Palliative Care for Geriatric Psychiatric Patients with Life-Limiting Illness

  • Margaret W. LeungEmail author
  • Lawrence E. Kaplan
  • James A. Bourgeois


Many geriatric psychiatric patients face life-limiting illness. Optimal palliative care which focuses on aggressive symptom management while exploring advance care planning to help anticipate goals of care begins at the time of diagnosis of disease and continues until the end of life. Major neurocognitive disorder is discussed as a terminal illness that merits early palliative care involvement as physical complications are anticipated as part of the natural progression of disease. As life-limiting illness progresses, psychiatrists are often asked to weigh in the management of delirium, depressive, anxiety, and substance abuse disorders in the palliative care setting. Diagnostic and treatment challenges arise in managing these disorders because of medical frailty and the overlap of symptoms related to disease progression. Psychiatrists may also be asked to participate in evaluating patients who request physician aid in dying.


Palliative care End-of-life care Prognosis Goals of care Major neurocognitive disorder Terminal delirium Depression Anxiety Substance use disorder Physician aid in dying 


  1. 1.
    Back A, Arnold RM, Quill TE. Hope for the best, and prepare for the worst. Ann Intern Med. 2003;138(5):439–44.PubMedCrossRefGoogle Scholar
  2. 2.
    Bernacki R, Block S. Communication about serious illness care goals: a review and synthesis of best practices. JAMA Int Med. 2014;174(12):1994–2003.CrossRefGoogle Scholar
  3. 3.
    Mitchell SL, Teno JM, Jiely DK, et al. The clinical course of advanced dementia. N Engl J Med. 2009;361(16):1529–38.PubMedPubMedCentralCrossRefGoogle Scholar
  4. 4.
    Dufour AB, Shaffer ML, D’Agata EM, et al. Survival after suspected urinary tract infection in individuals with advanced dementia. J Am Geriatr Soc. 2015;63(12):2472–7.PubMedPubMedCentralCrossRefGoogle Scholar
  5. 5.
    Givens JL, Jones RN, Shaffer ML, et al. Survival and comfort after treatment of pneumonia in advanced dementia. Arch Intern Med. 2010;170(3):1102–7.PubMedPubMedCentralGoogle Scholar
  6. 6.
    Ahronheim JC, Morrison RS, Baskin SA, et al. Treatment of the dying in the acute care hospital: advanced dementia and metastatic cancer. Arch Intern Med. 1996;156(18):2094–100.PubMedCrossRefGoogle Scholar
  7. 7.
    Mitchell SL, Kiely DK, Hamel MB. Dying with advanced dementia in the nursing home. Arch Intern Med. 2004;164(3):321–6.PubMedCrossRefGoogle Scholar
  8. 8.
    Teno JM, Gozalo P, Mitchell SL, et al. Feeding tubes and the prevention or healing of pressure ulcers. Arch Intern Med. 2012;172(9):697–701.PubMedPubMedCentralCrossRefGoogle Scholar
  9. 9.
    Garrow D, Pride P, Moran W, et al. Feeding alternatives in patients with dementia: examining the evidence. Clin Gastroenterol Hepatol. 2007;5(12):1372–8.PubMedCrossRefGoogle Scholar
  10. 10.
    Cintra MT, de Rezende NA, de Morales EN, et al. A comparison of survival, pneumonia and hospitalization in patients with advanced dementia and dysphagia receiving either oral or enteral nutrition. J Nutr Health Aging. 2014;18(10):894–9.PubMedCrossRefGoogle Scholar
  11. 11.
    Kuo S, Rhodes RL, Mitchell SL, et al. Natural history of feeding-tube use in nursing home residents with advanced dementia. J Am Med Dir Assoc. 2009;10(4):264–70.PubMedPubMedCentralCrossRefGoogle Scholar
  12. 12.
