Assessment, Evaluation, and Management of Suicidal Patients
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 (see Table 7). 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]
Table 7. Suggested Questions for the Assessment of
Suicidal Symptoms in People With Cancera
Questions
|
Assessment
|
aAdapted from Roth et al.[6]
|
Most people with cancer have passing
thoughts about suicide such as, “I might
do something if it gets bad enough.” |
Acknowledge normality by opening with a statement recognizing that a discussion
does not enhance risk |
Have you ever had thoughts like that?
Any thoughts of not wanting to live or
wishing your illness might hasten your death? |
Level of risk |
Do you have thoughts of suicide?
Have you thought about how you would do it?
Do you intend to harm yourself? |
Level of risk |
Have you ever been depressed or made a suicide
attempt? |
History |
Have you ever been treated for other psychiatric
problems or have you been psychiatrically
hospitalized before getting diagnosed with cancer? |
History |
Have you had a problem with alcohol or drugs? |
Substance abuse |
Have you lost anyone close to you recently?
(Family, friends, others with cancer) |
Bereavement |
Management
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.
Effect on Family and Health Care Providers
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]
Assisted Dying, Euthanasia, Decisions Regarding End of Life
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 of Life for more information.)
References
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Massie MJ, Gagnon P, Holland JC: Depression and suicide in patients with cancer. J Pain Symptom Manage 9 (5): 325-40, 1994.
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Kovacs M, Beck AT, Weissman A: Hopelessness: an indicator of suicidal risk. Suicide 5 (2): 98-103, 1975 Summer.
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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.
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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.
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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.
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Marzuk PM: Suicide and terminal illness. Death Stud 18 (5): 497-512, 1994.
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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.
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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.
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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.
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Chochinov HM, Wilson KG, Enns M, et al.: Desire for death in the terminally ill. Am J Psychiatry 152 (8): 1185-91, 1995.
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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.
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