Assessment
Management
Effect on Family and Health Care Providers
Assisted Dying, Euthanasia, Decisions Regarding End of Life

Assessment

Patients who are suicidal require careful assessment. In the assessment of suicide, it is important to recognize that the risk of suicide increases if the patient reports ideation (i.e., thoughts of suicide) plus a plan (i.e., description of the means). Risk continues to increase to the extent that the plan is lethal. Lethality is determined by an assessment of how likely death would follow, if the reported plan were carried out. Factors to consider in assessing lethality include availability of the means, reversibility of the means (once begun can it be stopped), and proximity to help. In the cancer patient reporting suicidal ideation, it is essential to determine whether the underlying cause is a depressive illness or an expression of the desire to have ultimate control over intolerable symptoms.[1] Prompt identification and treatment of major depression is essential in lowering the risk for suicide in cancer patients. Risk factors, particularly hopelessness (which is an even stronger predictive factor for suicide than is depression) should be carefully assessed.[2] The assessment of hopelessness is not straightforward in the patient with advanced disease with no hope of cure. It is important to assess the underlying reasons for hopelessness, which may be related to poor symptom management, fears of painful death, or feelings of abandonment.[3] Of 220 Japanese patients who had cancer and who were diagnosed with major depression after being referred for psychiatric consultation, approximately 50% reported suicidal ideation. In a retrospective analysis of predictors of suicidal ideation, researchers found that those with more symptoms of major depression and poorer physical functioning were significantly more likely to report suicidal ideation.[4]

Establishing rapport is of prime importance in working with suicidal cancer patients as it serves as the foundation for other interventions. The clinician must believe that talking about suicide will not cause the patient to attempt suicide. On the contrary, talking about suicide legitimizes this concern and permits patients to describe their feelings and fears, providing a sense of control.[5] A supportive therapeutic relationship should be maintained, which conveys the attitude that much can be done to alleviate emotional and physical pain. (Refer to the PDQ summary on Pain for more information.) A crisis intervention-oriented psychotherapeutic approach should be initiated that mobilizes as much of a patient's support system as possible. Contributing symptoms (e.g., pain) should be aggressively controlled and depression, psychosis, agitation, and underlying causes of delirium should be treated.[5] (Refer to the PDQ summary on Cognitive Disorders and Delirium for more information.) These problems are most frequently managed in the medical hospital or at home. Although uncommon, psychiatric hospitalization can be helpful when there is a clear indication and the patient is medically stable.[5]

In clinical practice, the goal of management of suicidal patients is to attempt to prevent suicide that is driven by desperation due to poorly controlled symptoms. Prolonged suffering due to poorly controlled symptoms can lead to such desperation. Thus, effective symptom management is critical to decrease psychological distress in suicidal cancer patients.[5] Patients close to the end of life may be unable to maintain a wakeful state without high levels of emotional or physical pain. This frequently leads to suicidal thoughts or requests for aid in dying. Such patients may require sedation to ease their distress. In practice, the number of such patients is extremely variable. Reports on sedating treatments at the end of life highlight a confusing terminology of descriptors and perceived problems.[7,8] In addition, the range for patients sedated at the end of life varies from 3% to 52%. The issue of sedation in terminally ill patients is controversial, but it is becoming a more accepted practice, particularly in the hospice setting.[3]

At times, it may be important to limit access to potentially lethal medications for patients considered at risk for suicide. When potentially lethal medications are limited, it is important to weigh the impact on symptom management against the impact on suicide risk because poorly controlled symptoms may contribute to risk. Furthermore, suicidal patients will often have other means available to complete suicide attempts and these must also be evaluated. Strategies to lessen suicidal risk include frequent contact to reassess suicidal risk and symptom control, as well as regular delivery of limited quantities of medications facilitating rapid dose titration for effective management of poorly controlled symptoms when necessary. For patients receiving parenteral or intrathecal opioids, programmable pumps with limited access to programming and locked, inaccessible cartridges may provide an element of safety.

Strategies to lessen suicide risk in cancer patients include the following:

• Use medications that work rapidly to alleviate distress (e.g., a benzodiazepine for anxiety or a stimulant for fatigue) while waiting for the clinical effects from antidepressant therapy.



• Pay scrupulous attention to symptom management.



• Limit access as appropriate to quantities of medications that are lethal in overdose.



• Maintain frequent contact with and closely observe the patient.



• Avoid having the patient spend long periods of time alone.



• Mobilize support for the patient.



• Carefully assess the patient's psychological responses at each crisis point over the course of the disease.

When suicide complicates bereavement, the loss can be especially difficult for survivors. A pattern of reactions that includes feelings of abandonment, rejection, anger, relief, guilt, responsibility, denial, identification, and shame may occur. This pattern is modified by such factors as the nature and intensity of the relationship, the nature of the suicide, the deceased person's age and physical condition, the perceived support network, and the survivor's coping skills and cultural/religious background.[5] Assisting survivors through the bereavement period is important. Mutual support groups are helpful in reducing isolation, providing opportunities for venting feelings, and finding ways to cope with the aftermath of suicide. (Refer to the PDQ summary on Loss, Grief, and Bereavement for further information.)