    Henderson CT, Trumbore LS, Mobarhan S, et al. Prolonged tube feeding in long-term care: nutritional status and clinical outcomes. J Am Coll Nutr. 1992;11(3):309–25.PubMedCrossRefGoogle Scholar
  13. 13.
    American Geriatrics Society Ethics Committee and Clinical Practice and Models of Care Committee. American Geriatrics Society feeding tubes in advanced dementia position statement. J Am Geriatr Soc. 2014;62(8):1590–3.CrossRefGoogle Scholar
  14. 14.
    Reisberg B. Functional assessment staging (FAST). Psychopharmacol Bull. 1988;24(4):653–9.PubMedGoogle Scholar
  15. 15.
    Mitchell SL, Kiely DK, Hamel MB, et al. Estimating prognosis for nursing home residents with advanced dementia. J Am Med Assoc. 2004;291(22):2734–40.CrossRefGoogle Scholar
  16. 16.
    Aminoff BZ. Mini-suffering state examination scale: possible key criterion for 6-month survival and mortality of critically ill dementia patients. Am J Hosp Palliat Care. 2008;24(6):470–4.CrossRefGoogle Scholar
  17. 17.
    Brown MA, Sampson EL, Jones L, et al. Prognostic indicators of 6-month mortality in elderly people with advanced dementia: a systematic review. Palliat Med. 2013;27(5):389–400.PubMedPubMedCentralCrossRefGoogle Scholar
  18. 18.
    Hendriks SA, Smalbrugge M, Galindo-Garre F, et al. From admission to death: prevalence and course of pain, agitation, and shortness of breath, and treatment of these symptoms in nursing home residents with dementia. J Am Med Dir Assoc. 2015;16(6):475–81.PubMedCrossRefGoogle Scholar
  19. 19.
    Hendriks SA, Smalbrugge M, Hertogh CM, et al. Dying with dementia: symptoms, treatment, and quality of life in the last week of life. J Pain Sympt Manage. 2014;47(4):710–20.CrossRefGoogle Scholar
  20. 20.
    Brecher DB, West TL. Underrecognition and undertreatment of pain and behavioral symptoms in end-stage dementia. Am J Hosp Palliat Med. 2016;33(3):276–80.CrossRefGoogle Scholar
  21. 21.
    Herr K, Busch H, Ersek M, et al. Use of pain-behavioral assessment tools in the nursing home: expert consensus recommendations for practice. J Gerontol Nurs. 2010;36(3):18–29.PubMedCrossRefGoogle Scholar
  22. 22.
    Kelly KG, Zisselman M, Cutillo-Schmitter T, et al. Severity and course of delirium in medically hospitalized nursing facility residents. Am J Geriatr Psychiatry. 2001;9(1):72–7.PubMedCrossRefGoogle Scholar
  23. 23.
    Lawlor PG, Fainsinger RL, Bruera ED. Delirium at the end of life: critical issues in clinical practice and research. JAMA. 2000;284(19):2427–9.PubMedCrossRefGoogle Scholar
  24. 24.
    Leonard M, Raju B, Conroy M, Donnelly S, et al. Reversibility of delirium in terminally ill patients and predictors of mortality. Palliat Med. 2008;22(7):848–54.PubMedCrossRefGoogle Scholar
  25. 25.
    Breitbart WC, Gibson C, Tremblay A. The delirium experience: delirium recall and delirium-related distress in hospitalized patients with cancer, their spouses/caregivers, and their nurses. Psychosomatics. 2002;43(3):183–94.PubMedCrossRefGoogle Scholar
  26. 26.
    Breitbart W, Alici Y. Agitation and delirium at the end of life: “we couldn’t manage him”. JAMA. 2008;300(24):2898–910.PubMedCrossRefGoogle Scholar
  27. 27.
    Coyle N, Breitbart W, Weaver S, et al. Delirium as a contributing factor to “crescendo” pain: three case reports. J Pain Symptom Manag. 1994;9(1):44–7.CrossRefGoogle Scholar
  28. 28.
