Evaluation and Treatment of Suicidal Patients with Cancer

Effects of suicide on family and health care providers

The incidence of suicide in cancer patients may be as much as 10 times higher than the rate of suicide in the general population. One study has shown that the risk of suicide in patients with cancer is highest in the first months after diagnosis, and that this risk decreases significantly over decades. Passive suicidal thoughts are fairly common in patients with cancer. The relationships between suicidal tendency and the desire for hastened death, requests for physician -assisted suicide, and/or euthanasia are complicated and poorly understood. Men with cancer are at an increased risk of suicide compared with the general population, with more than twice the risk. Overdosing with painkillers and sedatives is the most common method of suicide by patients with cancer, with most cancer suicides occurring at home. The occurrence of suicide is higher in patients with oral, pharyngeal, and lung cancers, and in HIV-positive patients with Kaposi sarcoma. The actual incidence of suicide in cancer patients is probably underestimated, since there may be reluctance to report these deaths as suicides.

General risk factors for suicide in a person with cancer include the following:

• A history of mental problems, especially those associated with impulsive behavior (such as borderline personality disorders).
• A family history of suicide.
• A history of suicide attempts.
• Depression.
• Substance abuse.
• Recent death of a friend or spouse.
• Having little social support.

Cancer-specific risk factors for suicide include the following:

• A diagnosis of oral, throat, or lung cancer (often associated with heavy alcohol and tobacco use).
• Advanced stage of disease and poor prognosis.
• Confusion /delirium.
• Poorly controlled pain.
• Physical impairments such as the following:
  • Loss of mobility.
  • Loss of bowel and bladder control.
  • Amputation.
  • Loss of eyesight or hearing.
  • Paralysis.
  • Inability to eat or swallow.
• Tiredness.
• Exhaustion.

Patients who are suicidal require careful evaluation. The risk of suicide increases if the patient reports thoughts of suicide and has a plan to carry it out. Risk continues to increase if the plan is "lethal," that is, the plan is likely to cause death. A lethal suicide plan is more likely to be carried out if the way chosen to cause death is available to the person, the attempt cannot be stopped once it is started, and help is unavailable. When a person with cancer reports thoughts of death, it is important to determine whether the underlying cause is depression or a desire to control unbearable symptoms. Prompt identification and treatment of major depression is important in decreasing the risk for suicide. Risk factors, especially hopelessness (which is a better predictor for suicide than depression) should be carefully determined. The assessment of hopelessness is not easy in the person who has advanced cancer with no hope of a cure. It is important to determine the basic reasons for hopelessness, which may be related to cancer symptoms, fears of painful death, or feelings of abandonment.

Talking about suicide will not cause the patient to attempt suicide; it actually shows that this is a concern and permits the patient to describe his or her feelings and fears, providing a sense of control. A crisis intervention -oriented treatment approach should be used which involves the patient's support system. Contributing symptoms, such as pain, should be aggressively controlled and depression, psychosis, anxiety, and underlying causes of delirium should be treated. These problems are usually treated in a medical hospital or at home. Although not usually necessary, a suicidal patient with cancer may need to be hospitalized in a psychiatric unit.

The goal of treatment of suicidal patients is to attempt to prevent suicide that is caused by desperation due to poorly controlled symptoms. Patients close to the end of life may not be able to stay awake without a great amount of emotional or physical pain. This often leads to thoughts of suicide or requests for aid in dying. Such patients may need sedation to ease their distress.

Other treatment considerations include using medications that work quickly to alleviate distress (such as antianxiety medication or stimulants) while waiting for the antidepressant medication to work; limiting the quantities of medications that are lethal in overdose; having frequent contact with a health care professional who can closely observe the patient; avoiding long periods of time when the patient is alone; making sure the patient has available support; and determining the patient's mental and emotional response at each crisis point during the cancer experience.

Pain and symptom treatment should not be sacrificed simply to avoid the possibility that a patient will attempt suicide. Patients often have a method to commit suicide available to them. Incomplete pain and symptom treatment might actually worsen a patient's suicide risk.

Frequent contact with the health professional can help limit the amount of lethal drugs available to the patient and family. Infusion devices that limit patient access to medications can also be used at home or in the hospital. These are programmable, portable pumps with coded access and a locked cartridge containing the medication. These pumps are very useful in controlling pain and other symptoms. Some pumps can give multiple drug infusions, and some can be programmed over the phone. The devices are available through home care agencies, but are very expensive. Some of the expense may be covered by insurance.

Suicide can make the loss of a loved one especially difficult for survivors. Survivors often have reactions that include feelings of abandonment, rejection, anger, relief, guilt, responsibility, denial, identification, and shame. These reactions are affected by the type and intensity of relationship; the nature of the suicide; the age and physical condition of the deceased; the survivor's support network and coping skills; and cultural and religious beliefs. Survivors should have help during this period of grieving. Mutual support groups can lessen isolation, provide opportunities to discuss feelings, and help survivors find ways to cope.

The reactions of health care providers to the suicide are similar to those seen in family members, although caregivers often do not feel they have the right to express their feelings.