Caught between intending and doing: older people ideating on a self-chosen death

Abstract

ObjectivesThe aim of this paper is to provide insight into what it means to live with the intention to end life at a self-chosen moment from an insider perspective.SettingParticipants who lived independent or semidependent throughout the Netherlands.Participants25 Dutch older citizens (mean age of 82 years) participated. They were ideating on a self-chosen death because they considered their lives to be no longer worth living. Inclusion criteria were that they: (1) considered their lives to be ‘completed’; (2) suffered from the prospect of living on; (3) currently wished to die; (4) were 70 years of age or older; (5) were not terminally ill; (6) considered themselves to be mentally competent; (7) considered their death wish reasonable.DesignIn this qualitative study, in-depth interviews were carried out in the participants’ everyday home environment (median lasting 1.56 h). Verbatim transcripts were analysed based on the principles of phenomenological thematic analysis.ResultsThe liminality or ‘in-betweenness’ of intending and actually performing self-directed death (or not) is characterised as a constant feeling of being torn explicated by the following pairs of themes: (1) detachment and attachment; (2) rational and non-rational considerations; (3) taking control and lingering uncertainty; (4) resisting interference and longing for support; (5) legitimacy and illegitimacy.ConclusionsOur findings show that the in-between period emerges as a considerable, existential challenge with both rational and non-rational concerns and thoughts, rather than a calculative, coherent sum of rational considerations. Our study highlights the need to take due consideration of all ambiguities and ambivalences present after a putatively rational decision has been made in order to develop careful policy and support for this particular group of older people.

Ethical uneasiness and the need for open-ended reflexivity: the case of research into older people with a wish to die

“…Driven by the outcomes of our research (and not by prefixed ideological ideas), we tend to favour restraint and qualify the public debate: the results have given insight into the shortcomings in the prevailing conception of people as independent, autonomous and self-determining agents; the need for due consideration of all ambiguities present in the wish to die; and the inadequacy of considering this wish to die to be an individual problem (van Wijngaarden et al, 2016a). Besides, we have suggested that addressing the social and positional aspects of the wish to die might be a more appropriate response to the concerns of these people than offering them a legal opportunity to die (van Wijngaarden et al, 2015a).…”

“…Besides, it turned out that the wish to die was not at all clear, coherent and unambiguous; rather it was characterized by ambivalent feelings of being torn, expressed in words like: 'dilemma' , 'doubt' , 'a difficult balancing act' and 'a split position ' (van Wijngaarden, Leget, & Goossensen, 2016a). Thus, after a putatively rational decision had been made (that life was considered to be over), all kinds of ambivalences and ambiguities remained present (van Wijngaarden et al, 2016a).…”

Assisted dying for healthy older people: a step too far?

“…4 At the same time, two of us conducted an independent in-depth study into the experiences of older people who consider their lives completed and do not wish to continue living. [23][24][25][26] This study has shown that completed life should be understood as "a tangle of inability and unwillingness to connect to life (to themselves, others, and the world) resulting in the experience that life is no longer worth living and death is preferred over life." 23 Those studied had no evidence of a severe physical or mental disease, but their disconnectedness arose from a profound sense of loneliness, the pain of not mattering, the growing inability to express themselves, existential and physical fatigue, and aversion to feared dependence and loss of control.…”

“…It is highly complicated-if not impossible-to establish whether the wish to die is truly consistent over time and without any (internalised) external pressure, whether the non-medical suffering is insoluble, and whether enabling an assisted death correctly addresses the (partly existential and social) needs and concerns in the lives of these older people. [23][24][25][26] In addition, allowing healthy older people the right to die might increase social pressure on this age group and reinforce negative ideas about old age. 24 Such concerns have led the medical profession, including the Dutch Association of Psychologists, 31 Dutch Nurses' Association, 32 and Royal Dutch Medical Association, 33 to raise objections to the governmental proposal.…”

First‐line nurse managers’ perceptions of the challenges involved in decision‐making when older patients’ wish to die

“…However, 5%–30% of older people who wish to die have no psychiatric or depressive disorder (Rurup, Deeg et al., ; van Wijngaarden, Leget, & Goossensen, ). Most older people who wish to die probably consider suicide unacceptable, as it is associated with despair and mutilation (van Wijngaarden, Leget, & Goossensen ). However, differences between older patients who wish to die and those who are suicidal have been described (Kim, Bogner, Brown, & Gallo, ).…”