    Maldonado JR. Neuropathogenesis of delirium: review of current etiologic theories and common pathways. Am J Geriatr Psychiatry. 2013;21(12):1190–222.PubMedCrossRefGoogle Scholar
  29. 29.
    Maldonado JR. Pathoetiological model of delirium: a comprehensive understanding of the neurobiology of delirium and an evidence-based approach to prevention and treatment. Crit Care Clin. 2008;24(4):789–856.PubMedCrossRefGoogle Scholar
  30. 30.
    Morita T, Tei Y, Tsunoda J, et al. Underlying pathologies and their associations with clinical features in terminal delirium of cancer patients. J Pain Symptom Manag. 2001;22(6):997–1006.CrossRefGoogle Scholar
  31. 31.
    Leonard MM, Nekolaichuk C, Meagher DJ, et al. Practical assessment of delirium in palliative care. J Pain Sympt Manage. 2014;48(2):176–90.CrossRefGoogle Scholar
  32. 32.
    Boettger S, Jenewein J, Breitbart W. Delirium and severe illness: etiologies, severity of delirium, and phenomenological differences. Palliat Support Care. 2015;13(4):1087–92.PubMedCrossRefGoogle Scholar
  33. 33.
    Moyer DD. Terminal delirium in geriatric patients with cancer at the end of life. Am J Hosp Palliat Med. 2011;28(1):44–51.CrossRefGoogle Scholar
  34. 34.
    Jackson KC, Lipman AG. Drug therapy for delirium in terminally ill patients. Cochrane Database Syst Rev. 2004;2:CD004770.Google Scholar
  35. 35.
    Ventafridda V, Ripamonti C, De Conno F, et al. Symptom prevalence and control during cancer patients’ last days of life. J Palliat Care. 1990;6(3):7–11.PubMedGoogle Scholar
  36. 36.
    Fainsinger RL, Waller A, Bercovici M, et al. A multicentre international study of sedation for uncontrolled symptoms in terminally ill patients. Palliat Med. 2000;4(4):257–65.CrossRefGoogle Scholar
  37. 37.
    Lo B, Rubenfeld G. Palliative sedation in dying patients: “we turn to it when everything else hasn’t worked”. JAMA. 2005;294(14):1810–6.PubMedCrossRefGoogle Scholar
  38. 38.
    Morita T, Chinone Y, Ikenaga M, et al. Efficacy and safety of palliative sedation therapy: a multicenter, prospective, observational study conducted on specialized palliative care units in Japan. J Pain Symptom Manag. 2005;30(4):320–8.CrossRefGoogle Scholar
  39. 39.
    Sykes N, Thorns A. Sedative use in the last week of life and the implications for end-of-life decision making. Arch Intern Med. 2003;163(3):341–4.PubMedCrossRefGoogle Scholar
  40. 40.
    Vitetta L, Kenner D, Sali A. Sedation and analgesia-prescribing patterns in terminally ill patients at the end of life. Am J Hosp Palliat Care. 2005;22(6):465–73.PubMedCrossRefGoogle Scholar
  41. 41.
    Block SD. Psychological issues in end-of-life care. J Palliat Med. 2006;9(3):751–72.PubMedCrossRefGoogle Scholar
  42. 42.
    Wilson KG, Lander M. Chochinov. Diagnosis and management of depression in palliative care. In: Chochinov HM, Breitbart W, editors. Handbook of psychiatry in palliative medicine. 2nd ed. New York: Oxford University Press; 2009. p. 39–68.Google Scholar
  43. 43.
    Passik SD, Dugan W, McDonald MV, et al. Oncologists’ recognition of depression in their patients with cancer. J Clin Oncol. 1998;16(4):1594–600.PubMedCrossRefGoogle Scholar
  44. 44.
    Irwin SA, Rao S, Bower K, et al. Psychiatric issues in palliative care: recognition of depression enrolled in hospice care. J Palliat Med. 2008;11(2):158–63.PubMedCrossRefGoogle Scholar
  45. 45.
