Suicide is the act of killing oneself on purpose. The term suicide stems from the Latin words sui, meaning “self,” and caedere, meaning “to kill.” Suicidal ideation is the thought of harming or killing oneself. Suicidal behavior includes acts of intentional attempts to inflict self-death.
Most people have causal fleeting thoughts of suicide at times of frustration, grief, and disappointment. Suicidal ideation and behavior in the general population have multiple causes, such as proximal stressors or triggers and predisposition. No single pathophysiologic mechanism causes suicidal ideation or behavioral attempts; the personal life history and physical, psychological, spiritual, and social factors collectively influence an individual’s beliefs about self-destruction.
Psychiatric illness is a major contributing factor in most suicides in the general population. The mood disorders, including major depression and bipolar illness, are most associated with suicide (Bertolote et al., 2003). Psychological autopsy studies, performed to discover the state of mind of the person before death, suggest that 90% of completed suicides had one or more mental illness, such as major depression or alcoholism (Luoma, 2003). Other contributing factors included the availability of lethal means, alcohol and drug abuse, lack of access to psychiatric treatment, attitude toward suicide, lack of help-seeking behavior, physical illness, marital status, age, and gender (Mann, 2002).
The desire of patients with advanced cancer for a hastened death is related to psychological distress, such as depression and anxiety (Mystakidou et al., 2005). Specific concerns also are related to thoughts of suicide, including unrelieved pain, poorly managed symptoms, depression, a sense of loss of control, a feeling of being a burden to others, being dependent for personal care, and loss of dignity (Eisenberg, 1992).
Depression rates in patients with cancer are high; nearly half of these patients show symptoms during screening (Carroll et al., 1993), and the prevalence is 25% in the palliative care setting (Martin & Jackson, 2000). Unfortunately, a high percentage of those who received a psychiatric diagnosis experienced a significant amount of cancer-related pain (Derogatis et al., 1998); however, the symptoms of depression may be a consequence of uncontrolled pain.
Another factor that influences suicidal ideation is a perceived loss of control. Patients with cancer who were accepting and adaptable were less likely to commit suicide than those who exhibited a need to be in control (Farberow et al., 1971). Suicidal ideation stems from stressful life events and/or mood or psychiatric disorders, and the factors involved in suicidal behavior seem to be related to impulsivity, hopelessness and/or pessimism, access to lethal means, and imitation.
Adolescents with cancer deal with a realm of psychosocial issues related to their developmental phase and individual characteristics. Suicidal ideation and attempts in this population are rare. Often the adolescent believes that his or her disease and life are more determined by fate, luck, or God than by the adolescent’s control. These young patients’ belief that the disease is outside their control and the lack of cognitive maturity needed to plan and implement a lethal attempt may account for the low incidence of suicide in the pediatric oncology population. Refusal of cancer treatment by adolescents is not a means of attempting suicide (NCI, 2006).
Patients’ preference for limiting life-sustaining treatment is a different concept from suicidal ideation and should be honored. Euthanasia and physician-assisted suicide (PAS) are distinctly different from suicidal ideation. However, the research exploring patients’ desire or request for PAS has provided insight into the reasoning of those who want to end their life. Euthanasia, the intentional bringing about of a patient’s death for his or her own sake, either by killing (active) the patient or allowing the patient to die (passive), can be classified as voluntary, nonvoluntary, or involuntary. Physician-assisted suicide refers to a physician acting to aid a patient’s request to end his or her life; it is legal only in the state of Oregon. Unfortunately, medically ill patients’ requests for PAS are not rare (Stoudemire, 1996).
EPIDEMIOLOGY AND ETIOLOGY
The exact number of people who contemplate suicide is unknown. However, suicide rates in the general population may provide some insight into the scope of the problem. A review of the literature shows that more than 90% of those who commit suicide had a psychiatric illness. Approximately 50% of suicides are associated with a major depressive episode (Lagomasino & Stern 1998).
Approximately 10% to 15% of bipolar patients commit suicide (Hirschfeld et al., 2003). Because suicide is highly associated with depression, it is noteworthy that 15% to 25% of patients with cancer experience depression (Lloyd-Williams & Freidman, 2001; Henriksson et al., 1995).
The prevalence of suicidal ideation in the cancer population is difficult to determine because it is not always assessed or recorded in patients. However, the rate as determined from nurse reports in hospitalized patients with cancer was 11% (Pasacreta & Massie, 1990); in ambulatory and hospitalized patients with cancer pain, it was 16% (Breitbart et al., 1992). In the palliative care unit, Brown and colleagues (1986) found a suicidal ideation rate of 20%.
The prevalence of suicidal ideation or attempts in childhood cancer is unknown. Research exploring the prevalence of suicidal ideation is limited, because the clinical impression may not accurately reflect the patient’s suicidal thoughts, and patients may not feel comfortable sharing suicidal thoughts with the researcher.
Suicide rates are also difficult to obtain accurately, because it often goes unrecognized and underreported. Intentional overdoses by the terminally ill may not be recognized or cited as the cause of death. Suicide in cancer patients occurs most frequently in the advanced stage (Fox et al., 1982). Considering all medical conditions, cancer and AIDS are associated with the highest rates of suicide and requests for hastened death (Louhiviour & Hakama, 1997; Kizer et al., 1988; Marzuk et al., 1988; Fox et al., 1982). The number of patients with cancer who actually commit suicide is small, but the relative risk of suicide in these patients is twice that of the general population (Breitbart, 1993).
