End-of-life is more than just physical health. It is about individual perceptions of what a life worth living looks like, and enabling people to create their own possibilities, hope and choices.
In the Western world in particular, people are living longer and death is becoming less visible and more medicalised. There is a growing movement to challenge this silence, and to facilitate conversations and communication about death and dying.1 Psychology has much to contribute to understanding issues of death and dying from the perspectives of theory, research and practice.
Psychologists can and should be involved in end-of-life issues in a variety of ways including: facilitating conversations and addressing the stigma around death and dying; contributing to policy development and best practice for the care of the terminally ill; involvement in the process of support and decision-making for family as well as the patient (including decisions about assisted dying if it is legal); the assessment of psychological disorders and mental competence; and the treatment and management of psychological disorders at the end-of-life.
Key points
- 70% of people want to die at home, yet only about 14% do so2.
- Psychologists have important knowledge and skills to contribute towards addressing some of the interpersonal and ethical challenges surrounding end-of-life trajectories. This contribution relates not only to the debate about legalising assisted dying, but also includes broader issues relating to comprehensive palliative care service systems and advance care planning protocols.
- Palliative care is the most established end of life model of care; however its capacity to prevent/alleviate severe suffering (including pain control and refractory symptoms) is not absolute, and it is not always available to all people who might benefit, or equally accessible to diverse community groups (such as residents of aged care facilities, people who have terminal illnesses other than cancer, people living in rural and remote communities, and people from Indigenous and culturally and linguistically diverse backgrounds). Furthermore, this model of care is not acceptable to a significant minority of dying people.
- In June 2019, it will be legal for doctors in Victoria to assist people over the age of 18 with a terminal illness (prognosis of less than 6 months) and suffering intolerable pain to die.
- It is important to understand how mental illness (e.g. severe depression) affects competence and advance care planning. In many cases (e.g. early stages of Alzheimers), people are competent to undergo advance care planning. While psychologists can play a key part in diagnosis of mental disorders and assessment of competence, a diagnosis of clinical depression or cognitive impairment should not automatically negate a person’s right to access care choices available to other patients.
- The adequacy of health care is likely to play an important role in the person’s decision-making, such that a request for assisted dying for example, may follow a failure of one or more parts of the health system to provide adequate care. Decisions about assisted dying are made in the context of serious social inequities in access to resources such as basic medical care.
- Dealing with issues surrounding the choice of a terminally ill person to request assistance from a medically qualified person to voluntarily terminate his or her life humanely is complex and challenging. This issue needs to be examined from a number of perspectives that encompass psychological, ethical/moral, medical, legal, religious, sociological and political considerations.
How the APS is involved
The APS has been actively involved in ensuring that psychology has a voice in current debates around end-of-life issues and care.
In 2017, 30 psychologists and others with relevant expertise came together for a roundtable on end of life care and choices. Key presentations on assisted dying legislation, grief and bereavement, palliative care, residential aged care, legal and ethical considerations, and suicide rates in mental health services were followed by focused group discussion. Outcomes of the roundtable are expected to include CPD offerings and other resources to assist psychologists to navigate their potential roles in end-of-life care and choices.
The APS has contributed to a number of State and Commonwealth government inquiries about end of life choices and frameworks both via written submissions and a public hearing.
In 2008, the discussion paper on Psychological perspectives on euthanasia and the terminally ill was updated.