Rally the Troops: Interdisciplinary Response to a Veteran Who Attempted Suicide on a Veterans Affairs Hospice Unit

Introduction

Patients with terminal diagnoses of cancer often experience physical, emotional, spiritual, and existential suffering. Occasionally this distress can contribute to a patient's wish to hasten his or her death. ¹ It is recommended that providers caring for these patients explore requests for hastened death to understand their nature fully. ² Among patients who request hastened death, psychiatric disorders such as major depression or anxiety are more likely to be present.^3,4 There are data suggesting that these specific disorders may be more prevalent in patients who are at the end of life. In one study exploring the presence of neuropsychiatric symptoms in a group of veteran hospice patients, more than half of those studied developed depression during hospice enrollment. ⁵ Suicidal ideation was present in a minority of these veterans. However, in those with suicidal ideation, depression was more likely to be present.

Suicide risk factors in the cancer population include age, gender, and occurrence of pain and depression. ⁶ In addition, hopelessness is an independent risk factor for suicidal ideation. ⁷ Despite increased risk of suicide among the cancer population, hospice staff are not always prepared to address suicidality, and feel they would benefit from learning further about this topic.^8,9 Patient suicides can have great psychological impact on hospice clinicians with the consequences of changing clinical practice and attitudes toward suicide. ¹⁰ This case report describes a veteran with a terminal diagnosis of cancer who attempted suicide while in an inpatient hospice unit, and the interdisciplinary team's response to this suicide attempt.

Case Description

Some demographic details have been altered to protect patient confidentiality.

Paul was a 75 year-old Vietnam-era veteran with nonsmall cell lung cancer. He had a mental health history of depression for several decades, a diagnosis that was later amended to bipolar disorder. He also had a decades-long alcohol-use disorder that was in remission. At various times throughout his treatment history, Paul displayed grandiosity, entitlement, condescension, and preoccupation with how others regarded him, suggestive of narcissistic personality traits. He was on a regimen of five psychotropic medications for management of his mood symptoms, with no recent changes.

Paul was diagnosed with his malignancy two years before the present case, and initially had good response to chemotherapy. However, follow-up imaging revealed disease progression with spinal lesions. During a hospitalization for cancer-related back pain, he was found to have spinal cord compression at T6. It was felt that the risks of surgical intervention outweighed the benefits and decompression was not offered. He was subsequently admitted to our inpatient hospice and palliative care unit (HPCU) due to his ongoing symptoms and difficulty managing his care at home.

One week after admission to the HPCU, Paul developed acute worsening of his lower extremity weakness. Magnetic resonance imaging (MRI) demonstrated progressive spinal cord compression. Surgical teams again felt that the risks of complications from surgical intervention outweighed the benefits. He remained in the HPCU for ongoing management and support. His lower extremity weakness progressed for the following week and he became completely paralyzed. After his paralysis, he began to express a desire for hastened death.

Our mental health colleagues consulted on Paul's care from the time of admission to the HPCU as he had been exhibiting disinhibited behaviors. He denied depressed, irritable, or elevated mood, and denied suicidal or homicidal ideation. He was experiencing a superimposed delirium, affecting his cognition, mood, and impulsivity in a waxing and waning manner.

During visits from psychiatry, he acknowledged depressed mood, stating he was “ready to die.” He denied specific suicidal intent or plan. He noted feeling impatient, remarking, “Let's get on with this.” He said this feeling was similar to what he felt going into combat, waiting for the action to begin. Noting that death was inevitable, he wanted it to come as quickly as possible. He often expressed concern that he would lose the ability to move his arms in addition to his legs.

Two weeks after his complete lower extremity paralysis, Paul attempted suicide by breaking a mirror at his bedside and cutting his neck and wrists. He sustained superficial lacerations. On the morning after his suicide attempt, an interdisciplinary meeting was held to determine a safe and patient-centered care plan. Various options were discussed, including ongoing care in the HPCU, transfer to an acute psychiatric facility on our campus, and transfer to an acute care hospital. Given his limited prognosis, it was felt that the most patient-centered plan would be ongoing care in the HPCU with a one-to-one safety sitter, as well as increased visits from mental health and other disciplines.

To enhance Paul's care in the HPCU, our interdisciplinary team consulted other colleagues, including our suicide prevention coordinator. In addition, a question arose on whether resuscitation would be indicated in this patient with a do-not-resuscitate (DNR) order in place in the event that he should sustain cardiac arrest related to another suicide attempt. We consulted our ethics team to provide guidance for this potential scenario. Their recommendation was to attempt resuscitation in the event of cardiac arrest resulting from suicide, despite a DNR order.

On follow-up visits with mental health, Paul described having had a “fantastic day,” but also had the feeling he was going “crash” into depression. When asked about his goals and concerns, he stated, “I want to feel I went out like a soldier.” He acknowledged a desire for control and dignity in the dying process. He expressed ambivalence about his wish to die, acknowledged fear about dying, and wanted to learn more about what he would experience.

For the coming weeks, with support from one-to-one sitters and increased visits from the mental health and medical teams, Paul did not express further suicidal ideation. With this additional support and opioid titration, he experienced improvement in his physical and emotional pain. He became more delirious and unable to form coherent thoughts in the weeks before his passing. He died peacefully five weeks after his suicide attempt.

