Jerzy Kosinski, the Polish novelist and holocaust survivor, committed suicide in May 1991. Like other individuals suffering with chronic medical illnesses, he chose suicide as a means of controlling the course of his disease and the circumstances of his death. ``I am not a suicide freak, but I want to be free,'' Kosinski told an interviewer in 1979. ``If I ever have an accident or a terminal disease that would affect my mind or body, I will end it.'' These sentiments are shared by a significant segment of our society. The movement advocating ``death with dignity'' and autonomy for patients regarding how they die has been growing in this country. While Kosinski suffered with a cardiac condition, these issues are particularly compelling for those individuals with life-threatening illnesses such as cancer or AIDS. Perhaps of all medical conditions, cancer and AIDS are associated with the highest rates of suicide and of requests for hastened death (5,23,33,39,40). The movement to legalize euthanasia and the debate over physician-assisted suicide sparked by Derek Humphry's Final Exit (29a), have both centered on the plight of dying patients with cancer or acquired immunodeficiency syndrome (AIDS). Information that can shed light on our understanding of the factors that contribute to suicidal ideation, requests for hastened death, or suicide in cancer and AIDS patients will contribute greatly not only to the societal debate over these issues, but directly to humane patient care.
Uncontrolled pain has been recognized as an important contributing factor to suicide in cancer and AIDS patients (5,6,8,21,22). Persistent pain and terminal illness are the most common reasons for requests for euthanasia or physician-assisted suicide (28,63). Clinicians who specialize in pain management in cancer or AIDS settings will be confronted with these issues. The goal of this chapter is to provide the clinician with a factual framework on which to base an approach to managing cancer or AIDS patients with pain who are at risk of suicide or who request a hastened death. What follows is a review of the current research data on suicide, suicidal ideation, and suicide risk factors in cancer and AIDS patients, with particular focus on the roles of pain and psychiatric comorbidity. Additionally, a discussion of the ethical dilemmas presented by euthanasia and physician-assisted suicide is followed by an outline of principles in the management of suicidal cancer or AIDS patients.
The information presented in this chapter suggests that danger lies in the premature assumption that suicidal ideation or a request to hasten death in a cancer or AIDS patient represents a ``rational act'' unencumbered by physical symptom distress or psychiatric comorbidity. Clearly, there are suicides that occur in this population that many would view as rational expressions of personal autonomy; however, they represent only a small minority of suicides in cancer or AIDS patients. The vast majority of cancer or AIDS patients, particularly those with advanced disease, who express suicidal ideation or request a hastened death do so while suffering with unrecognized and untreated psychiatric disturbances (depression, confusional states), and poorly controlled physical symptoms (pain).
|Advanced Illness, poor prognosis|
|Loss of control, helplessness|
|Prior suicide history, family history|
Cancer patients commit suicide most frequently in the advanced stages of disease (5,21,22,23,39). Eighty-six percent of suicides studied by Farberow et al. (22) occurred in the preterminal or terminal stages of illness, despite greatly reduced physical capacity. Poor prognosis and advanced illness usually go hand in hand, so it is not surprising that in a Swedish study, those who were expected to die within a matter of months were the most likely to commit suicide. Of 88 cancer suicides, 14 had an uncertain prognosis, and 45 had a poor prognosis (5). With advancing disease, the incidence of significant cancer pain increases. Pain itself is an important cancer suicide risk factor, and will be discussed in great detail later on in this chapter. Patients with advanced illness are at high risk, perhaps because they are most likely to have such cancer complications as pain, depression, delirium, and deficit symptoms that increase vulnerability to suicide.
