Table 7. Suggested Questions for the Assessment of Suicidal Symptoms in People With Cancera continued...
Effect on Family and Health Care Providers
When suicide complicates bereavement, the loss can be especially difficult for survivors. A pattern of reactions that includes feelings of abandonment, rejection, anger, relief, guilt, responsibility, denial, identification, and shame may occur. This pattern is modified by such factors as the nature and intensity of the relationship, the nature of the suicide, the deceased person's age and physical condition, the perceived support network, and the survivor's coping skills and cultural/religious background. Assisting survivors through the bereavement period is important. Mutual support groups are helpful in reducing isolation, providing opportunities for venting feelings, and finding ways to cope with the aftermath of suicide. (Refer to the PDQ summary on Grief, Bereavement, and Coping With Loss for further information.)
Staff reactions to the suicide of a patient are similar to those seen in family members, although staff often do not feel that they have the same right to express their feelings. The suicide of a patient may lead a staff member to question his or her professional judgment. It is often helpful for the staff to conduct a psychological autopsy in an attempt to understand why and how the suicide happened, signs and symptoms of risk, and how routines might be altered to prevent similar problems in the future.
Assisted Dying, Euthanasia, and Decisions Regarding End of Life
The principle of respecting and promoting patient autonomy has been one of the driving forces behind the hospice movement and right-to-die issues that range from honoring living wills to promoting euthanasia. These issues can create a conflict between patient autonomy and the physician's obligation to beneficence.
Answers to the questions of euthanasia and physician-assisted suicide belong to the realm of the law, ethics, medicine, and philosophy. Physicians and other health care professionals have essential clinical roles to play in addressing and untangling these issues when working with depressed, terminally ill patients.[1,8,9,10,11,12,13] Additionally, religious and cultural issues may strongly influence this decision-making process. A 1994 survey suggests that hospice physicians favor vigorous pain control and strongly approve of the right of patients to refuse life support even if life is secondarily shortened. However, these physicians strongly oppose euthanasia or assisted suicide, clearly making a sharp distinction between these two interventions. Often patients who specifically request physician-assisted suicide can be prescribed measures that augment their comfort, relieve symptoms, and obviate considering drastic measures. A recent study suggests that agreement with euthanasia is associated with male sex, lack of religious beliefs, and general beliefs about the suffering of cancer patients. A 1995 study of persons with advanced cancer who expressed a consistent and strong desire for hastened deaths suggested that this desire is related to the presence of depression. Patients with the desire to die should be carefully assessed and treated for depression as necessary. Whether their desire to die would persist or decrease with improvement in mood disorder has not yet been studied. It is important to maintain a shared decision-making process from the beginning of the professional relationship. (Refer to the PDQ summary on Last Days of Life for more information.)
- Massie MJ, Gagnon P, Holland JC: Depression and suicide in patients with cancer. J Pain Symptom Manage 9 (5): 325-40, 1994.
- Kovacs M, Beck AT, Weissman A: Hopelessness: an indicator of suicidal risk. Suicide 5 (2): 98-103, 1975 Summer.
- Breitbart W, Passik SD: Psychiatric aspects of palliative care. In: Doyle D, Hanks GW, MacDonald N, eds.: Oxford Text Book of Palliative Medicine. New York: Oxford University Press, 1993, pp 609-26.
- Akechi T, Okamura H, Yamawaki S, et al.: Why do some cancer patients with depression desire an early death and others do not? Psychosomatics 42 (2): 141-5, 2001 Mar-Apr.
- Breitbart W, Krivo S: Suicide. In: Holland JC, Breitbart W, Jacobsen PB, et al., eds.: Psycho-oncology. New York, NY: Oxford University Press, 1998, pp 541-7.
- Roth AJ, Holland JC: Psychiatric complications in cancer patients. In: Brain MC, Carbone PP, eds.: Current Therapy in Hematology-Oncology. 5th ed. St. Louis, Mo: Mosby-Year Book, Inc., 1995, pp 609-18.
- Miller RJ: Supporting a cancer patient's decision to limit therapy. Semin Oncol 21 (6): 787-91, 1994.
- Masdeu JC: Physician-assisted suicide and euthanasia. JAMA 276 (3): 196-7, 1996.
- Siegler M: Is there a role for physician-assisted suicide in cancer? No. Important Adv Oncol : 281-91, 1996.
- Back AL, Wallace JI, Starks HE, et al.: Physician-assisted suicide and euthanasia in Washington State. Patient requests and physician responses. JAMA 275 (12): 919-25, 1996.
- Marzuk PM: Suicide and terminal illness. Death Stud 18 (5): 497-512, 1994.
- Suarez-Almazor ME, Belzile M, Bruera E: Euthanasia and physician-assisted suicide: a comparative survey of physicians, terminally ill cancer patients, and the general population. J Clin Oncol 15 (2): 418-27, 1997.
- Howard OM, Fairclough DL, Daniels ER, et al.: Physician desire for euthanasia and assisted suicide: would physicians practice what they preach? J Clin Oncol 15 (2): 428-32, 1997.
- Suarez-Almazor ME, Newman C, Hanson J, et al.: Attitudes of terminally ill cancer patients about euthanasia and assisted suicide: predominance of psychosocial determinants and beliefs over symptom distress and subsequent survival. J Clin Oncol 20 (8): 2134-41, 2002.
- Chochinov HM, Wilson KG, Enns M, et al.: Desire for death in the terminally ill. Am J Psychiatry 152 (8): 1185-91, 1995.
- Chandler SW, Trissel LA, Weinstein SM: Combined administration of opioids with selected drugs to manage pain and other cancer symptoms: initial safety screening for compatibility. J Pain Symptom Manage 12 (3): 168-71, 1996.