Abstract
Background
Ethics
Core principles
It is a core obligation of physicians to prevent a patient from initiating suicide and to intervene medically to prevent a patient from dying after a suicide attempt. 3 This obligation can include detaining and restraining patients against their will and the use of invasive medical interventions such as mechanical ventilation if needed, although such restrictions to a patient's liberty should be kept to the minimum necessary. Most suicidal patients are considered impaired by depression or other mental illnesses and their actions are not considered autonomous, thus justifying detaining patients and providing medical interventions against their will. 4 Such interventions can create further opportunities to treat the patient's psychiatric condition, and only 20% of people who are prevented from committing suicide subsequently complete another attempt.
Exceptions at life's end
The above logic is less compelling in terminally ill patients who have attempted suicide, particularly with short prognoses, e.g., <1 month. In these patients most medical interventions are unlikely to restore health or significantly alter the dying process in a way that would materially benefit the patient. Clinicians may opt to forgo certain interventions (e.g., mechanical ventilation), particularly if family/proxy decision makers consider such interventions inappropriate in their dying loved ones. In these situations clinicians are advised to (1) verify the certainty of the very short prognosis, utilizing consultants liberally; (2) discuss with proxy decision makers all possible treatment plans including, when feasible, less-invasive supportive care options with treatment limitations, examples of which are ICU monitoring, gastric lavage, and charcoal administration for an overdose, while establishing a do-not-resuscitate/do-not-intubate order even if the patient deteriorates; and (3) seek ethics consultation.
Advance directives
Advance directives such as living wills stating a patient's wish to not be mechanically ventilated are not binding in the setting of a suicide attempt. However, they should be honored in patients with short prognoses per the discussion above. Advance directives specifying treatment limitations should be reevaluated if it is suspected those statements were made during a period of undetected depression.5,6
Epidemiology and Risk Factors
The rate of suicide attempts in terminally ill patients is unknown, and there has been limited research into specifically terminally ill populations. What is clear is that advancing age and psychiatric comorbidity are risk factors for suicide, along with male sex, AIDS diagnosis, a family history of suicide, and uncontrolled pain.7,8 Cancer patients have nearly twice the incidence of suicide relative to the general population (rate of 31.4/100,000 patient-years versus 16.7/100,000 patient-years). 6 Lung, stomach, and head and neck cancers have the highest suicide rates among all cancer types. 9 Up to 8.5% of terminally ill cancer patients express a sustained and pervasive wish for an early death, and in one survey of terminally ill patients, 10% of patients reported seriously pursuing physician assisted suicide.10,11 Rates of suicide attempts are presumably lower.
Assessment
All patients with life-limiting illnesses should be routinely assessed for depression and mood disorders (see Fast Facts #7 and #43); depressed patients should be screened for suicidal thoughts. Patients who admit to suicidal thoughts or a desire for hastened death should be asked about specific plans for self-harm, past history of suicide attempts, access to firearms or other lethal means to carry out a suicidal act, and level of support/supervision available in the home (e.g., family caregivers). Although some clinicians may be concerned that exploring suicidal thoughts may make suicide more likely, there is no evidence that this occurs. Many ill patients who express a desire for death are communicating unresolved emotional and existential concerns about dying (see Fast Facts #156 and #159).
Responding to Suicidal Intent
All patients who are seriously threatening self-harm or who have pervasive thoughts of ending their life should be evaluated urgently by a psychiatrist. 12 Immediate resources that are available locally vary and can include prompt evaluation by an established psychiatrist, medical or psychiatric urgent care clinics, emergency departments, or voluntary hospital admission. Options include voluntary psychiatric treatment, arranging 24-hour safety monitoring from the patient's family and friends, introducing home hospice or home nursing support, removing means to carry out a suicidal act, and imposing emergency detention. For disabled patients close to death, often sufficient and minimally restrictive are removing the means of self-harm (e.g., limiting access to pain medications as long as a reliable family member can administer them) and providing close supervision through, for instance, hospice services.