    Lloyd-Williams M, Shiels C, Taylor F, et al. Depression-an independent predictor of early death in patients with advanced cancer. J Affect Disord. 2009;113(1–2):127–32.PubMedCrossRefGoogle Scholar
  46. 46.
    Noorani NH, Montagnini M. Recognizing depression in palliative care patients. J Palliat Med. 2007;10(2):458–64.PubMedCrossRefGoogle Scholar
  47. 47.
    Block SD. Assessing and managing depression in the terminally ill patient. Ann Intern Med. 2000;132(3):209–18.PubMedCrossRefGoogle Scholar
  48. 48.
    Endicott J. Measurement of depression in patients with cancer. Cancer. 1984;53(10S):2243–8.PubMedCrossRefGoogle Scholar
  49. 49.
    Kissane DW, Clarke DM. Demoralization syndrome: a relevant psychiatric diagnosis for palliative care. J Palliat Care. 2001;17(1):12–21.PubMedGoogle Scholar
  50. 50.
    Block SD. Psychological considerations, growth, and transcendence at the end of life. JAMA. 2001;285(22):2898–905.PubMedCrossRefGoogle Scholar
  51. 51.
    Shear MK. Grief and mourning gone awry: pathway and course of complicated grief. Dialogues Clin Neurosci. 2012;14(2):119–28.PubMedPubMedCentralGoogle Scholar
  52. 52.
    McCabe PJ, Christopher PP. Symptom and functional traits of brief major depressive episodes and discrimination of bereavement. Depress Anxiety. 2016;33(2):112–9.PubMedCrossRefGoogle Scholar
  53. 53.
    Chochinov HM, Wilson KG, Enns M, et al. “Are you depressed?” screening for depression in the terminally ill. Am J Psychiatr. 1997;154(5):674–6.PubMedCrossRefGoogle Scholar
  54. 54.
    Mitchell AJ. Are one or two questions sufficient to detect depression in in cancer and palliative care? A Bayesian meta-analysis. Br J Cancer. 2008;98(12):1934–43.PubMedPubMedCentralCrossRefGoogle Scholar
  55. 55.
    Lloyd-Williams M, Dennis M, Taylor F. A prospective study to compare three depression screening tools in patients who are terminally ill. Gen Hosp Psychiatry. 2004;26(5):384–9.PubMedCrossRefGoogle Scholar
  56. 56.
    Hardy SE. Methylphenidate for the treatment of depressive symptoms, including fatigue and apathy, in medically ill older adults and terminally ill adults. Am J Geriatr Pharmacother. 2009;7(1):34–59.PubMedPubMedCentralCrossRefGoogle Scholar
  57. 57.
    Prommer E. Methylphenidate: established and expanding roles in symptom management. Am J Hosp Palliat Med. 2012;29(6):483–90.CrossRefGoogle Scholar
  58. 58.
    Raynor L, Price A, Evans A, et al. Antidepressants for the treatment of depression in palliative care: systematic review and meta-analysis. Palliat Med. 2011;25(1):36–51.CrossRefGoogle Scholar
  59. 59.
    Feigenberg L, Shneidman E. Clinical thanatology and psychotherapy: some reflections on caring for the dying person. Omega. 1979;10(1):1–8.Google Scholar
  60. 60.
    Chochinov HM. Dignity therapy: final words for final days. New York: Oxford University Press; 2012.CrossRefGoogle Scholar
  61. 61.
    Martinez M, Arantzamendi M, Belar A, et al. “Dignity therapy”: a promising intervention in palliative care: a comprehensive systemic literature review. Palliat Med. 2016;31(6):492–509. pii: 0269216316665562.PubMedPubMedCentralCrossRefGoogle Scholar
  62. 62.
    Juliao M, Oliveira F, Nunes B, et al. Efficacy of dignity therapy on depression and anxiety in Portuguese terminally ill patients: a phase II randomized controlled trial. J Palliat Med. 2014;17(6):686–95.CrossRefGoogle Scholar
  63. 63.