Discussion

This case illustrates several discussion points: challenges in assessing requests for hastened death, risk factors for suicide at the end of life, and the ethics of resuscitation in the context of a suicide attempt at the end of life.

On becoming paralyzed, Paul requested hastened death. A particular challenge in the assessment and management of Paul was differentiating acceptance of death from a desire for hastened death, or from suicidal ideation. Paul had initially presented as somnolent and confused, but not depressed nor suicidal. On subsequent assessments, he acknowledged depressed mood and described desire for hastened death. He also presented as alert, with bright affect and gregarious rapport. He often made provocative statements as a feature of his coping style, and his statements related to desire for hastened death were consonant with other provocative statements he made. His expression that he wanted to die was viewed as a reiteration of his typical coping pattern of wanting to “get this over with.” It was a response to the tension of anticipation and a desire for action.

It is common for clinicians to accept psychological distress as a normal part of the dying process. Given this, existential distress might not be distinguished from clinical depression. ¹¹ The desire to hasten death, sometimes referred to as the wish to hasten death, has been defined as a reaction to various forms of suffering, including physical, social, psychological, and existential. Desire to hasten death is a concept in palliative care that differs from suicidal ideation, but seems to include suicidal ideation along the spectrum of its presentation. ¹²

Several studies have examined desire for hastened death in the setting of terminal illness. According to their findings, the prevalence of terminally ill patients voicing desire for hastened death ranged from 17% to 45%, depending on the population studied, illness severity, treatment setting, and method of evaluation.^13,14 Psychological and social factors, such as depression, hopelessness, and loss of dignity, rather than physical ones, such as functional limitation or pain, are the major determinants of desire for hastened death. ³ In Paul's case, this was related to poor perceived quality of life, lack of comfort with the uncertainty of his medical trajectory, and concern over losing further function.

When viewed through a psychiatry lens, desire for hastened death is more commonly viewed as suicidal ideation. As such, it is considered a symptom to be monitored and treated, as well as a threat to patient safety to be addressed through preventive interventions. Some have inferred that it is not possible to distinguish between a desire to hasten death and suicidal ideation when patients have psychological or emotional problems. What is most evident is the importance of ruling out depression or another mental disorder when attempting to diagnose the desire for hastened death. ¹²

Risk factors for suicidality in terminally ill patients include hopelessness, depression, delirium, and comorbid psychiatric illness.^7,11 One study of suicide in lung cancer patients found a suicide incidence of 7–9/10,000, with more than a third of suicides occurring in the first three months after diagnosis. This represents a frequency that is 13 times the U.S. suicide risk. ¹⁵ Paul reported a long history of suicidal ideation, but no prior suicide attempts. After his suicide attempt, he disclosed an incident of suicide “rehearsal” at age 12. This could have been a risk factor, given that he tended to view suicide as a viable alternative. It is possible that the interpretation of his report was somewhat colored by an unacknowledged reluctance to disrupt his care on the hospice unit.

As noted previously, our ethics team recommended attempting resuscitation in the event of cardiac arrest resulting from suicide, despite a DNR order. The justification for this was twofold. First, health care providers have an obligation to prevent suicide. Suicide was felt to be an exception to the rule that a patient's decision-making capacity is not determined by the content of their decision. This patient would be deemed not to have capacity at the time of a suicide attempt and his autonomy would be overridden, despite his previously expressed wishes to not be resuscitated. Second, our health care system currently prohibits physician-aided dying, and it was felt that not attempting resuscitation in the event of cardiac arrest related to suicide could be viewed as assisting in his death.

The dilemma in determining whether to resuscitate a patient with a DNR order often arises from a conflict between autonomy and beneficence. Some authors have suggested that prior DNR orders should be upheld in the event of suicide. ¹⁶ They note that suicide can be a rational decision by terminally ill patients to maintain control. Others have reinforced this rationale, stating that the principle of autonomy extends to a patient's right to determine the course of their death. ¹⁷ Under the principle of beneficence, however, providers should act in the best interest of the patient. This might imply that terminally ill patients with a DNR order should be resuscitated as the alternative would be death. ¹⁸ Acknowledging that the decision to resuscitate a patient with a DNR order in place is not algorithmic, it has been recommended that institutions have policies to address this specific issue. ¹⁷

Our distress in thinking about the potential scenario of resuscitating Paul was consistent with the dilemma between autonomy and beneficence. We were aware of his stated wishes to have a peaceful death but wanted to abide by the policies of our health care institution, as recommended by our ethics team. A third ethical principle, that of nonmalfeasance, also arose in team discussion. Resuscitation of a terminally ill patient with metastatic cancer was not felt to be consistent with the tenet of “do no harm,” which caused providers unease. Fortunately, Paul did not attempt suicide again and had a peaceful death, in accordance with his wishes.

The quality of life and safe care that Paul experienced after his suicide attempt were a direct reflection on the collaboration and flexibility of our team. In discussing this case, we hope to highlight the challenge of distinguishing a desire for hastened death from suicidality, and the ethical dilemma providers face when a terminally ill patient with a DNR order attempts suicide.