Bridging the Gap: Conference Record [Abstract book, International Conference on AIDS (12th: 1998: Geneva, Switzerland)]

488 Abstracts 24244-24247

12th World AIDS Conference

multiple loss by providing services such as consultation, educational seminars
and experiential grief workshops.
Methods: Surveys were completed by 155 staff members and 25 Executive
Directors (ED) from 33 ASOs across Ontario. Five agencies were selected for
on-site visits and group interviews.
Results: The majority of respondents have worked in the HIV/AIDS community
for at least three years (71%) and have endured the loss of at least two service
users, co-workers or other people to AIDS (69%, 47% and 83%, respectively).
Staff members from remote northern regions reported the most negative impact
of multiple loss on work quality but they have also worked the longest and experienced the highest number of deaths. Respondents from all regions reported
problems at work, including apathy (58%), poor morale (56%), anger (83%), and
blurring of boundaries (70%). Even though the prevalent reaction to multiple loss
was negative, respondents also reported that it added "meaning to" and "appreciation of" life (91% and 83%, respectively). A total of 77 staff and 14 EDs reported
using various ABPO services. ABPO interventions helped to: improve their work
effectiveness (68%); set limits (59%); and improve their work with service users
(64%). Using ABPO services also helped staff and EDs to verbalize their own
grief (73%) as well as identify and support other people's grief responses in the
workplace (83% and 79%, respectively). Immediate reactions to ABPO workshops
ranged from a "tremendous relief" of "stored up grief" to "opening a can of worms"
reflecting differences in attitudes toward mixing personal and professional lives.
Conclusion: AIDS-service organizations are grief saturated. Multiple loss appears to have had both a negative and positive impact on individuals and their
organizations. The majority of individuals surveyed and interviewed emphasized
the importance, usefulness, and need for the AIDS Bereavement Project of
Ontario in assisting them to cope more effectively and creatively with multiple
loss.
43*/24244 AIDS and euthanasia: old problems, new issues
Fabrizio Starace. Via G. Santacroce 19/E, Italy
Issue: Despite the ongoing moral and legal debate, there is still a paucity of
empirical literature on end-of-life issues in persons with HIV infection or AIDS
Project: This paper systematically reviews currently available literature on euthanasia (EU) and physician assisted suicide (PAS) in people with HIV infection
or AIDS, with particular emphasis on epidemiological surveys.
Results: The prevalence of EU/PAS in AIDS patients ranges from 13.4% to
26.0% (as compared to 2.3*ndash;7.0% in cancer patients). EU seems to have
very little impact on survival time. Practicing physicians judge that life is shortened
by no more than one month in 72% of cases. EU/PAS ideation and planning may
be no more likely in HIV-infected persons than in people with other terminal
diseases. Noticeably, no association seems to hold between suicidal ideation
and attempts and EU planning and arrangements. A positive attitude towards the
legalisation of EU/PAS has been found in a proportion of HIV/AIDS subjects ranging from 63.0% to 95.2%. The studies of physicians' attitudes towards EU/PAS
have shown a change over time: in 1990, responding to a case vignette, 35.0%
reported they would have granted an AIDS patient's adamant request; in 1995
the proportion was 51.0%.
Lessons Learned: The empirical evidence reported in this paper shows that
EU/PAS ideation and acts are much more common than expected in persons with
AIDS and physicians caring for such patients should be aware of this. All AIDS
patients should receive a systematic assessment of psychological state mid of
personal attitude towards end-of-life issues.
24245 "A grief observed": The impact of HIV-related death on
women's mental health
Jeannette Ickovics', J.R. Ickovics', A.C. Morrill2. 1Yale University Dept. of
Epidemiology PO Box 208034 New Haven, CT 06520-8034; 2New England
Research Institutes Watertown MA, USA
Objectives: To date, no studies have examined the effects of AIDS-related losses
on women's mental health. The objectives of this study were to: (1) document the
proportion of inner-city women who experienced AIDS-related loss; (2) compare
the demographic characteristics of those who experienced AIDS-related loss versus no loss; (3) examine prospectively the effects of the number of AIDS-related
losses on women's mental health.
Design: Prospective, longitudinal cohort study
Methods: 168 women representative of patients from public health clinics in
New Haven, CT. Structured interviews were completed 5 times across a 2 year
period. At each interview, women reported whether they knew anyone who died
of AIDS (including # of deaths, nature of relationships). Mental health was measured using the Hopkins Symptom Checklist for anxiety and depression; it was
assessed prior to the first instance of loss and compared to reports post-loss,
controlling for potential confounding variables (e.g., relationship to the deceased,
HIV status).
Results: 72% of the women personally knew someone who died of AIDS since
the beginning of the epidemic; 52% experienced multiple losses, knowing 2 or

more individuals who died (e.g., husband/partner, close friend, family member).
This high rate of AIDS loss reflects a concentration of deaths in the communities
served by the clinic sites. Women of color, with less education, older, and with
a history of drug use were more likely to know someone who died (all p <.05).
Women who experienced multiple AIDS-related losses over the course of the
study were more anxious than those who experienced no loss or one loss (F =

