Live and let die: existential decision processes in a fatal disease.

Decisions and determinants of decisions to prolong or shorten life in the course of fatal diseases like ALS are poorly understood. Decisions and desire for hastened death of N = 93 ALS patients were investigated in a prospective longitudinal approach three times in the course of 1 year. Determinants of decisions were evaluated: quality of life (QoL), depression, feeling of being a burden, physical function, social support and cognitive status. More than half of patients had a positive attitude towards life-sustaining treatments and they had a low desire for hastened death. Of those with undecided or negative attitude, 10 % changed attitudes towards life-sustaining treatments in the course of 1 year. Patients' desire to hasten death was low and decreased significantly within 1 year despite physical function decline. Those with a high desire for hastened death decided against invasive therapeutic treatments. QoL, depression and social support were not predictors for vital decisions and remained stable. Feeling of being a burden was a predictor for decisions against life-supporting treatments. Throughout physical function loss, decisions to prolong life are flexibly adapted while desire to shorten life declines. QoL was stable and not a predictor for vital decisions, even though anticipated low QoL has been reported to be the reason to request euthanasia. In contrast, feeling of being a burden in decision making needs more attention in clinical counselling. Considering a patient's possible adaptation processes in the course of a fatal disease is necessary.

Quality of life in fatal disease: the flawed judgement of the social environment.

Decisions to prolong or shorten life in fatal diseases like amyotrophic lateral sclerosis are strongly influenced by healthy individuals, such as caregivers and physicians. Furthermore, many believe that amyotrophic lateral sclerosis (ALS) patients should decide ahead of time on advanced directives to circumvent confounding effects of subsequent cognitive impairments. The ability of healthy persons (caregivers and age-matched healthy subjects) to anticipate patients' quality of life (QoL), depression and vital decisions was determined in a cross-sectional approach. Eighty-nine ALS patients, 86 caregivers and 102 age-matched healthy subjects were asked to judge ALS patients' QoL and depression and the patients' wish for hastened death. Patients judged their own, the caregivers judged that of the patient under their care, healthy subjects were asked to judge that of a virtual patient. Additionally, healthy persons were asked to judge their own QoL and depression. Patients reported a satisfactory well-being and a low wish for hastened death. Healthy persons rated the patients' QoL significantly lower and the rate of depression significantly higher. The wish for hastened death was significantly lower in the patient group compared to what healthy subjects thought the patient would wish. The assessment by others was closely related to the persons' own well-being. Significant differences were identified between caregiver's perspectives and the patient's own perception of their psychological well-being. Our data suggest that caregivers and the general public significantly underestimate the QoL of ALS patients. A positive affective state can indeed be preserved in a progressive, fatal disease.

Perseverative thinking in depression and anxiety.

The current study investigated the impact of worry and brooding as moderators of the tripartite model of depression and anxiety (TMDA). We hypothesized that both types of perseverative thinking would moderate the association between negative affectivity (NA) and both anxiety and depression. Complete data sets for this questionnaire survey were obtained from 537 students. Participants' ages ranged from 16 to 49 years with a mean age of 21.1 years (SD = 3.6). Overall, results from path analyses supported the assumptions of the TMDA, in that NA was a non-specific predictor for both depression and anxiety whilst lack of positive affectivity (PA) was related to depression only. Unexpectedly, perseverative thinking had an effect on the dependency of negative and positive affectivity. Worry was a significant moderator for the path NA-anxiety. All other hypothesized associations were only marginally significant. Alternative pathways as well as methodological implications regarding similarities and differences of the two types of perseverative thinking are discussed.

Cardiac autonomic regulation and anger coping in adolescents.

The current study investigated spontaneous anger coping, cardiac autonomic regulation and phasic heart rate responses to anger provocation. Forty-five adolescents (27 female, mean age 14.7 years) attended the single experimental session, which included monitoring of continuous heart rate and blood pressure responses to anger provocation (receiving an unfair offer) using a modified version of the Ultimatum Game (UG). Vagal activation was operationalized as high frequency component of heart rate variability during rest periods, and spontaneous baroreflex-sensitivity (SBR) during the UG. Adolescents employing cognitive reappraisal showed higher vagal activity under resting conditions and attenuated heart rate deceleration after receiving the unfair offer compared with participants who tended to ruminate about their anger and experienced injustice. Results from SBR suggested vagal withdrawal in anger ruminators during contemplation of the unfair offer. These results provide further support for the specificity and sensitivity of vagal responses to higher cortical functions such as emotion regulation.