    Thomas LP, Meier EA, Irwin SA. Meaning-centered psychotherapy: a form of psychotherapy for patients with cancer. Curr Psychiatry Rep. 2014;16(10):488.PubMedCrossRefGoogle Scholar
  64. 64.
    Breitbart W, Poppito S, Rosenfeld B, et al. Pilot randomized controlled trial of individual meaning-centered psychotherapy for patients with advanced cancer. J Clin Oncol. 2012;30(12):1304–9.PubMedPubMedCentralCrossRefGoogle Scholar
  65. 65.
    Breitbart W, Rosenfeld B, Gibson C, et al. Meaning-centered group psychotherapy for patients with advanced cancer: a pilot randomized controlled trial. Psychooncology. 2010;19(1):21–8.PubMedPubMedCentralCrossRefGoogle Scholar
  66. 66.
    Nissen R, Freeman E, Lo C, et al. Managing Cancer and Living Meaningfully (CALM): a qualitative study of a brief individual psychotherapy for individuals with cancer. Palliat Med. 2011;26(5):713–21.CrossRefGoogle Scholar
  67. 67.
    Lo C, Hales S, Jung J, et al. Managing Cancer and Living Meaningfully (CALM): phase 2 trial of a brief individual psychotherapy for patients with advanced cancer. Palliat Med. 2043;28(3):234–42.CrossRefGoogle Scholar
  68. 68.
    Roth AJ, Massie MJ. Anxiety in palliative care. In: Chochinov HM, Breitbart W, editors. Handbook of psychiatry in palliative medicine. 2nd ed. New York: Oxford University Press; 2009. p. 69–80.Google Scholar
  69. 69.
    Roscoe JA, Morrow GR, Aapro MS, et al. Anticipatory Nausea and Vomiting. Support Care Cancer. 2011;19(10):1533–8.PubMedCrossRefGoogle Scholar
  70. 70.
    Ganzel BL. Trauma-informed hospice and palliative care. Gerontologist. 2016.
  71. 71.
    Cicero TJ, Inciardi JA, Munoz A. Trends in abuse of Oxycontin and other opioid analgesics in the United States: 2002–2004. J Pain. 2005;6(10):662–72.PubMedCrossRefGoogle Scholar
  72. 72.
    Gilson AM, Ryan KM, Joranson DE, et al. A reassessment of trends in the medical use and abuse of opioid analgesics and implications for diversion control: 1997–2002. J Pain Symptom Manag. 2004;28(2):176–88.CrossRefGoogle Scholar
  73. 73.
    Dev R, Parsons HA, Palla S, et al. Undocumented alcoholism and its correlation with tobacco and illegal drug use in advanced cancer patients. Cancer. 2011;117(19):4551–6.PubMedPubMedCentralCrossRefGoogle Scholar
  74. 74.
    Barclay JS, Owens JE, Blackhall LJ. Screening for substance abuse risk in cancer patients using the opioid risk tool and urine drug screen. Support Care Cancer. 2014;22(7):1883–8.PubMedCrossRefGoogle Scholar
  75. 75.
    Lundberg JC, Passik SD. Alcohol and cancer: a review for psycho-oncologists. Psycho-Onc. 1997;6(4):253–66.CrossRefGoogle Scholar
  76. 76.
    Passik SD, Portenoy RK, Ricketts PL. Substance abuse issues in cancer patients. Part 2: evaluation and treatment. Oncology. 1998;12(5):729–34.PubMedGoogle Scholar
  77. 77.
    Ramer L, Richardson JL, Cohen MZ, et al. Multimeasure pain assessment in an ethnically diverse group of patients with cancer. J Transcult Nurs. 1999;10(2):94–101.PubMedCrossRefGoogle Scholar
  78. 78.
    Ward SE, Goldberg N, Miller-McCauley V, et al. Patient-related barriers to management of cancer pain. Pain. 1993;52(3):319–24.PubMedCrossRefGoogle Scholar
  79. 79.