Psychiatric disorders are frequently present in hospitalized cancer patients who are suicidal. A recent review of our psychiatric consultation data at Memorial Sloan-Kettering Cancer Center (MSKCC) showed that one-third of suicidal cancer patients had a major depression, about 20% suffered from a delirium, and 50% were diagnosed with an adjustment disorder with both anxious and depressed features at the time of evaluation (6,8). Depression is a factor in 50% of all suicides. Those suffering from depression are at 25 times greater risk of suicide than the general population (27,52). The role depression plays in cancer suicide is equally significant. Approximately 25% of all cancer patients experience severe depressive symptoms, with about 6% fulfilling DSM-III criteria for the diagnosis of major depression (12,16,50). Among those with advanced illness and progressively impaired physical function, symptoms of severe depression rise to 77% (12). Hopelessness is a key variable that links depression and suicide in the general population. Furthermore, hopelessness is a significantly better predictor of completed suicide than is depression alone (4,34). With the typical cancer suicide being characterized by advanced illness and poor prognosis, hopelessness is an all too common experience. In Scandinavia, the highest incidence of suicide was found in cancer patients who were offered no further treatment and no further contact with the health care system (5,39). Being left to face illness alone creates a sense of isolation and abandonment that is critical to the development of hopelessness. The prevalence of organic mental disorders (primarily delirium) among cancer patients requiring psychiatric consultation has been found to range from 25% to 40% (16,37) and as high as 85% during the terminal stages of illness (41). While earlier work (22) suggested that delirium was a protective factor in regard to cancer suicide, our clinical experience has found these confusional states to be a major contributing factor in impulsive suicide attempts, especially in the hospital setting.
Loss of control and a sense of helplessness in the face of cancer are important factors in suicide vulnerability. Control refers to both the helplessness induced by symptoms or deficits due to cancer or its treatments, as well as the excessive need on the part of some patients to be in control of all aspects of living or dying. Farberow noted that patients who were accepting and adaptable were much less likely to commit suicide than cancer patients who exhibited a need to be in control of even the most minute details of their care (22). This controlling trait may be prominent in some patients and cause distress with little provocation. However, it is not uncommon for cancer-related events to induce a great sense of helplessness even in those who are not typically controlling individuals. Impairments or deficits induced by cancer or cancer treatments include loss of mobility, paraplegia, loss of bowel and bladder function, amputation, aphonia, sensory loss, and inability to eat or swallow. Most distressing to patients is the sense that they are losing control of their minds, especially when they are confused or sedated by medications. The risk of suicide is increased in cancer patients with such physical impairments, especially when accompanied by psychological distress and disturbed interpersonal relationships due to these deficit factors (21).
Fatigue, in the form of exhaustion of physical, emotional, spiritual, financial, familial, communal, and other resources, increases risk of suicide in the cancer patient (6,8). Cancer is now often a chronic illness. Increased survival is accompanied by increased numbers of hospitalizations, complications, and expenses. Symptom control thus becomes a prolonged process with frequent advances and setbacks. The dying process also can become extremely long and arduous for all concerned. It is not uncommon for both family members and health care providers to withdraw prematurely from the cancer patient under these circumstances. A suicidal patient can thus feel even more isolated and abandoned. The presence of a strong support system for the patient that may act as an external control of suicidal behavior reduces risk of cancer suicide significantly.
Holland (29) advises that it is extremely rare for cancer patients to commit suicide without some degree of premorbid psychopathology that places them at increased risk. Farberow (22) described a large group of cancer suicides as the ``dependent dissatisfied.'' These patients were immature, demanding, complaining, irritable, hostile, and difficult ward management problems. Staff often felt manipulated by these patients and became irritable due to what they saw as excessive demands for attention. Suicide attempts or threats were often seen as ``hysterical'' or manipulative. Our consultation data on suicidal cancer patients showed that half had a diagnosable personality disorder (6,8).
