Making end-of-life (EOL) decisions (e.g., resuscitation, prolonging treatments, suicide or physician-assisted suicide) is a difficult experience that is influenced or motivated by many factors, including an individual’s depression status, religion/spirituality issues, pain level, and race/ethnic factors 1234. Much of the literature on EOL decisions has focused solely on non-Hispanic Whites. There is little literature about attitudes toward chronic pain and suicide or physician-assisted suicide (PAS) in various ethnic groups. 5 found that Mexican Americans were more likely to have positive attitudes toward PAS than non-Hispanic Whites. Consequently, more studies should to focus on the attitudes of Latino elders regarding EOL decisions and about the determinant factors that are associated with those attitudes.

When studying end of life decisions, pain and depression can be individually- or jointly-considered vulnerability factors for asking not to be resuscitated (DNR), or having more favorable attitudes toward suicide, and/or physician assisted suicide (PAS) 678910. With regard to pain, patients who reported moderate or severe pain were more likely to consider euthanasia or PAS 11 or to pursue assisted suicide 12. However, an important aspect to take into account when performing pain-related studies is to note how pain is measured and perceived. Specifically, EOL decisions motivated by pain might be moderated by race/ethnicity. For example, research suggests that Latinos in the U.S. have more pain sensitivity and report higher pain severity 13, or lower heat and cold pain tolerance than non-Hispanic Whites 14. Also, there appears to be a positive association between depression and favorable suicide attitudes 15161718, as well as with favorable attitudes toward PAS 1920. However, Latinos’ negative attitudes toward mental illness or mental health services can delay or prevent them from seeking mental health treatments, or can affect treatment outcomes 2122.

Just as pain and depression has been shown to be positively associated with decisions and attitudes toward suicide, PAS, and life shortening palliation, religiosity has been negatively associated with these attitudes 2324252627. In a study with non-Hispanic White and Latino elders, religiosity was associated with attitudes toward PAS among non-Hispanic White elders only 28. Another study, 29, found that quality of life was central to considering not pursuing treatment, however, religion mediated this decision by swaying perceptions toward pursuing treatment. Further, 30 found that Latinos were more likely non-Hispanic Whites to rely on prayer as a way of coping with pain.

Another motivational factor related to EOL attitudes is prognosis. For example, a study among metastatic colorectal cancer patients found that those who perceived a better prognosis (estimated their 2-month survival to be ≥90%) were more likely to want cardiopulmonary resuscitation (CPR) than their counterparts 31. Based on the research findings of prior research, our study sought to expand upon previous studies by focusing on older Latinos and pursuiing two main goals: 1) to examine possible race/ethnic (non-Hispanic Whites and Latinos) differences among older adults (60 years or older) in terms of (a) attitudes toward suicide and (b) attitudes toward PAS, in chronic pain scenarios where the chance of managing the pain and the prognosis varied, and 2) to examine the factors associated with Latino attitudes (a) toward suicide and (b) toward PAS in scenarios of chronic pain.

In the initial analysis step, the task was to estimate if the main outcome variables were normally distributed. Histograms, skewness and kurtosis test results implied the AS and PAS did not attain normality. For analysis purposes, AS and PAS were dichotomized. The second step was to examine the distribution of the study sample’s descriptive characteristics, for which our statistical approach was means, frequencies, and percentages for the individual level variables. Bivariate analyses including t-test, Chi-square, and Pearson correlation were conducted to test differences, and to assess relationships among variables and between groups as appropriate (non-Hispanic Whites and Latinos; Form A and Form B; Spanish survey and English survey). In subsequent analysis steps, the statistical approach involved unadjusted and adjusted logistic regression, individually, for the attitudes toward suicide and attitudes toward PAS (dichotomous variables) as the main dependent variables.

We examined the association of the main independent variables (AS and PAS) with potential motivational factors of those attitudes in three models. Model 1 examined the total study sample (n=204), Model 2 examined the non-Hispanic White study sample (n= 106), and Model 3 examined the Latino study sample (n=98). The first step involved including only those variables in the models which resulted in p ≤ .20. For this purpose, we used forward selection stepwise modeling, beginning with a full logistic regression model with all of the independent variables: race/ethnicity, gender, education, income, marital status, religiosity, self-reported current health, depression scale, MMSE, IADL, and form. Because the questions that assessed AS and PAS were four different questions, and in order to obtain comparable models, we kept the variables that resulted in a p ≤ .20 after running the forward selection stepwise modeling (religiosity, depression, form, education) as well as the variables that were theoretically relevant to our analysis (race, gender and Latino acculturation level) in our final models. Overall, the final model controlled for race, depression, religiosity, self-reported health, form, educational level and gender. The second step involved examining the association of the main outcomes with potential determinant factors. We ran logistic regression for PAS and AS statements to achieve this study aim.

