Shining light in a Tunnel: Suicide Prevention in Palliative Care
– Ms. Michelle Normen, Bengaluru
The World Health Organization and the International Association for Suicide Prevention (IASP) every year on 10th September celebrates World Suicide Prevention Day (WSPD). The aim of events all over the globe towards this cause is to sustain a universal commitment to focus attention on the prevention of suicide. WSPD’s 2022 theme was chosen as ‘Creating hope through action’ and beckons communities to come together to address this urgent public health issue.
The National Crimes Record Bureau’s (NCRB) report on Accidental Deaths & Suicides in India, 2020, stated that a total of 1,53,052 suicides were reported in the country during 2020, showing an increase of 10.0% in comparison to 2019 where the rates of suicides had increased by 8.7% during 2020 over 2019. The leading causes of suicide were due to family problems (33.6%) and Illness (18%)1. 1 in 5 suicides in India are committed by individuals living with an advanced, chronic or a life-limiting condition2. The statistics reported here are noteworthy and require us as palliative care professionals to deliberate on the topic of suicide. The grim reality is that most often we do not openly elicit from our patients or caregivers about their thoughts regarding suicide. The primary and most common fear from within being that ‘I may just give them the idea to commit suicide!’.
As professionals working in the field of palliative care, we must remember that a diagnosis of cancer invariably brings about thoughts of mortality to the forefront of a patient’s mind and quite often increases physical, mental, and spiritual stresses on personal resources3. Evidence suggests that patients with cancer are at a higher risk to commit suicide during the first few months of a diagnosis4. Some sites of cancer such as respiratory and gastrointestinal cancers were found to be more commonly associated with greater risk of suicide5.
Key concepts & Definitions:
Before we go into understanding the risk factors of suicide, we must understand a few key concepts and definitions.
|Death Wish or wish to die||Relatively common in patients with advanced illness. It is a reaction to suffering, in the context of a life-threatening condition, from which the patient can see no way out other than to accelerate his or her death. This could be due to physical symptoms (either present or foreseen), psychological distress (e.g., depression, hopelessness, fears, etc.), existential suffering (e.g., loss of meaning in life), or social aspects (e.g., feeling that one is a burden)6|
|Suicidal Ideation||Can range from a fleeting passive wish to die, often normal in cancer at all stages of the disease, to more severe preoccupation with thoughts of harming oneself7|
|Suicidal Intent or plan||A desire to act on these feelings is expressed and a potential method is described7|
As a palliative care professional, it is essential to take stock of these key concepts which aids in the understanding of wishes with regard to death.
Risk factors in Suicide:
Clinical experiences from mental health and psychiatry suggest that starting a conversation on suicide that could ease a patient’s distress and burden, and may even lead to prevention. Often times, patients and families want clinicians to proactively address distress with regard to death and dying as they believe it to foster open emotional communication and improve the overall patient clinician relationship to help preserve the will to live8. The main risk factors specific to suicide are:
(i) Demographics and Illness characteristics
(ii) Depression and hopelessness
(iii) Helplessness, loss of control and burden to others
(iv) pain and physical symptoms
(v) cognitive dysfunction and delirium
(vi) social support
(vii) psychiatric history and personality factors
(viii) spiritual and existential concerns9
Assessing for Suicide:
The need for early and careful assessment of suicide risk is a first step towards the planning for interventions to manage those patients at risk. Hudson and colleagues (2006) devised a comprehensive framework for healthcare professionals who need to assess for suicide risk10. It becomes important to evaluate multiple factors through assessment tools (eg: HADS, PHQ-9, etc) and using the clinical interview to identify individuals who are at risk for suicide based on factors such as- predisposition to suicidal behaviour, precipitants or stressors, nature of suicidal thinking, hopelessness, impulsivity, lack of protective factors and somatic symptoms11.
Interventions and Strategies:
As palliative care professionals it is important to engage in thorough psychological assessments to plan for the best interventions suited to the patient’s needs to provide relief from distressing symptoms and suffering which can be lifesaving.
The professional will need to use their skills of empathy, active listening, be realistic and also make referrals as required to other specialities based on the situation.
Depending on the severity of risk, the care plan needs to involve the use of suicide prevention resources, contracting with the patient for safety, limiting access to harmful objects and documenting in the case files which becomes paramount.
The support of family members and staff also needs to be improved at this stage to ensure a collaborative effort to safeguard the patient.
By recognizing the main risk factors a combination of pharmacotherapy and psychotherapies (Supportive Psychotherapy, Cognitive behaviour therapy, Meaning-centred psychotherapy, dignity therapy) can go a long way to preserve dignity and explore the most important goals of patients9.