The frequency of suicide attempts in cancer patients has not been well studied. While the frequency of suicidal thinking in the cancer setting may be in question, its relationship to suicide attempts or completions is clearer. Bolund (5) reports that fully half of all Swedish cancer suicides had previously conveyed suicidal thoughts or plans to their relatives. In addition, many of the completed cancer suicides had been preceded by an attempted suicide. This is consistent with the statistics of suicide in general, which show that a previous suicide attempt greatly increases the risk of completed suicide (19,43). A family history of suicide is of increasing relevance in assessing suicide risk.
|Achte and Vaukhonen (1971)||<1||Ambulatory breast cancer|
|Silberfarb et al. (1980)||<1||Ambulatory mixed cancer types|
|Breitbart (1987)||8.6||Psychiatric consultations, hospitalized cancer patients|
|Pasacreta and Massie (1990)||11||Nurse reports,
|Breitbart et al. (1992)||16.3||Ambulatory and hospitalized patients with cancer pain|
|Brown et al. (1986)||20||Pallitive Care Unit|
Thoughts of suicide probably occur quite frequently, particularly in the setting of advanced cancer, and seem to act as a steam valve for feelings often expressed by patients as ``If it gets too bad, I always have a way out.'' It has been our experience in working with cancer patients that, once a trusting and safe relationship develops, patients almost universally reveal that they have had occasionally persistent thoughts of suicide as a means of escaping the threat of being overwhelmed by cancer. Recent published reports, however, suggest that suicidal ideation is relatively infrequent in cancer and is limited to those with more advanced disease, those who are hospitalized or in palliative care settings, or those who have pain or are significantly depressed (see Table 2). Any discrepancy between clinical impression and research conclusions may be due to the limitations of the research interview in eliciting report of suicidal ideation. Silberfarb et al. (59) found that only three of 146 breast cancer patients with local disease receiving ambulatory care reported suicidal thoughts to a research interviewer, while none of the 100 cancer patients interviewed in a Finnish study expressed suicidal thoughts (1). At Memorial Hospital, suicide risk evaluation accounted for 8.6% of psychiatric consultations in 1986, usually requested by staff in response to a patient verbalizing suicidal wishes (6,8). Three-quarters of those evaluated for suicide wishes (n=71) in fact were found to be actively suicidal, requiring that steps be taken to assure their safety. The vast majority of those hospitalized cancer patients with suicidal ideation had serious psychiatric disorders that had not been recognized or treated. One-half of the group had an adjustment disorder, 30% had a major depression, and approximately 20% had a delirium at the time of their psychiatric evaluation. With appropriate psychiatric interventions, suicidal ideation disappeared or diminished significantly in this group of patients. Pasacreta and Massie (47) distributed a psychosocial survey to the entire inpatient nursing staff at Memorial Hospital in October 1987. Nurses were asked a number of questions including ``Has your patient expressed suicidal ideas or wishes to you in the past week?'' Eleven percent of the 550 hospitalized cancer patients at Memorial Hospital had expressed suicidal ideation to their nurse. We recently studied 196 cancer patients with pain at Memorial Hospital and found that suicidal ideation occurred in 17% of the study population (8). A study conducted in the Palliative Care Unit at St. Boniface Hospice in Winnipeg, Canada demonstrated that 10 of 44 terminally ill cancer patients were suicidal or desired an early death, and all 10 were suffering from clinical depression (11).
The role of cancer pain in suicidal ideation is complex. There is evidence to suggest that it is not merely the extent or degree of pain that plays a role in cancer-related suicidal ideation, but rather the suffering experienced as part of one's psychological reactions to cancer pain, such as depression and hopelessness. Studies at MSKCC examined the relationship of cancer pain to suicidal ideation (6,8). In a series of 71 cancer patients who had suicidal ideation with serious intent, significant pain was a factor in only 30% of cases. In striking contrast, virtually all 71 suicidal cancer patients had a psychiatric disorder (mood disturbance or organic mental disorder) at the time of evaluation (6). We also studied 196 cancer pain patients involved in ongoing research protocols of the MSKCC Pain and Psychiatry Services (8). Suicidal ideation occurred in 17% of the study population, with the majority reporting suicidal ideation without intent to act. Interestingly, in this population of cancer patients who all had significant pain (VAS pain intensity mean score of 5.4), suicidal ideation was not directly related to pain intensity, but rather was strongly related to the degree of depression and mood disturbance (as measured by the Beck Depression Inventory and the Memorial Pain Assessment Card=mVisual Analog Scale Mood Scale). Duration of pain also did not predict suicidal ideation. Pain was related to suicidal ideation indirectly in that patients' perception of poor pain relief was associated with suicidal ideation. Perceptions of pain relief may have more to do with aspects of hopelessness than pain itself.