    Anderson KO, Mendoza TR, Valero V, et al. Minority cancer patients and their providers: pain management attitudes and practice. Cancer. 2000;88(8):1929–38.PubMedCrossRefGoogle Scholar
  80. 80.
    Gonzales GR, Coyle N. Treatment of cancer pain in a former opioid abuser: fears of the patient and staff and their influence on care. J Pain Symptom Manag. 1992;7(4):246–9.CrossRefGoogle Scholar
  81. 81.
    Passik SD, Kirsh KL, Webster L. Pseudoaddiction revisited: a commentary on clinical and historical considerations. Pain Management. 2011;1(3):239–48.PubMedCrossRefGoogle Scholar
  82. 82.
    Kirsh KL, Passik SD. Palliative care of the terminally ill drug addict. Cancer Investig. 2006;24(4):425–31.CrossRefGoogle Scholar
  83. 83.
    Passik S, Kirsh KL, Casper D. Addiction-related assessment tools and pain management: instruments for screening, treatment planning, and monitor compliance. Pain Med. 2008;9(S2):S145–66.CrossRefGoogle Scholar
  84. 84.
    Starrels JL, Becker WC, Alford DP, et al. Systemic review: treatment agreements with urine drug testing to reduce opioid misuse in patients with chronic pain. Ann Intern Med. 2010;152(11):712–20.PubMedCrossRefGoogle Scholar
  85. 85.
    Pesce A, West C, Egan City K, Strickland J. Interpretation of urine drug testing in pain patients. Pain Med. 2012;13(7):868–85.PubMedCrossRefGoogle Scholar
  86. 86.
    Attal N, Cruccu G, Baron R, et al. EFNS guidelines on the pharmacological treatment of neuropathic pain: 2010 revision. Eur J Neurol. 2010;17(9):1113–e88.–1331.2010.02999.x.PubMedCrossRefGoogle Scholar
  87. 87.
    Dowell D, Haegerich TM, Chou R. CDC guideline for prescribing opioids for chronic pain—United States, 2016. JAMA. 2016;315(15):1624–45.PubMedCrossRefGoogle Scholar
  88. 88.
    Prommer EE. Ketamine for pain: an update of uses in palliative care. J Palliat Med. 2012;15(4):474–83.PubMedCrossRefGoogle Scholar
  89. 89.
    Chow R, Chiu L, Navari R, et al. Efficacy and safety of olanzapine for the prophylaxis of chemotherapy-induced nausea and vomiting (CINV) as reported in phase I and II studies: a systemic review. Support Care Cancer. 2016;24(2):1001–8.PubMedCrossRefGoogle Scholar
  90. 90.
    Naing A, Dalal S, Abderlrahim M, et al. Olanzapine for cachexia in patients with advanced cancer: an exploratory study of effects on weight and metabolic cytokines. Support Care Cancer. 2015;23(9):2649–54.PubMedCrossRefGoogle Scholar
  91. 91.
    Spathis A, Fife K, Blackhall F, et al. Modafanil for the treatment of fatigue in lung cancer: results of a placebo-controlled, double-blinded, randomized trial. J Clin Oncol. 2014;32(18):1882–8.PubMedCrossRefGoogle Scholar
  92. 92.
    Minton O, Richardson A, Sharpe M, et al. A systematic review and meta-analysis of the pharmacological treatment of cancer-related fatigue. J Natl Cancer Inst. 2008;100(16):1155–66.PubMedCrossRefGoogle Scholar
  93. 93.
    Patel T, Yosipovitch G. Therapy of pruritus. Expert Opin Pharmacother. 2010;11(10):1673–82.PubMedPubMedCentralCrossRefGoogle Scholar
  94. 94.
    Sullivan MD, Ganzini L, Youngner SJ. Should psychiatrists serve as gatekeepers for physician-assisted suicide? Hast Cent Rep. 1998;28(4):24–31.CrossRefGoogle Scholar
  95. 95.
