • ↵** A procedure revision in Oregon, adopted mid-year 2010, accepts information only when a physician or other health care provider is present at time of death; thus, resulting in a larger number of unknowns beginning in 2010.

    • ↵†† Noted for 2001–2010.

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Journal of the American Academy of Psychiatry and the Law Online: 42 (3)
Journal of the American Academy of Psychiatry and the Law Online
Vol. 42, Issue 3
1 Sep 2014
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End-of-Life Mental Health Assessments for Older Aged, Medically Ill Persons With Expressed Desire to Die
Linda E. Weinberger, Shoba Sreenivasan, Thomas Garrick
Journal of the American Academy of Psychiatry and the Law Online Sep 2014, 42 (3) 350-361;

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End-of-Life Mental Health Assessments for Older Aged, Medically Ill Persons With Expressed Desire to Die
Linda E. Weinberger, Shoba Sreenivasan, Thomas Garrick
Journal of the American Academy of Psychiatry and the Law Online Sep 2014, 42 (3) 350-361;
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  • Article
    • Abstract
    • Epidemiology of Suicide in Later Life
    • Suicide of Elderly Persons in Los Angeles County
    • States with Assisted Suicide or Death With Dignity Acts
    • Death and Existential Concerns
    • Refusal of Treatment as Passive Suicidal Ideation
    • Legal and Moral Aspects of Assisted Suicide in the United States
    • Ethics Guidelines Related to Assisted Suicide and End of Life
    • Conclusions
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