Academic journal article Generations

Exploring the Will to Live and Distinguishing Depression at End of Life

Academic journal article Generations

Exploring the Will to Live and Distinguishing Depression at End of Life

Article excerpt

Discussing the will to live with older adults may foster a more person-centered perspective on end of life than the current healthcare focus.

Among the best predictors of an older adult's wish to prolong life is their will to live (Carmel and Mutran, 1997) and depression (Lawton, 2001). Although the will to live and depression are associated (Chochinov et al., 2005; Carmel, 2011), they are distinct phenomena. The will to live is a psychological expression of the natural drive of human beings toward life. Existing across the life cycle, this will becomes more consciously salient during health crises and at the end of life. An individual's will to live may activate personal choices at the end of life. In contrast, clinical depression is a treatable disease that also impacts end-of-life planning.

Moody (2010) points to the need to honor an older person's will to live, as evidenced by their end-of-life decisions and, at the same time, urges practitioners to assess and respond to older adults with depression: "Failing to diagnose and treat late-life depression could consign untold numbers of older people to self-imposed death by neglect under the label of self determination, but regarding anyone who refuses treatment as suffering from mental illness is disrespectful of the patient's autonomy."

Defining Will to Live and Valuation of Life

Will to live and recognizing the inevitability of death are essential aspects of human existence (Yalom, 1980). Freud identifies these existential elements as the life force, Eros, versus death drive, Thanatos. We will explore how this dynamic manifests as we age-as a dance or a wrestling match.

For elders, life force and acceptance or even desire for death depends upon many factors. As practitioners in the field of aging, we should ask ourselves: For how long, for whom, and under what circumstances does this persistence continue? Humanities scholars long have explored these issues, and now there is intriguing social science research that may help us find answers to these important questions in our era of longevity.

Sara Carmel and colleagues conducted six large research studies on older Israelis' will to live, encompassing rational and instinctual underpinnings, which can be self-assessed (Carmel, 2001). The studies measure will to live through one direct question: "If you could describe your will to live, on a scale of 0 to 5, would you say that it is: 5=very strong, 4=strong, 3=intermediate, 2=weak, 1=very weak, 0=no will to live?"

To validate hypothesized associations between a will to live and indicators of psychological well-being and quality of life, one needs specific criteria. Though longer reliable and valid scales have been developed, the one-item scale is just as good as a measure, similar to the single-item self-assessed health measure (Carmel, 2011).

Will to live was found to be an important indicator of general well-being, encompassing psychological and physical dimensions. When life was not threatened, older adults' will to live was quite strong (Carmel and Mutran, 1997; Carmel, 2001, 2011).

Not surprisingly, a greater will to live strongly correlated with wishes to prolong life, even when subjects were hypothetically severely ill (Carmel and Mutran, 1997). In the studies, will to live decreased with advanced age, as did decisions to prolong life. Will to live was weaker among women than men (Carmel and Mutran, 1997; Carmel, 2001, 2011), and moderated a decline in life satisfaction common when close to death (Carmel, Shrira, and Shmotkin, 2013). Psychosocial indicators of well-being and fear of death affected will to live more than health factors (Carmel, 2001). Additionally, will to live was a significant predictor of older Israelis' survival over a seven-and-a-half-year follow-up (Carmel, Baron-Epel, and Shemy, 2007) and over a ten-year follow-up in a Finnish study ( Karppinen et al., 2012).

Valuation of life is a related concept that aims to capture a person's active attachment to life (Lawton, 2001). …

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