Assessment, Evaluation, and Management of Suicidal Patients
Table 7. Suggested Questions for the Assessment of Suicidal Symptoms in People With Cancera
a Adapted from Roth et al.
|Questions || Assessment|
|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|
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. 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.
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.