Most physicians end up encountering and caring for terminally ill patients in some capacity as a part of their routine practice. Likewise, most physicians also have been forced to face the aftermath of a death by suicide.
It may have been an established patient, a relative or friend of a patient, or, even more tragic – a personal friend or family member. These circumstances always seem to have a sudden painful recourse, often with so many unanswered questions: so many “whatifs?” and/or “what could I/we have done differently?” to prevent such an unexpected act of finality. It is important to try and gain a better understanding of when terminal illness and suicide intersect in the end-of-life continuum.
Our hospice [Family Hospice & Palliative Care, PA] had two “successful” suicides in the past six months, and we all have been asking ourselves these exact same questions over and over. Both patients were middle-aged men with cancer, who had been enrolled in our hospice for several months before ending their lives with self-inflicted gunshot wounds. They were both at home and found by loved ones immediately. They both had a history of partially treated depression and had some degree of uncontrolled emotional and physical suffering brought on by their terminal cancer. When asked previously by hospice staff, they both denied having access to firearms in their homes. Neither had previously expressed suicidal thoughts, ideations or suicide attempts. Neither had pursued requests for palliative sedation or anything to hasten death from hospice staff. It would be unfair to classify these patient outcomes as “typical” or “not surprising,” but instead they have amounted to a somewhat rare and unexpected suicide cluster in an organization that admits and pronounces around 3,000 patients annually.
There is very little data and research on suicide in terminally ill patients, but cancer patients have been shown to have nearly twice the incidence of suicide that the general population (rate of 31.4/100,000 vs 16.7/100,000 patient-years).¹ Other suicide risk factors which are common in the terminally ill patient population would be advancing age, psychiatric comorbidity, uncontrolled pain and, of course, family history of suicide and male sex.² Certainly, accessing and treating anxiety, grief and depression can have a huge impact on preventing suicide in end-of-life patients because of the high prevalence of such in this patient population.
It also is important to differentiate between grief and depression, with the latter being more persistent, but also more amenable to treatment with therapy and medication. Common measurable and observable physical end-of-life symptoms such as pain, dyspnea and fatigue contribute to and exacerbate the pervasive existential suffering in terminally ill patients. All hospice team members, including nurses, social workers and chaplains, must be proficient at screening and recognizing the often subtle symptoms of depression, as well as suicidal thoughts and ideations that can accompany depression. Ensuring patient safety is paramount, so screening for weapons in the home is typically routine in all hospice admissions.
In caring for terminally ill patients, both casual and direct requests to hospice clinicians to hasten death by a patient and/or family member is not uncommon.³ Sometimes, it may be an “off the cuff” remark or request, or sometimes it can be a pointed request to prescribe or increase their medicine to make them “to go sleep and never wake up.” This may stem from untreated symptoms, extreme loss of function or often the overwhelming feeling of being a burden to family, friends and society. Sometimes these conversations may occur privately in a calm and peaceful setting, while other times they can be significantly more dramatic, when a patient is in crisis in the hospital or hospice unit. Pain and dysnea can predominate in an actively dying patient, who may yell out or demand in front of others to “Please, just end my suffering!” In either case, further discussions to clarify the patient’s question/request, as well as providing the patient with the right amount of support and treatment to address unremitting physical and psychological distress is imperative.
The Death with Dignity Act, which originated in Oregon in 1994, was the first legislation in our country to empower terminal patients with autonomy, in regard to the manner in which they die. The momentum has significantly increased nationally in recent year, and five more states (Washington, California, Colorado, Vermont and Hawaii) as well as the District of Columbia, have adopted similar statutes. Not surprisingly, there remain many ethical and moral dilemmas surrounding this legislation which have polarized various special interest groups. Even the language defining the act has been modified in recent years. The term “Physician Assisted Suicide” has appropriately been replaced with “Physician Assisted Death” (PAD) when referencing these practices.
Pennsylvania appears to be far from adopting a Death with Dignity Act. Although state Sen. Daylin Leach re-introduced a Pennsylvania Death with Dignity Bill in 2017, the previous six times it failed to make it out of the Senate Judiciary Committee. Certainly, one can’t help but wonder if our two recent hospice patients who chose violent suicide would have chosen an alternative pathway if they lived in a state with a Death with Dignity Act?
Personally, although I support advocacy to promote Death with Dignity legislation, I have very mixed feelings on whether I would feel comfortable prescribing a lethal dose of medication if it were legal to do so in my state. I have seen firsthand so much peace and solace with actively dying patients, as they spend time alone or with their loved ones in the final hours and days of life. The evolution of palliative care as a medical subspecialty has likewise occurred simultaneously with Death with Dignity legislation in these past two decades in the United States. There are legal and peaceful alternatives to PAD, which still promote patient autonomy and allow goals of care that may hasten death to alleviate suffering. What if these men would have felt comfortable expressing their fears and wishes to their hospice physician? Perhaps alternatives to hastening death could have been discussed, such as Voluntarily Stopping of Eating and Drinking (VSED). Alternatively, implementation of more aggressive symptom control could have been attempted, and if necessary, the use of palliative sedation at home or in an inpatient hospice unit could have been offered for specific refractory symptoms. These are discussions that are welcome at the end of life and can occur between patients and the hospice interdisciplinary team.
At our hospice, in the aftermath of these recent suicides, we have offered bereavement and grief support to all staff involved in caring for these two patients. We also have reviewed and redeveloped our curriculum to make sure that all disciplines are re-educated on symptoms of depression and risk factors for suicide, with the hopes of reducing and eliminating this ultimate form of hastened death. The suicide crisis resources, resolve, available to Allegheny County [PA] residents, also will be providing additional education on-site at our hospice in the future. It is imperative that ongoing evaluation and re-evaluation of those hospice patients at highest risk of suicide is required by all hospice disciplines, even if the patient’s lifespan is measured in only days or weeks.
Dr. Lagnese is chief medical officer at Family Hospice & Palliative Care.
References
Misono S, Weiss NS, Fann JR, RedmanM, Yueh B. Incidence of suicide in persons with cancer. J Clin Oncol. 2008: 26: 4731-4738.Block SD, Chapter 6: Assessing and managing depression in the terminally ill patient. Physician’s Guide to End of Life Care. Snyder, Louis ACP Press; 2001.Quill TE. Doctor, I want to die. Will you help me? JAMA 1993; 270: 870-873