The etiology of suicidal ideation in patients with cancer may be highly variable. It includes psychological distress, the patient’s coping ability, the individual’s medical condition and physical well-being, and social and spiritual factors (Box 45-1). A sense of hopelessness correlated more with suicidal ideation in terminally ill cancer patients than did depression (Chochinov et al., 1998). Patients with advanced cancer who express suicidal ideation are likely to be experiencing underrecognized and undertreated physical symptoms or psychiatric disturbances. Suicidal ideation is relatively infrequent in cancer and is limited to those who have advanced disease, are hospitalized, in palliative care settings, or have pain or depression (Breitbart, 1993). Refusal of cancer treatment, noncompliance, and requests for allowing a natural death should not be equated with suicidal ideation, and the reason for these decisions should be explored further, misconceptions corrected, and decisions respected.
BOX 45-1
FACTORS THAT MAY INFLUENCE THE DESIRE TO HASTEN DEATH IN PATIENTS WITH CANCER
Psychological Factors • Mood • Depression • History of mental illness • Family history of suicide • Previous suicidal attempts • Anxiety • Loss of autonomy • Loss of sense of control • Hopelessness • Loss of independence • Fear of being a burden • Loss of dignity • Delirium • Personality disorder • Inability to participate in pleasurable activities | Physical Factors • Terminal stage • Poor prognosis • Advanced disease • Pain • Dyspnea • Fatigue • Insomnia • Nausea • Inability to eat or swallow • Poor physical functioning • Immobility • Paralysis • Loss of bowel or bladder control • Amputation • Loss of eyesight or hearing • Older age • Substance abuse |
Spiritual Factors • Decreased spiritual well-being • Existential distress • Guilt • Lack of spiritual resources | Social Factors • Lack of social support • Isolation • Altered communication • Inability to participate in social activities • Recent death of a friend or spouse |
RISK PROFILE
• Terminal stage of cancer (Breitbart et al., 2004).
• Advanced illness (Blound, 1985).
• Pre-existing psychopathology.
• Personality disorder (Breitbart, 1987& 1990).
• Pain (Breitbart, 1990).
• Unrelenting physical symptoms (Foley, 1991).
• Terminal phase of a progressive chronic illness (Valente & Trainor, 1998).
• Hopelessness (Chochinov et al., 1998).
• Pancreatic, head and neck, and gastrointestinal cancers (Holland, 2002.)
• Cancer associated with heavy and prolonged tobacco and alcohol use, impaired function, and facial disfigurement (Farberow et al., 1971).
• Loss of autonomy (Oregon Department of Human Services, 2003).
• Loss of sense of control (Farberow et al., 1971).
• Poor physical functioning (Akechi et al., 2001).
• Decreased ability to participate in enjoyable activities (Oregon Department of Human Services, 2003).
• Loss of dignity (Oregon Department of Human Services, 2003).
• Depression (Massie et al., 1994).
• Delirium (Breitbart, 1990).
• Fatigue (Breitbart, 1987).
• Previously conveyed suicidal thoughts or plans (Blound, 1985).
• Fear of being a burden on others (Block, 2000; Eisenbergh, 1992).
• Poor social support (Pearlman et al., 2000).
• History of previous suicide attempts.
• Older age (sixth and seventh decades) (Louhivouri & Hakama, 1997).
PROGNOSIS
The goal of identifying suicidal ideation in patients with cancer is to prevent suicide. Most causes of suicidal ideation, such as pain and depression, are treatable. Morbidity is higher in cancer patients with depression or uncontrolled symptoms than in those without symptoms. Nursing care should be aimed at reducing morbidity by identifying patients at high risk and providing aggressive symptom management and psychosocial support.
PROFESSIONAL ASSESSMENT CRITERIA (PAC)
1. Identify cancer patients at risk (see Risk Profile section), so that prevention and psychosocial interventions can be initiated.
2. If a patient has made direct statements about suicidal intent, further assessment must be done immediately (Box 45-2).
BOX 45-2
ASSESSING SUICIDAL IDEATION AND RISK IN CANCER PATIENTS
Approach
Evaluation of a patient’s suicidal thoughts should include sensitive exploration of the topic of self-inflicted death.
• Clarify what the patient is saying about thoughts of ending his or her life.
• Support the patient’s need to express emotions and validate the person’s feelings. Identify specific factors that may be contributing to the patient’s suffering and demonstrate your commitment to providing care that will enhance his or her quality of life.
• Evaluate the patient’s mental status and decision-making capacity.
• Treat the factors contributing to the patient’s suffering.
• Refer the patient to the appropriate health care team members (psychiatrist or psychiatric nurse practitioner, pain clinical nurse specialist, pastoral care, or social worker).
Questions to Help Assess Suicidal Intent
1. It sounds as if you have been through a lot of changes and issues related to your illness and treatment. Tell me how it has been for you.
2. Do you ever feel hopeless?
3. Do you ever wish you could go to sleep and never wake up?
4. Have you ever had thoughts of harming yourself?
if yes: What would you do to harm yourself?
5. Do you have a person you could call if you felt tempted to harm yourself?
if no: What stops you from harming yourself?
6. Have you ever thought of suicide?
if yes: How likely are you to act on your thoughts? Do you have a plan/means to carry this out? What specifically would you do to end your life? Do you have a person you could call if you were thinking about suicide?
7. Have you ever acted on your plans?
if no: What has stopped you from taking your life?
3. All patients with cancer should be screened for depression and suicidal ideation. Many patients with advanced terminal disease experience a spectrum of suicidal thoughts, ranging from fleeting thoughts of death to hastening death or suicidal intention; it is important to assess the level of deliberate self-harm. The discussion and questions should start with general and unthreatening questions (Box 45-2).
4. Assessment tools for depression include the Hospital Depression Assessment Scale and the Geriatric Depression Scale.
5. An assessment tool for hopelessness is the Beck Hopelessness Scale.
6. Obtain a psychiatric history, including a history of depression, mental illness, substance abuse, previous suicidal attempts, or a family history of suicide.
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