Dr. Saul Ebema

A few years ago, I visited a hospice patient who was suffering from suicidal ideation. She felt like her life was meaningless and needed physician assisted suicide. When the doctor told her then that it was not legal in our state, she said “I treated my dog better by putting her to sleep.”

Those who work with the dying know that the subject of suicide comes up from time to time. Few people who are enrolled in hospice care actually commit suicide, yet a number of them have thoughts of killing themselves or of finding someone who will assist them in the act of ending their lives.

When patients ask about suicide, it is an indication that something is seriously wrong. They may be quite depressed. Sometimes this suicidal ideation is triggered by loss of control.

I remember visiting a patient who was contemplating committing suicide. When I asked him why he wanted to commit suicide, he said, “My life has no meaning. I can’t do anything for myself. I have to rely on other people for everything. I can’t stand it, I would rather die.”

For others, suicidal ideation is triggered by being dependent on family, friends and caregivers. Some people do not know how to deal with the fact that they are dependent on others.

Others with advanced illness see no value to their existence. They see no future, and the present is filled with discomfort and often, severe pain.

For some, suicidal ideation is triggered by fear of abandonment. Many older people have seen, or heard stories, about what happens to dying people in some hospitals and nursing homes and they would rather consider killing themselves than be part of that distressing scenario.

The most common reasons patients give for wanting to commit suicide are:

• Current pain and suffering;
• Fear of pain and suffering yet to come.
• Loss of control over what is happening.
• Fear of becoming even more dependent.
• Fear of abandonment, isolation, dying alone.
• Inability to cope with the impact of the illness on family and friends.
• Loss of personal integrity, fear of disfigurement.
• Economic impact of further expensive care; exhausted financial resources.
• Desire to “join” previously deceased spouse, parent, child.

Hospice team protocol for managing suicide

All hospice team members are responsible for monitoring suicide risk among the patients and their family members.

• Consider which team leader is most appropriate for immediate notification if any staff member has concerns about a patient or family members’ potential risk for suicide.
• Consider utilizing the hospice chaplain and social worker as primary team members for conducting a more thorough suicide assessment to determine the degree of risk and appropriate interventions
• Maintain regular discussion about potential suicide risk during IDT meetings

Basic Treatment Interventions

• Engage the person in a conversation that focuses on his or her feelings (identify the “locus” of pain)
• Identify if the person is thinking about suicide or demonstrating a passive process of “letting go.”
• Inquire about the reasons for and against suicide (developing discrepancy – must be identified by the patient)
• Assess the degree of risk for suicide at this point in time (consider lethality).
• Screen for History of Suicide Attempts: – “Has anyone in your family or close friends experienced a situation of suicide?”  – “Can you share with me any experiences you have felt the urge to harm yourself on purpose?”

It is important to ask about suicidal thoughts and intent regularly, especially at times of transition when disease is worsening, symptoms are increasing, or the patient is entering a more serious phase of illness.

Creating an environment where these issues can be openly explored without being judged is critical.

If a patient is considering any potentially life-ending act, whether it be stopping potentially effective treatment, stopping eating and drinking, or contemplating physician-assisted suicide, explore the underlying meaning of the request and look for confounding depression, anxiety, and pain before responding.

Lessening suffering of seriously ill patients through the diligent application of palliative measures and alleviating their aloneness and despair by maintaining an open, committed, receptive relationship may be the most important preventive measures with regard to suicide in hospice care.