|Organic mental disorder: delirium, dementia|
|Depression: guilt, hopelessness, bereavement|
|Substance abuse: intravenous drug use, cocaine, alcohol|
|Preexisting psychopathology: personality disorder, avoidance coping|
|Absence of social support: isolation|
|Inadequate pre- and post-HIV test counseling|
|Suicide history: attempts, expression of thoughts|
|Disease status: stages II, III/AIDS (IV)|
|Pain: functional interference|
Factors related to increased risk of suicide with HIV infection are listed in Table 3. Organic mental disorders, particularly delirium and dementia, occur with increased frequency in AIDS patients as disease advances. The majority of suicidal patients with Kaposi's sarcoma and AIDS, who were evaluated by the Psychiatry Service at Memorial Hospital, had prominent signs of delirium often superimposed on an AIDS-associated dementia (6,8). Treatment of delirium in these patients often results in resolution of suicidal ideation or behavior. Depression is as important a factor in AIDS-related suicide as it is in suicide in general. Marzuk et al. (40) reported that 50% of AIDS patients who committed suicide were significantly depressed, and 40% saw a psychiatrist within four days of committing suicide. One-third of suicidal AIDS patients evaluated at Memorial Hospital were suffering from an undiagnosed major depression (6,8). Perry and his colleagues (49) reported that suicidal ideation in HIV seropositives was primarily a function of concomitant depression. Hopelessness is a key variable linking depression to suicide. Guilt about past behavior, multiple bereavements, isolation from family and friends, and hopelessness are common factors in many AIDS-related suicides (24). Rabkin et al. (53) showed that absence of social support and depression correlated highly with hopelessness in HIV-infected persons. Gutierrez and colleagues (26) found that suicidal HIV-infected men tended to have less social support, and relied more heavily on avoidance as a coping strategy, than nonsuicidal HIV-infected men. Risk factors for suicide attempt in HIV-seropositive individuals in the military include social isolation, perceived lack of social support, adjustment disorder, personality disorder, substance/alcohol abuse, past history of depression, and HIV-related interpersonal or occupational problems (55). Expression of suicidal thoughts or intent will often predate a suicide attempt in patients with AIDS (24). In the Marzuk et al. (40) study, 25% of AIDS patients who committed suicide had made prior suicide attempts. Frierson and Lippman (24) believe AIDS patients in remission are the most likely to summon the necessary energy to complete suicide. Clearly, however, even debilitated patients with advanced AIDS have successfully committed suicide. Disease-related factors, such as pain related to AIDS, and other physical symptoms probably play a role in suicide, although this has not been studied as of yet. Substance abuse and preexisting psychopathology heighten the risk of suicide with HIV infection. Alcoholics and substance abusers generally have a rate of suicide 10 to 20 times higher than the general population. Clinicians must be alert to the increased risk of suicide in AIDS patients and promote early intervention for such psychiatric complications as delirium, depression, and social isolation.