17.4, p <.001). There was no dose-response effect for depression. These effects
were not mediated by type of relationship with the deceased or other factors.
Conclusions: Like the "primary" AIDS epidemic of infected persons, the "secondary" epidemic of affected persons includes a substantial proportion of women.
Women experienced heightened anxiety following multiple loss due to AIDS. However, there were no effects of AIDS-related losses on depression. It is important
to recognize the patterns and sequelae of AIDS-related losses. Understanding
the antecedents of poor outcomes can be used to determine who might benefit
most from mental health interventions.
24246_ "Dear Mr. Death": Community bereavement for
multi-grieved adults and adolescents in a poor AIDS
stricken area
Dorothy Greene, C. Norwood, S. Romsey-Ahmed, C. Gillespie. c/o Health Force:
Women and Men against AIDS, 509 Willis Avenue, Bronx, New York 10455, USA
Issues: Adults and children in the South Bronx, the poorest area in the United
States with NYC's highest AIDS rate, have experienced multiple deaths from parents, relatives and friends. Outlets/rituals for helping people cope with this massive
grief are almost nonexistent. Health Force's "Dear Mr. Death" project explores
accessible ways for helping overwhelmed communities cope with unrelenting
grief while documenting the ongoing impact of death in a poor AIDS-stricken
community.
Project: The "Dear Mr. Death" project uses letters addressed directly to "death"
enabling individuals to express their feelings and release their emotions about
what death has done to them and their community. More than 200 HIV+ people
and their families members wrote letters. The letter-writing was accompanied by
discussion with a grief counselor. Interest in writing these letters was intense.
Reflecting the community's diversity, letters were written in English, Spanish,
French, Swahili, and Arabic. The letters were blown up and displayed at places
ranging from churches to courthouses to the UN Headquarters in New York City.
Results: An accompanying "Dear Mr. Death Survey" showed that, on average,
letter writers had lost 6 people close to them in the past ten years, 35% from
AIDS. On the whole, the letters were extraordinarily eloquent. The participants not
only not only found solace in writing the letters, but many stated the letter-writing
had, for the first time, helped them deal with overwhelming emotions. This was
particularly the case with teenagers. Exhibits of the blown-up letters were seen
by more than 50,000 people, helping them also understand the impact of AIDS
deaths.
Lessons Learned: Efforts to deal with massive death are imperative for AIDS
stricken communities. The writing and display of letters provides a means of
expressing deep emotions about death which is widely accessible, even for people unaccustomed to writing. In a poor community like the South Bronx people
seemed to feel that writing their thoughts signaled they were being taken seriously
(for once). Based on participants' feedback, we conclude this had more immediate
therapeutic impact than standard counseling.
45* / 24247 Morphine as a euthanatic: Subjective experiences
from care providers
Russel Ogden. Flat 5, Clydesdale Court, Clydesdale Road, Exerter EX44QX,
England
Issues: The clandestine practice of euthanasia using morphine has received little
empirical investigation. Although "slow euthanasia" is reputed to happen with
regularity, the doctrine of "double effect" is usually invoked to justify a primary
intent to alleviate suffering, with a secondary effect being the possible hastening
of death.
Project: In-depth interviews with persons involved in acts of euthanasia or
assisted suicide were analysed to examine incidents of morphine-facilitated euthanasia. Interviewees came from the USA, Canada, and England and comprised
friends, partners and a physician of the deceased persons.
Results: Of 26 interview transcripts analysed, 14 interviewees described 24
death hastening acts involving morphine. A qualitative analysis suggests that
morphine is used frequently with intent to hasten the deaths of persons with
end-stage AIDS symptoms. In many instances, partners and friends caring for
persons with AIDS interpret health professionals to be giving implicit support to
administer potentially fatal doses of morphine by "turning a blind eye" or through
instructions on how to adjust intravenous flow. In some deaths, patients were not
believed to be experiencing pain when the morphine treatment was introduced,
yet dosages were increased rapidly. In general, interviewees felt they had "done
the right thing" in attempting to cause death. One respondent expressed a preference to be euphemistic in order to create social and moral distance. Some felt that
their actions, in hindsight, may have been motivated, in part, by the exhaustion
and fatigue experienced as a primary care provider. The individual nature of each
death offered no evidence to support a "slippery slope" argument.
Lessons Learned: The illegality of euthanasia contributes to the use of morphine treatment as a camouflage for the hastening of death. Subjective reports
from persons caring for dying persons with AIDS suggest that large morphine

doses are frequently given with the intent of causing death; pain is not always
present during the decision to initiate morphine treatment. Patient consent was
not always possible and weariness from the demands of providing care was
identified as sub-conscious factor for increasing morphine doses.