Abstract
Dear Editor:
Suicide in the terminally ill hospice patient is a traumatic event for all involved. There is extensive literature about demographics and risk factors for suicide in patients with serious disease, especially cancer.1,2 Narrative data about completed suicides in the American hospice literature are lacking. This report retrospectively reviews completed suicides in a West Virginia hospice focusing on narrative details that might be helpful in recognizing patients at risk for suicide in this setting.
West Virginia exceeds the national average in deaths by suicide. 3 It is a state with a high rate of gun ownership and the suicide risk is 3.7 times higher than in states with low gun ownership. National Violent Death Reporting System data reveal that rates of firearm suicide are highest among males aged 70 and older. Only 26.5% disclose their intent to commit suicide and the most commonly identified circumstances are depressed mood, mental health problems, and physical health problems. 4 Elderly West Virginia men who are terminally ill may therefore be at greater risk to commit suicide with a firearm.
The charts of five suicide cases that occurred in our hospice in the last decade were reviewed. The hospice serves urban and rural areas and has an average daily census of 300 patients. Patient characteristics, setting, and events leading up to the act were reviewed and staff members were interviewed when possible. All five patients were retired white males with an average age of 73 years (range, 64–78 years). Four had advanced cancer and one had end-stage lung disease. The mean length of hospice care was 50 days (range, 2–141 days). Their previous occupations varied from company executive to retail work. Four had been in military service. All five used a firearm to end their lives and were alone. While the circumstances prior to the suicide varied, the majority of the patients had suffered marked decline in the days before the event. Selective narrative details of the five cases are summarized in the following sections.
Case 1
This patient could no longer care for his wife who suffered from dementia and placed her in a nursing home shortly after his hospice admission. He began antidepressants soon thereafter. His total hospice stay was over 4 months. The week before he died, he fell due to increasing weakness and his dyspnea became more severe; he expressed fears of suffocation and asked if the oxygen could be keeping him alive. He had good support from his pastor and his son who was staying with him at the time. His son had just left to go to the store when the patient shot himself.
Case 2
An unmarried man with brain metastases, resulting in right hemiparesis, expressive aphasia, and diplopia was discharged to home hospice after a 19-day hospital stay. The hospital palliative care team had supported his requests: arranging for a visit from a priest; continuance of intravenous hydration to help him be coherent, and a hospice referral so that he could die at home. In the hospital, he was described as withdrawn at times, but he had denied pain and never expressed suicidal ideation. Less than 48 hours after he returned home, he shot himself in the head. He was alone at the time. After his death one of the family commented that “he would have found a way to do this regardless.”
Case 3
This patient lived alone until a fall from progressive weakness led to his son's visit 2 days before his death. Transfer to an inpatient facility was being considered. He was alone on the back porch with a cup of coffee and a cigar by his chair when he shot himself. His symptoms were well controlled, he was known for his sense of humor, and he was well supported by his friends from Alcoholics Anonymous. He talked openly about his wish to die peacefully and did not want to be a burden to his adult children who all lived out of town. He had mentioned to the nursing assistant once that he thought about suicide, but brushed it off when the nurse explored this and refused to discuss it further.
Case 4
A widowed patient was rarely alone due to homemaker support, an attentive nearby sister, and visiting friends. Significant symptom burden included severe dyspnea, chronic back pain, and a long history of depression, but he refused to see a counselor or a chaplain and appeared cheerful to some of the staff. He said he was ready to die. His opioids had recently been increased to relieve dyspnea and pain. He reported efficacy but felt more drowsy and nauseated. Despite anti-emetic therapy, he began to vomit, and the caregiver called for advice. The nurse spoke to the patient and, because he had refused continuous care in the home, suggested going to the inpatient facility for symptom management to which he agreed. He shot himself soon after that phone call, while the caregiver had stepped out.
Case 5
The last patient was being cared for by his girlfriend, who was sometimes absent for extended periods. He had expressed a strong desire to live and was “hoping for a miracle.” He had significant symptom burden with pain, nausea, and vomiting, which was not satisfactorily controlled. He was noncompliant with medication regimens, admitted to depressive feelings, but refused antidepressants or counseling to help with his estranged daughters. He avoided discussion of family affairs and advance directives. Earlier on the day of his death, he expressed fears and reluctance about placement in an inpatient facility, which was offered to improve his symptoms. He said he just wanted to die. Later, he asked his friend to take him for a ride. When the friend left him alone to get a soda he requested, he shot himself.
Family members responded to these violent deaths in very different ways, but over time most of them accepted that their loved ones needed to take control and avoid further loss of independence. Reactions varied from how would they cope with the social stigma of suicide to how would they ever be able to clean up the area where this occurred to relief that the suffering was over for their loved one. All hospice staff caring for these patients expressed surprise and had not anticipated that they might end their lives in such a violent manner. It is known that one third to four fifths of all suicide attempts are impulsive. 5 In one study, nearly half of the patients who attempted suicide reported that the period between the first current thought of suicide and the actual attempt had lasted 10 minutes or less. 6
Our findings suggest a need for heightened awareness of suicide risk in terminally ill men with a history of military service, especially as they reach a point in their illness when they are no longer able to care for themselves in their own home. Others have also reported autonomy as a strong theme in the face of ongoing losses. 2 Access to a loaded firearm and an opportunity to be alone may have allowed these patients to act on an impulsive decision to commit suicide.
As a result of our experience, we recommend, in addition to annual education of staff on suicide prevention:
Development of a checklist for identifying high-risk patients Implementation of a protocol for following high-risk patients. This would include general measures such as inquiry about access and presence of firearms in the home, family education, meticulous attention to symptoms, and enhanced continuity of care by the staff, as well as consideration of need for consultation with a psychiatric nurse specialist. It would also include measures tailored to the individual patient such as identifying specific ways to maximize patient control, increased attentiveness by the team to signs of decline, and extra care in discussing transfers out of the home Identify a cleaning agency that can respond promptly at any time to the cleaning needs of family in the event of a firearm suicide Assure prompt and ongoing debriefing and support services to involved employees as well as specifically tailored bereavement services to families Establish a baseline for completed suicides in hospice patients by national and/or regional tracking to include pertinent demographics, risk profile data, and mode of executing the act.