Staff reactions to the suicide of a patient are similar to those seen in family members, although staff often do not feel that they have the same right to express their feelings. The suicide of a patient may lead a staff member to question his or her professional judgment. It is often helpful for the staff to conduct a psychological autopsy in an attempt to understand why and how the suicide happened, signs and symptoms of risk, and how routines might be altered to prevent similar problems in the future.[5]

The principle of respecting and promoting patient autonomy has been one of the driving forces behind the hospice movement and right-to-die issues that range from honoring living wills to promoting euthanasia. These issues can create a conflict between patient autonomy and the physician's obligation to beneficence.[9]

Answers to the questions of euthanasia and physician-assisted suicide belong to the realm of the law, ethics, medicine, and philosophy. Physicians and other health care professionals have essential clinical roles to play in addressing and untangling these issues when working with depressed, terminally ill patients.[1,10-15] Additionally, religious and cultural issues may strongly influence this decision-making process. A 1994 survey suggests that hospice physicians favor vigorous pain control and strongly approve of the right of patients to refuse life support even if life is secondarily shortened. However, these physicians strongly oppose euthanasia or assisted suicide, clearly making a sharp distinction between these 2 interventions.[9] Often patients who specifically request physician-assisted suicide can be prescribed measures that augment their comfort, relieve symptoms, and obviate considering drastic measures.[1] A recent study suggests that agreement with euthanasia is associated with male sex, lack of religious beliefs, and general beliefs about the suffering of cancer patients.[16] A 1995 study of persons with advanced cancer who expressed a consistent and strong desire for hastened deaths suggested that this desire is related to the presence of depression. Patients with the desire to die should be carefully assessed and treated for depression as necessary. Whether their desire to die would persist or decrease with improvement in mood disorder has not yet been studied.[17] It is important to maintain a shared decision-making process from the beginning of the professional relationship.[18] (Refer to the PDQ summary on Last Days and Hours of Life for more information.)

References

1. Massie MJ, Gagnon P, Holland JC: Depression and suicide in patients with cancer. J Pain Symptom Manage 9 (5): 325-40, 1994.  [PUBMED Abstract]
   
   
2. Kovacs M, Beck AT, Weissman A: Hopelessness: an indicator of suicidal risk. Suicide 5 (2): 98-103, 1975 Summer.  [PUBMED Abstract]
   
   
3. Breitbart W, Passik SD: Psychiatric aspects of palliative care. In: Doyle D, Hanks GW, MacDonald N, eds.: Oxford Text Book of Palliative Medicine. New York: Oxford University Press, 1993, pp 609-26. 
   
   
4. Akechi T, Okamura H, Yamawaki S, et al.: Why do some cancer patients with depression desire an early death and others do not? Psychosomatics 42 (2): 141-5, 2001 Mar-Apr.  [PUBMED Abstract]
   
   
5. Breitbart W, Krivo S: Suicide. In: Holland JC, Breitbart W, Jacobsen PB, et al., eds.: Psycho-oncology. New York, NY: Oxford University Press, 1998, pp 541-7. 
   
   
6. Roth AJ, Holland JC: Psychiatric complications in cancer patients. In: Brain MC, Carbone PP, eds.: Current Therapy in Hematology-Oncology. 5th ed. St. Louis, Mo: Mosby-Year Book, Inc., 1995, pp 609-18. 
   
   
7. Fainsinger RL: Use of sedation by a hospital palliative care support team. J Palliat Care 14 (1): 51-4, 1998 Spring.  [PUBMED Abstract]
   
   
8. Fainsinger RL, Landman W, Hoskings M, et al.: Sedation for uncontrolled symptoms in a South African hospice. J Pain Symptom Manage 16 (3): 145-52, 1998.  [PUBMED Abstract]
   
   
9. Miller RJ: Supporting a cancer patient's decision to limit therapy. Semin Oncol 21 (6): 787-91, 1994.  [PUBMED Abstract]
   
   
10. Masdeu JC: Physician-assisted suicide and euthanasia. JAMA 276 (3): 196-7, 1996.  [PUBMED Abstract]
    
    
11. Siegler M: Is there a role for physician-assisted suicide in cancer? No. Important Adv Oncol : 281-91, 1996.  [PUBMED Abstract]
    
    
12. Back AL, Wallace JI, Starks HE, et al.: Physician-assisted suicide and euthanasia in Washington State. Patient requests and physician responses. JAMA 275 (12): 919-25, 1996.  [PUBMED Abstract]
    
    
13. Marzuk PM: Suicide and terminal illness. Death Stud 18 (5): 497-512, 1994. 
    
    
14. Suarez-Almazor ME, Belzile M, Bruera E: Euthanasia and physician-assisted suicide: a comparative survey of physicians, terminally ill cancer patients, and the general population. J Clin Oncol 15 (2): 418-27, 1997.  [PUBMED Abstract]
    
    
15. Howard OM, Fairclough DL, Daniels ER, et al.: Physician desire for euthanasia and assisted suicide: would physicians practice what they preach? J Clin Oncol 15 (2): 428-32, 1997.  [PUBMED Abstract]
    
    
16. Suarez-Almazor ME, Newman C, Hanson J, et al.: Attitudes of terminally ill cancer patients about euthanasia and assisted suicide: predominance of psychosocial determinants and beliefs over symptom distress and subsequent survival. J Clin Oncol 20 (8): 2134-41, 2002.  [PUBMED Abstract]
    
    
17. Chochinov HM, Wilson KG, Enns M, et al.: Desire for death in the terminally ill. Am J Psychiatry 152 (8): 1185-91, 1995.  [PUBMED Abstract]
    
    
18. Chandler SW, Trissel LA, Weinstein SM: Combined administration of opioids with selected drugs to manage pain and other cancer symptoms: initial safety screening for compatibility. J Pain Symptom Manage 12 (3): 168-71, 1996.  [PUBMED Abstract]
    
    

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