Researchers at Duke University Medical Center have found that the very population most likely to be affected by legalizing physician-assisted suicide is the group that favors it the least.

Their survey of 168 frail, elderly patients at Duke's Geriatric Evaluation and Treatment Clinic revealed that 39.9% of them favored physician-assisted suicide for terminally ill patients. In contrast, the survey found that 59.3% of the patients' relatives--146 spouses, children, and siblings--favored the measure under the same circumstance.

Neither group felt as disposed toward assisted suicide for patients with chronic illness or mental disability, said Duke psychiatrist Dr. Harold Koenig, lead investigator of the study. And there was little evidence that overburdened caretaker relatives were more likely to sanction assisted suicide.

"To the best of our knowledge, ours is the first systematic study in a clinical setting to examine attitudes of frail, elderly patients and families toward physician-assisted suicide," Koenig said. Results of the study, cowritten by Diane Wildman-Hanlon and Dr. Kenneth Schmader, are published in the October 28th issue of the Archives of Internal Medicine.

The survey, supported by the National Institute of Mental Health's Clinical Research Center for the Study of Psychopathology in the Elderly, also showed that the types of patients most opposed to the idea were those most vulnerable to external influence and those who had the least control over their circumstances. These patients generally included women, blacks, poorly educated patients, and patients with mild to moderate dementia. Those with severe mental or physical handicaps were excluded from the study.

"These findings are provocative and of great concern because the frail elderly, poorly educated and demented members of our society have little power to influence public policy that may directly affect them," Koenig said. "If physician-assisted suicide is made legal, then this population may warrant special protective measures."

Lack of Data in the Elderly

Koenig undertook this research because he felt that there was a lack of data on how elderly people feel toward physician-assisted suicide--a controversial issue now stirring public and professional debate. Considerable research has been done on attitudes toward this measure--most of it showing that two-thirds of adults approve of it--but the respondents were generally healthy and younger than age 60. "This is the group least likely to be affected either personally or by public policy changes in this area," Koenig said.

Koenig polled elderly patients and their relatives at Duke University Hospital over a 20-month period.

Besides finding that frail, elderly people favor the measure less than their relatives, the survey found that spouses and children were only marginally able to predict their elderly relatives' attitudes toward physician-assisted suicide. Koenig said that finding makes the use of advanced directives or living wills more important.

The survey also found that relatives of the patient had difficulty agreeing among themselves as to what course of action to take with regard to the patient, Koenig said.

"Our data highlights a situation of concern in which relatives often feel different from patients, they often don't know how the patient feels, and they often can't agree among themselves on how they think the patient feels," said Koenig.

He said the survey results are important because if assisted suicide is legalized on a widescale basis, relatives may be called on to make decisions on behalf of patients who become incompetent, cognitively impaired, or otherwise unable to make a choice for themselves.

Further Research Needed in Other Parts of the Country

However, he cautioned that additional research should be conducted in other parts of the country to rule out variables that might be unique to this particular population. For example, the majority of patients in the Duke survey were white women with conservative Protestant religious backgrounds who had significant physical and/or mental health problems. Black patients comprised 13% of the sample, and the mean age of the patients was 76 years. Compared to older adults in the United States, patients in the Duke survey were relatively well-educated and financially secure, yet substantially more frail in their general health status.

"In general we feel that our findings should be applicable to similar clinical settings in the North Carolina area, the southeastern United States, and possibly in other parts of the country, as well," he said.

Koenig said that patients who had more favorable feelings about assisted suicide tended to be male, white, better educated, and less cognitively impaired. Older female patients and those with more conservative religious backgrounds tended to feel less favorable toward assisted suicide, Koenig said. Factors that did not affect attitude toward assisted suicide included marital status, living situation, psychiatric disorders other than dementia, and physical health status.

Although patients were not asked for the reasons behind their responses, those who were in favor often volunteered the opinion that assisted suicide would relieve their pain and suffering. Those opposed to it often cited religious beliefs.