Evaluation and Treatment of Suicidal Patients with Cancer
Effects of suicide on family and health care providers
The incidence of suicide in cancer patients may be as much as 10 times higher
than the rate of suicide in the general population. One study has shown that the risk of suicide in patients with cancer is highest in the first months after diagnosis, and that this risk decreases significantly over decades. Passive suicidal thoughts
are fairly common in patients with cancer. The relationships between suicidal
tendency and the desire for hastened death, requests for physician -assisted
suicide, and/or euthanasia are complicated and poorly understood. Men with
cancer are at an increased risk of suicide compared with the general
population, with more than twice the risk. Overdosing with painkillers and sedatives is the most common method of suicide by patients with cancer, with most
cancer suicides occurring at home. The occurrence of suicide is higher in
patients with oral, pharyngeal, and lung cancers, and in HIV-positive patients
with Kaposi sarcoma. The actual incidence of suicide in cancer patients is
probably underestimated, since there may be reluctance to report these deaths
as suicides.
General risk factors for suicide in a person with cancer include the following:
Cancer-specific risk factors for suicide include the following:
Patients who are suicidal require careful evaluation. The risk of suicide
increases if the patient reports thoughts of suicide and has a plan to carry it
out. Risk continues to increase if the plan is "lethal," that is, the plan is
likely to cause death. A lethal suicide plan is more likely to be carried out
if the way chosen to cause death is available to the person, the attempt cannot
be stopped once it is started, and help is unavailable. When a person with
cancer reports thoughts of death, it is important to determine whether the
underlying cause is depression or a desire to control unbearable symptoms.
Prompt identification and treatment of major depression is important in
decreasing the risk for suicide. Risk factors, especially hopelessness (which
is a better predictor for suicide than depression) should be carefully
determined. The assessment of hopelessness is not easy in the person who has advanced cancer with no hope of a cure. It is important to determine the basic
reasons for hopelessness, which may be related to cancer symptoms, fears of
painful death, or feelings of abandonment.
Talking about suicide will not cause the patient to attempt suicide; it
actually shows that this is a concern and permits the patient to describe his
or her feelings and fears, providing a sense of control. A crisis
intervention -oriented treatment approach should be used which involves the
patient's support system. Contributing symptoms, such as pain, should be aggressively controlled and depression, psychosis, anxiety, and underlying
causes of delirium should be treated. These problems are usually treated in a
medical hospital or at home. Although not usually necessary, a suicidal
patient with cancer may need to be hospitalized in a psychiatric unit.
The goal of treatment of suicidal patients is to attempt to prevent suicide
that is caused by desperation due to poorly controlled symptoms. Patients
close to the end of life may not be able to stay awake without a great amount
of emotional or physical pain. This often leads to thoughts of suicide or
requests for aid in dying. Such patients may need sedation to ease their distress.
Other treatment considerations include using medications that work quickly to
alleviate distress (such as antianxiety medication or stimulants) while
waiting for the antidepressant medication to work; limiting the quantities of
medications that are lethal in overdose; having frequent contact with a health
care professional who can closely observe the patient; avoiding long periods of
time when the patient is alone; making sure the patient has available support;
and determining the patient's mental and emotional response at each crisis
point during the cancer experience.
Pain and symptom treatment should not be sacrificed simply to avoid the
possibility that a patient will attempt suicide. Patients often have a method
to commit suicide available to them. Incomplete pain and symptom treatment
might actually worsen a patient's suicide risk.
Frequent contact with the health professional can help limit the amount of
lethal drugs available to the patient and family. Infusion devices that limit
patient access to medications can also be used at home or in the hospital.
These are programmable, portable pumps with coded access and a locked cartridge
containing the medication. These pumps are very useful in controlling pain and
other symptoms. Some pumps can give multiple drug infusions, and some can be
programmed over the phone. The devices are available through home care
agencies, but are very expensive. Some of the expense may be covered by
insurance.
Effects of suicide on family and health care providers
Suicide can make the loss of a loved one especially difficult for survivors.
Survivors often have reactions that include feelings of abandonment, rejection,
anger, relief, guilt, responsibility, denial, identification, and shame. These
reactions are affected by the type and intensity of relationship; the nature of
the suicide; the age and physical condition of the deceased; the survivor's
support network and coping skills; and cultural and religious beliefs.
Survivors should have help during this period of grieving. Mutual support
groups can lessen isolation, provide opportunities to discuss feelings, and
help survivors find ways to cope.
The reactions of health care providers to the suicide are similar to those seen
in family members, although caregivers often do not feel they have the right to
express their feelings.
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