Chapter 4 Table 4: Suicidal ideation and AIDS: lifetime suicidal thoughts/attempts
|Atkinson et al. (1990)||Homosexual men
|Gutierrez et al. (1990)||Homosexual men, miliary|
|HIV- at risk||55|
|HIV- at risk||20|
|Orr et al. (1990)||HIV Psychiatric clinic|
|Orr et al. (1990)||HIV Psychiatric clinic|
|Drexler et al (1990)||Military, inpatient alcohol unit|
|Suicide an option over next year||HIV+||16.7|
|Perry et al. (1990)||HIV testing|
|Pretest suicidal ideation||HIV+||28.6|
|(BDI item 9)||HIV-||30.6|
|2 Months Posttest suicidal ideation||HIV+||16.3|
|(BDI item 9)||HIV-||15.9|
|Breitbart et al. (1990)||Ambulatory HIV medical clinic|
|current suicidal ideation||All HIV+||26|
|(BDI item 9)||HIV+ no pain||20|
|Pain related to AIDS|
|Pain related to AIDS therapy|
|Antivirals (AZT, DDI, DDC)|
|Biological modifiers (GM-CSF)|
|Pain unrelated to AIDS|
The term euthanasia encompasses a number of concepts, all of which have become controversial but important issues in the care of terminally ill patients. Active euthanasia refers to the intentional termination of a patient's life by a physician. Physician-assisted suicide is the provision by a physician of the means by which patients can end their own lives. Passive euthanasia refers to the withholding or withdrawal of life-sustaining measures, and is viewed as acceptable in many societies (48). Active euthanasia and physician-assisted suicide, however, are perhaps the most intensely and bitterly debated issues in medical ethics today. Active euthanasia has been taking place in the Netherlands for a decade (17,63). Although still illegal, the active termination of a patient's life by a physician is tolerated under the conditions that: (i) the patient's consent is free, conscious, explicit, and persistent; (ii) the patient and physician agree that the suffering is intolerable; (iii) other measures for relief have been exhausted; (iv) a second physician concurs; and (v) these facts are documented. A best estimate is that 1.8% of deaths in the Netherlands are the result of euthanasia with physician involvement (63). Common reasons for requesting euthanasia include loss of dignity (57%), pain (46%), unworthy dying (sic) (46%), being dependent on others (33%), and tiredness of life (sic) (23%) (63). Recently, the states of California and Washington have considered initiatives that would allow for active euthanasia along the Netherlands model. The case of ``Debbie'' published in JAMA in 1988 forced a debate on active euthanasia in this country that is ongoing (20,25,30,31,60,64).
Physician-assisted suicide has also become a topic of public debate, following the dramatic case in 1990 of a woman with Alzheimer's disease who utilized Dr. Jack Kevorkian's ``suicide machine.'' Dr. Kevorkian was acquitted by a Michigan court of any wrongdoing. Dr. Timothy E. Quill, a physician who assisted a leukemia patient in committing suicide, was not indicted by a Rochester grand jury in July 1991. Dr. Quill's account of his participation in his patient's suicide was published in the March 7, 1991 issue of the New England Journal of Medicine (51) and sparked continued debate regarding the physician's role in aiding dying patients. In interviews after he published this article, Dr. Quill said he had decided to go public in order to present an alternative to Dr. Kevorkian's approach, using a machine in the death of a patient whom Dr. Kevorkian did not know well. In contrast to the Kevorkian case, Dr. Quill had been treating the patient with leukemia for 8 years and knew her quite well. In his article, Dr. Quill described the process that he and the patient undertook, exploring her choice to actively take her life. He also described recommending that the patient contact the Hemlock Society, and prescribing barbiturates for sleep one week later at the patient's request.
The Humane and Dignified Death Act, a proposed law that would free doctors from criminal and civil liability if they participated in voluntary active euthanasia, did not appear on the 1988 California ballot because the sponsoring group (Americans Against Human Suffering) barely failed to get the required number of signatures. That group, an affiliate organization of the national Hemlock Society, did, however, undertake a survey of California physicians as part of their efforts to build support for the act. The survey was quite revealing (28). Seventy percent of physicians who responded agreed that patients should have the option of active euthanasia in terminal illness. More than half of the physicians said that they would practice active voluntary euthanasia if it were legal. Twenty-three percent revealed that they already had practiced active euthanasia at least once in their careers. Of the 60% of physicians who indicated that they had been asked by patients with terminal illness to hasten death, nearly all agreed that such requests from patients can be described as ``rational.'' Public support for ``the right to die'' has been growing as well. Sixty-five to 85 percent of the general population support a change in the law to permit physicians to help patients die, and there is greater acceptance by the public of suicide when pain and suffering coexist with terminal illness.