    Rich BA. Pathologizing suffering and the pursuit of a peaceful death. Camb Q Healthc Ethics. 2014;23(4):403–16.PubMedCrossRefGoogle Scholar
  96. 96.
    Hudson PL, Kristjanson LJ, Ashby M, et al. Desire for hastened death in patients with advanced disease and the evidence base of clinical guidelines: a systemic review. Palliat Med. 2006;20(7):693–701.PubMedCrossRefGoogle Scholar
  97. 97.
    Olden M, Pessin H, Lichtenthal WG, et al. Suicide and desire for hastened death in terminally ill. In: Chochinov HM, Breitbart W, editors. Handbook of psychiatry in palliative medicine. 2nd ed. New York: Oxford University Press; 2009. p. 101–12.Google Scholar
  98. 98.
    Kelly B, Burnett P, Pelusi D, et al. Factors associated with the wish to hasten death: a study of patients with terminal illness. Psychol Med. 2003;33(1):75–81.PubMedCrossRefGoogle Scholar
  99. 99.
    Block SD, Billings JA. Patient requests to hasten death: evaluation and management in terminal care. Ann Intern Med. 1994;154(18):2039–47.CrossRefGoogle Scholar
  100. 100.
    Steinhauser KE, Christakis NA, Clipp EC, et al. Factors considered important at the end of life by patients, families, and other care providers. JAMA. 2000;284(19):2476–82.PubMedCrossRefGoogle Scholar
  101. 101.
    Breitbart W, Rosenfeld B, Pessin H, et al. Depression, hopelessness, and desire for hastened death in terminally ill patients with cancer. JAMA. 2000;284(22):2907–11.PubMedCrossRefGoogle Scholar
  102. 102.
    Breitbart W. Spirituality and meaning in supportive care: spirituality- and meaning-centered interventions in advanced cancer. Support Care Cancer. 2002;10(4):272–80.PubMedCrossRefGoogle Scholar
  103. 103.
    Weinberger LE, Sreenivasan S, Garrick T. End-of-life mental health assessments for older aged, medically ill persons with expressed desire to die. J Am Acad Psychiatry Law. 2014;42(3):350–61.PubMedGoogle Scholar
  104. 104.
    Loggers ET, Starks H, Shannon-Dudley M, et al. Implementing a death with dignity program at a comprehensive cancer center. N Engl J Med. 2013;368(15):1417–24.PubMedCrossRefGoogle Scholar
  105. 105.
    Ganzini L. Legalised physician-assisted death in Oregon. QUT Law Rev. 2016;16(1):76–83.CrossRefGoogle Scholar
  106. 106.
    Ganzini L, Goy ER, Dobscha SK. Prevalence of depression and anxiety in patients requesting physicians’ aid in dying: a cross sectional survey. BMJ (Clinical research ed). 2008;337:a1682.CrossRefGoogle Scholar
  107. 107.
    Appelbaum PS. Assessment of patients’ competence to consent to treatment. NEJM. 2007;357(18):1834–40.PubMedCrossRefGoogle Scholar
  108. 108.
    Jayes M, Palmer R. Initial evaluation of the consent support tool: a structured procedure to facilitate the inclusion and engagement of people with aphasia in the informed consent process. Int J Speech Lang Pathol. 2014;16(2):159–68.PubMedCrossRefGoogle Scholar

Copyright information

© Springer International Publishing AG, part of Springer Nature 2018

Authors and Affiliations

  • Margaret W. Leung
    • 1
    Email author
  • Lawrence E. Kaplan
    • 2
  • James A. Bourgeois
    • 3
  1. 1.Kaiser PermanenteRosevilleUSA
  2. 2.University of California San FranciscoSan FranciscoUSA
  3. 3.Baylor Scott and White Department of PsychiatryTexas A&M University College of MedicineTempleUSA

Personalised recommendations