Support for family members- completed suicide:
At times despite best efforts, we as professionals may find ourself in situations where patients choose to end their life. Our care at this time must involve “Postvention” (term coined by Edwin Shneidman, 1968) for bereaved family members who often experience embarrassment, shame, guilt and anger towards the deceased for their choices. These interventions address the care of bereaved survivors, caregivers, and health care providers, to destigmatize the tragedy of suicide and to assist with the recovering process and serves as a secondary prevention effort to minimize the risk of subsequent suicides due to complicated grief, contagion, or unresolved trauma12.
It is therefore essential as palliative care professionals to rely on the support of fellow colleagues especially when working in challenging situations such as suicide prevention. By looking out for red flags of suicide, professionals can tailor-make interventions so as to continue to care for patients and their families.
- Daniel C. McFarland, DO, Leah Walsh, MS, Stephanie Napolitano, MA, Jody Morita, MD, Reena Jaiswal, MD, Oncology, Oncology Vol 33 No 6, Volume 33, Issue 6, June, 2019
- Liu Q, Wang X, Kong X, Wang Z, Zhu M, Ren Y, Dong H, Fang Y, Wang J. Subsequent risk of suicide among 9,300,812 cancer survivors in US: A population-based cohort study covering 40 years of data. EClinicalMedicine. 2022 Feb 12;44:101295. doi: 10.1016/j.eclinm.2022.101295. PMID: 35198920; PMCID: PMC8850339.
- Mohandoss AA, Rooban T. A study on suicide among Indians living with cancer during 2001–2014. Indian J Cancer 2016;53:435-40.
- Balaguer A, Monforte-Royo C, Porta-Sales J, Alonso-Babarro A, Altisent R, Aradilla-Herrero A, Bellido-Pérez M, Breitbart W, Centeno C, Cuervo MA, Deliens L, Frerich G, Gastmans C, Lichtenfeld S, Limonero JT, Maier MA, Materstvedt LJ, Nabal M, Rodin G, Rosenfeld B, Schroepfer T, Tomás-Sábado J, Trelis J, Villavicencio-Chávez C, Voltz R. An International Consensus Definition of the Wish to Hasten Death and Its Related Factors. PLoS One. 2016 Jan 4;11(1):e0146184. doi: 10.1371/journal.pone.0146184. Erratum in: PLoS One. 2018 Apr 26;13(4):e0196754. PMID: 26726801; PMCID: PMC4700969.
- Rosenfeld B. Methodological issues in assisted suicide and euthanasia research. Psychol Public Policy Law. 2000 Jun;6(2):559-74. PMID: 12661541.
- Porta-Sales J, Crespo I, Monforte-Royo C, Marín M, Abenia-Chavarria S, Balaguer A. The clinical evaluation of the wish to hasten death is not upsetting for advanced cancer patients: A cross-sectional study. Palliat Med. 2019 Jun;33(6):570-577. doi: 10.1177/0269216318824526. Epub 2019 Jan 28. PMID: 30688146.
- Pessin, H & Breitbart, W.S. (2016). Suicide. In Holland, J.C, Breitbart, W.S, Jacobsen, P.B, Loscalzo, M.J, McCorkle, R, Butow,P.N (3rd Ed) Psycho-Oncology (745-746).United States of America.Oxford University Press.
- Hudson PL, Schofield P, Kelly B, Hudson R, O’Connor M, Kristjanson LJ, Ashby M, Aranda S. Responding to desire to die statements from patients with advanced disease: recommendations for health professionals. Palliat Med. 2006 Oct;20(7):703-10. doi: 10.1177/0269216306071814. PMID: 17060269.
- Rudd, M. D., & Joiner, T. E., Jr. (1999). Assessment of suicidality in outpatient practice. In L. VandeCreek & T. L. Jackson (Eds.), Innovations in clinical practice: A source book, 17, pp. 101–117). Professional Resource Press/Professional Resource Exchange.
- Erlich MD, Rolin SA, Dixon LB, Adler DA, Oslin DW, Levine B, Berlant JL, Goldman B, Koh S, First MB, Pabbati C, Siris SG. Why We Need to Enhance Suicide Postvention: Evaluating a Survey of Psychiatrists’ Behaviors after the Suicide of a Patient. J Nerv Ment Dis. 2017 Jul;205(7):507-511. doi: 10.1097/NMD.0000000000000682. PMID: 28590263; PMCID: PMC5962958.
About the Author: Ms. Michelle Normen (BSc, MSc., M.Phil Psycho-Oncology) is a Psycho-oncologist and Lead for Counselling Services at Bangalore Hospice Trust-Karunashraya, Bengaluru.
She has a decade of clinical experience in the field of Psycho-oncology and has worked in a variety of cancer settings. Her keen interests are in Communication Skill Training, Supportive Psychotherapy in Pain & Palliative care and mixed methods research in healthcare.