Each SBMConnect post briefly explains an issue or news item intended to have salience for our members. Each post is accompanied by a poll to get a sense of where SBM members stand on the topic. Discussion of each topic also takes place on our LinkedIn page.
And contact us if you’d like to post a conversation to SBMConnect and enhance your connection to SBM members.
California Gov. Jerry Brown signed the “End of Life Act” on October 5, making it legal for doctors in California to prescribe life-ending drugs to terminally ill patients who choose to die. Oregon, Washington, Vermont, and Montana have passed similar laws, and 23 other states have aid-in-dying bills in their legislatures.
Rates of desire for death among terminally ill patients vary according to population and assessment methods, but they have been estimated at 17-45%, including fleeting desire to die. These estimates are consistent with the fact that a minority of terminal patients in Oregon request lethal prescriptions. Most, but not all, of these patients go on to use their prescriptions.
End of Life Act Details
Correlates of the desire to die among terminally ill patients include major depression, hopelessness (independent of major depression), perceiving oneself as a burden to others, poor family cohesion, and having both a small number and a poor quality of social supports.
It is impossible to determine the “efficacy” of aid-in-dying policies using ordinary case-comparisons of patients who chose to die versus those who did not. However, there are other things we can do as professionals. When a patient expresses desire to die, we can assess the underlying reasons in an effort to present all available options. And we can build an evidence base for how to best support patients and providers in this process.
Shared decision making research could increase insight into the role of family functioning and burden perception on desire to die. Better quality social support may prevent patients from developing a desire to die. Effects of intervening on predictors of patient desire to die could guide clinical decision making. Research on doctor-patient communication might inform how providers discuss this subject. Providing patients the best opportunity to make a well-informed decision is important to our role as health professionals.
We must also understand ourselves. Why do (or don’t) we support patients in this decision process? What assumptions do we make about patients’ desires to die? About their medical and mental conditions? As scientists and practitioners, we must be open to considering our work differently.
Our way forward must include integrating mental health care into primary care delivery and developing effective assessments of the desire to die. These are not simple or easy goals, but it is our duty to improve and evolve the ways in which we serve the public.
What health decision making research is most critical, right now, for helping patients better navigate aid-in-dying conversations and options? Tell us what you think by answering the poll to the right. Then view the results and join our LinkedIn discussion.
Electronic cigarettes (e-cigarettes) have been labeled a disruptive technology resulting in much speculation as to whether they are likely to help or hinder efforts to reduce tobacco-related morbidity and mortality. Awareness of e-cigarettes has increased dramatically and public perceptions of their harmfulness vary (HINTS brief no. 28, February 2015). E-cigarette adoption has far outpaced knowledge of the actual harms and benefits, making informed discussion difficult for consumers, clinicians, and scientists alike.
What are E-Cigarettes?
E-cigarettes are a type of non-combustible, electronic nicotine delivery system (ENDS) that delivers aerosolized nicotine often called vapor. The nicotine in e-cigarettes comes in the form of a liquid made of nicotine, water, and a propellant (propylene glycol and/or glycerin) plus other chemical constituents like flavors. With the caveat that these products are currently unregulated and manufacturing varies, e-cigarette vapor contains no known carcinogens and fewer toxicants than cigarette smoke.
Friend or Foe?
E-cigarettes have been touted as a way to make combustible tobacco products obsolete either by helping smokers to quit or by replacing conventional cigarettes. Although far from definitive, the research available to date demonstrates promise for e-cigarettes in harm reduction. One randomized trial compared e-cigarettes to nicotine replacement therapy and found no difference in quitting outcomes. However, the relevance of these early trials and observational research, which studied first- and second-generation devices, is unclear in today’s market which includes third- and fourth-generation e-cigarettes, e-hookahs, and personal tank-style vaporizers which can deliver higher concentrations of nicotine. More research is needed to examine whether e-cigarettes can safely help more smokers than currently available cessation medications. If smokers who are unable to quit switched to e-cigarettes, this could also be a path toward eliminating tobacco-related illness. On the other hand, most e-cigarette users are dual users, meaning that they use both e-cigarettes and traditional cigarettes together. Replacing some but not all cigarettes with e-cigarettes may not yield measurable health benefits. From a public health perspective, opponents of e-cigarettes worry that normalizing smoking behavior could undo the progress achieved by decades of anti-smoking efforts like advertising bans and smoke-free laws. The strongest argument against e-cigarettes comes from concern over uptake among youth. Delivery of nicotine from e-cigarettes may harm the developing brain directly or serve as a gateway to further tobacco use.
Further studies are needed to understand the potential risks and benefits of e-cigarettes. Federal regulation and defining a clear research agenda, such as that recommended jointly by the American Association for Cancer Research and the American Society of Clinical Oncology (Brandon et al. 2015), are key steps toward understanding the promise or peril of e-cigarettes.