In this analysis, we stress precision of the study estimates with a focus on 95% confidence intervals and p-values are presented as an aid to interpretation. All analyses were conducted using Stata/IC 11.1.

These study findings are consistent with previous studies, suggesting that there are ethnic differences in terms of the factors associated with attitudes toward suicide and PAS 414243. The findings extend knowledge from these previous studies in that after controlling for potential confounders (i.e., gender, educational level, religiosity, and acculturation level), depression was positively associated with Latinos’ attitudes toward suicide in chronic pain scenarios, but not with non-Hispanic Whites’ attitudes toward suicide. Suicidal thoughts are possible symptom of depression, which could explain part of the positive relationship with suicide scenarios among older Latinos. These findings support the importance of screening for depression in primary care settings. Depression screening can save lives 44. Yet, depression may not be what influences

the attitudes toward suicide, but rather the combination of depression with chronic pain scenarios.

We suspect that there are potential mediating factors between Latinos’ attitudes toward suicide in chronic pain scenarios and depression. For example, among Latinos, depression might be related with other co-morbidities, with behaviors in terms of seeking health care, and with delaying health care 454647. All of these factors can also influence attitudes about suicide or PAS. In terms of PAS, Latinos’ acculturation level was negatively associated with attitudes toward PAS in chronic pain scenarios (PAS1 and PAS2). Further research is needed to investigate if the term "physician-assisted suicide" has a different meaning for Latinos compared to other ethnic groups, and if there are differences among Latinos based on their acculturation level, as acculturation was a stronger predictor of attitudes toward PAS than depression. It may be that those same factors that we believe are related to depression and attitudes toward suicide (co-morbidities; behaviors in terms of seeking health care, and with delaying health care) are also mediators in the association between acculturation and the consideration of PAS in chronic pain scenarios.

In terms of the non-Hispanic White study sample, religiosity was the most consistent factor associated with non-Hispanic Whites’ attitudes toward suicide and PAS. Results from previous studies lead us to argue that the examination of individual indicators (instead of composite scores) of religiosity and/or spirituality measurements might lead to different conclusions 4849. For example, attitudes and knowledge about PAS are negatively associated with the belief in the afterlife (indicator of religiosity) 50, and specific religious affiliations (i.e., Protestants, Catholics) might be associated with greater opposition to suicide 51. Religion is a coping strategy among patients with depression and pain 52; however, there are race differences in the use of this strategy. Latinos might use some aspects of religion (e.g., praying and hoping) as coping strategies more than non-Hispanic Whites 53. These findings call for future research with individual indicators of religion or spirituality, instead of a scale of religiosity/spirituality.

The level of analyses in this study was mainly at the individual level (health related and socio-demographic characteristics). Therefore, adding other social, cognitive, affective and behavioral factors at both the individual and community level would help to explain and understand the ethnic/cultural differences 54 that this study’s findings suggest. For example, this study found ethnic/cultural differences in the meaning of pain, levels of social support from family and community, and the experiences in access to services at both the individual and group levels. The Latino sample for the seemed to be on the higher acculturation range, further research would be needed to include those lesser acculturated.

The design of this study was cross-sectional and it is not clear whether attitudes toward suicide were present before depressive symptoms appeared of were a result of such symptoms. Future longitudinal or prospective research is necessary to confirm our study findings and to examine possible pathways between access to services, depression, pain, religiosity, acculturation and attitudes toward suicide or PAS among Latinos. Lastly, the study did not use a sample of patients with active pain symptoms, which may have influenced their responses.

In summary, even when there might not be differences among ethnic groups in their attitudes toward suicide and PAS in chronic pain scenarios, the motivational factors of those attitudes are different for non-Hispanic White and Latino elders. This study’s findings suggest that depression and acculturation among Latino elders, and religion among non-Hispanic White elders, are determinant factors of these attitudes in chronic pain scenarios. The sample in this study was relatively highly acculturated, which should have made it more similar to White populations, however, the significant difference points to a possible cultural or educational disparity in interpreting the communication of chances for survival. Future research is needed to confirm our findings with more heterogeneous study samples, including Latinos from different countries of origin (e.g., Mexican Americans, Puerto Ricans, Cubans), and more heterogeneous ethnic groups regarding socioeconomic status and educational level characteristics. This study’s findings suggest that in the extreme chronic pain scenarios, the order in which the attitude questions were presented (Form A vs. Form B) influenced the attitudes toward PAS only among non-Hispanic Whites, suggesting different effects on the ethnic groups. In the non-Hispanic White study sample, those who received Form B had significantly higher attitudes toward PAS when there was chance of managing the chronic pain with long-term treatment. Future research is necessary to determine which question(s) had the most effect on these attitudes. However, this was outside of the scope of this study. Research in this area is warranted.