Wishing to hasten death

In 2021, the Canadian government brought in Bill C-7: An Act to Amend the Criminal Code (Medical Assistance in Dying), expanding the right to seek medical assistance in dying (MAID) to Canadians who aren’t near death immediately but who are intolerably suffering. People suffering solely from mental illnesses will have access to MAID as of March 2023. 

This will enable an exit from life for patients in the throes of as-yet incurable mental illness. Experts estimate that the number of requests for MAID from such severely ill persons will be small.

There is, however, another group of unwell persons who are not eligible for MAID. Those who may wish to hasten their death but who do not suffer from severe somatic or mental illness (some living in assisted-living settings) or, in rare situations, those who refuse to accept available treatments. The amendments in Bill C-7 are not applicable to those who present to their physicians with, for example, “tiredness of life.” These suffering individuals require professional clarification of their “death wishes,” which may not necessarily signify a true wish to end their life, but still require individually tailored health and social care in the context of their situation, especially when they are housed in an assisted-living facility. 

In 2020, the results of a large cross-sectional survey published in the Netherlands and Belgium reported the prevalence and characteristics of older adults with a persistent wish to die but without severe illness. Over 32 000 Dutch citizens over 55 years of age were questioned about health, existential issues, and the nature of their death wish (if present). Over 65% responded to the survey. Close to 1% reported an active wish to hasten their death without having a severe illness. The survey did not focus on residents in assisted-living situations.  

There are no equivalent BC data, but it is anecdotally recognized that there are elderly persons in assisted-living settings who have a persistent wish to hasten their death. These residents are often physically frail but without severe illness and usually still cognitively fit. They feel a tiredness of life, or may think that it would be better for them to die and put an end to a lonely or poor quality of life. There are also those who are in the grasp of a life-threatening treatable illness but who refuse available treatment—an equivalent to suicidal intent perhaps related to various background factors like denial of their situation, rebellion against their fate, or just not being able to see a future for themselves. 

The storyline of a 2016 Canadian movie, The Second Time Around, provides a realistic presentation, almost a case study, of the complexities of just such a situation in the context of the loneliness and isolation in some people’s lives in assisted-living settings. As the movie begins, an elderly widow has a bad fall, fracturing her hip. Against her wish she is moved into assisted living. A lover of operatic music, she had a lifelong plan to visit opera houses in Italy. Her plans are now shelved. Needing to have some clothing repaired, she gets help from a withdrawn, lonely, moody elderly resident, formerly an accomplished tailor, who is also a music lover. The two become romantically friendly through their love of music. Her enthusiasm for visiting Italian opera houses once her hip heals is contagious and her new friend catches her excitement. He becomes energized and plans to accompany her, visualizing his freedom from loneliness. Just then several unfortunate events impact his life. A friend of his in the residence takes his own life. Then he suffers a minor fall and in the course of his doctor’s visit his physician discovers a major medical threat to his life—a form of cancer with a hope of lengthy recovery with available treatment. Despite this reassurance, he reacts to the mounting realities likely to curtail his plans to accompany his friend to Italy. He feels powerless and defeated and responsible for the collapse of the travel plans. He turns to alcohol and isolates himself to withdraw from the relationship. His renewed interest in life is shattered. To hasten his death, he decides against any medical treatment.  

Spoliers follow. The movie has an upbeat ending; they do get to Italy. The unfolding story serves to illuminate the potential power of intimate relationships at vital turning points in life, when death appears preferable to enduring life. The supporting, rational intervention of a fellow male resident and the gentle, loving, music-filled intimate approach from the woman friend rekindles their closeness.  
—George Szasz, CM MD

Suggested reading
Cheung G, Edwards S, Sundram F. Death wishes among older people assessed for home support and long-term aged residential care. Int J Geriatr Psych 2016. doi: 10.1002/gps.4624.

Hartog ID, Zomers ML, van Thiel GLMW, et al: Prevalence and characteristics of older adults with a persistent death wish without severe illness: A large cross-sectional survey. BMC Geriatr 2020;20:342.

Ohnsorge K, Gudat H, Rehmann-Sutter C. What a wish to die can mean: Reasons, meanings and functions of wishes to die, reported from 30 qualitative case studies of terminally ill cancer patients in palliative care. BMC Palliat Care 2014;13:38.

Taber JM, Leyva B, Persoskie A. Why do people avoid medical care? A qualitative study using national data. J Gen Intern Med 2015;30:290-297.

This post has not been peer reviewed by the BCMJ Editorial Board.

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George Szasz says: reply

Adding to this blog post: Just a few days ago I came across an article from the Netherlands, published in Social Science and Medicine 2021 - describing a longitudinal study between 2013 and 2019 of 25 men and women of mean age 82, who expressed a wish to die a a self chosen moment. All were mentally competent and not terminally ill. 9 of the 25 ended heir lives. The remaining 16 still alive in 2019 reported that their wish to die disappeared because unexpected changes occurred in their lives, including meaningful volunteer work, new relationships, a successful move, reengaging in old interest, meaningful social connectedness with family and community. The study challenges the notion of almost inevitable increasing decline in old age: it can be a period of growth, changes and personal development. Social Science and Medicine 284 (2021) 114180.

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