Those of us who provide clinical care for cancer or AIDS patients with pain and advanced illness are sympathetic to the goals of symptom control and relief of suffering, but are also obviously influenced by those who view suicide or active voluntary euthanasia as rational alternatives for those already dying and in distress. Danger lies in the premature assumption that suicidal ideation or a request to hasten death in the cancer or AIDS patient represents a rational act that is unencumbered by psychiatric disturbance. Accepted criteria for ``rational suicide'' (57,58) include the following: (i) the person must have clear mental processes that are unimpaired by psychological illness or severe emotional distress, such as depression; (ii) the person must have a realistic assessment of the situation; and (iii) the motives for the decision of suicide are understandable to most uninvolved observers. Clearly there are suicides that occur in the cancer or AIDS setting that meet these criteria for rationality; however, a significant percentage, possibly the majority, do not, by virtue of the fact that significant psychiatric comorbidity exists. By reviewing the current research data on suicide in cancer and AIDS and the role of such factors as pain, depression, and delirium, we hope to provide a factual framework on which to base guidelines for managing this vulnerable group of patients.
The clinician who works in a cancer or AIDS setting should anticipate that the topic of euthanasia or physician-assisted suicide may arise with some patients and should be ready to respond in a fashion that is most consistent with his or her beliefs. One should be reminded, however, that euthanasia and assisted suicide are not legal in the United States. Many clinicians find it useful to explain to patients that, although they cannot participate in euthanasia or assisted suicide, they will aggressively and without limitation pursue pain control and comfort during all phases of illness, particularly the late terminal phases. It is also sometimes reassuring to explicitly explain that pain medications such as morphine will be used for pain control and comfort without limitation even to the point of complete sedation if necessary. Although many physicians do not feel comfortable prescribing medications to be used specifically for the purpose of suicide, most do feel comfortable prescribing pain medicines or sedatives for symptom control knowing full well that the patient has control over the use of these medicines in the home setting. Active and aggressive pursuit of maximal palliative care, focusing on both physical and psychological symptom distress, is the approach that best characterizes what most clinicians view as our obligation to terminally ill cancer and AIDS patients (64). Unfortunately, this does not always take place. Many argue that until quality palliative care is available to the majority of terminally ill patients, debate over euthanasia or assisted suicide is dangerous (48,64). Our society and the medical profession may someday come to believe that euthanasia or assisted suicide is proper and appropriate in selected cases. While debate over these issues is ongoing, it is helpful to keep the following in mind: (i) euthanasia and physician-assisted suicide remain illegal; (ii) these acts not only do away with the patient's suffering, they do away with the patient; and (iii) in agreeing to euthanize or assist a patient in suicide, one may be confirming the patient's sense that life has no more meaning or purpose, and this may be the wrong message to convey at such a vulnerable period in the patient's life. Finally, clinicians should be cautioned against falling into the trap of ``secret collusion'' with a patient regarding a request for euthanasia or assisted suicide. The doctor-patient relationship is more complex than most of us are often aware and is subject to powerfully intense emotional forces, particularly when the relationship has been long and the doctor's identification with the patient is strong. It is advisable to share the management of such cases with colleagues, particularly those with palliative care expertise or psychiatric expertise. When medical ethicists or medical ethics committees are available, it is also helpful to seek consultation from them in managing patients with whom euthanasia or assisted suicide has been raised as a serious issue.
|Establish rapport with an empathic approach.|
|Obtain patient's understanding of illness and present symptoms.|
|Assess mental status (internal control).|
|Assess vulnerability variables, pain control.|
|Assess support system (external control).|
|Obtain history of prior emotional problems or psychiatric disorders.|
|Obtain family history.|
|Record prior suicide threats, attempts.|
|Assess suicidal thinking, intent, plans.|
|Evaluate need for one-to-one nurse in hospital or companion at home.|
|Formulate treatment plan, immediate and long term.|