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 cancer patients is highest in the first months after diagnosis, and that this risk decreases significantly over decades. Passive suicidal thoughts are fairly common in cancer patients. 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 cancer patients, 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 cancer patient 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.

Glossary Terms

Cancer that has spread to other places in the body and usually cannot be cured or controlled with treatment.

A quickly growing cancer.

A chemical substance found in beer, wine, and liquor. Alcohol is also found in some medicines, mouthwashes, essential oils (scented liquid taken from plants), and household products.

Surgery to remove part or all of a limb or appendage.

A drug used to treat depression.

Feelings of fear, dread, and uneasiness that may occur as a reaction to stress. A person with anxiety may sweat, feel restless and tense, and have a rapid heart beat. Extreme anxiety that happens often over time may be a sign of an anxiety disorder.

In healthcare, a process used to learn about a patient’s condition. This may include a complete medical history, medical tests, a physical exam, a test of learning skills, tests to find out if the patient is able to carry out the tasks of daily living, a mental health evaluation, and a review of social support and community resources available to the patient.

The organ that stores urine.

BPD. A serious mental illness marked by unstable moods and impulsive behavior. People with BPD have problems with relationships, family and work life, long-term planning, and self-identity. Symptoms include intense bouts of anger, depression, and anxiety that may lead to self-injury or suicide, drug or alcohol abuse, excessive spending, binge eating, or risky sex. A person with BPD who is diagnosed with cancer may be at an increased risk of suicide. Also called BPD.

The long, tube-shaped organ in the abdomen that completes the process of digestion. The bowel has two parts, the small bowel and the large bowel. Also called the intestine.

A term for diseases in which abnormal cells divide without control. Cancer cells can invade nearby tissues and can spread to other parts of the body through the blood and lymph systems. There are several main types of cancer. Carcinoma is cancer that begins in the skin or in tissues that line or cover internal organs. Sarcoma is cancer that begins in bone, cartilage, fat, muscle, blood vessels, or other connective or supportive tissue. Leukemia is cancer that starts in blood-forming tissue such as the bone marrow, and causes large numbers of abnormal blood cells to be produced and enter the blood. Lymphoma and multiple myeloma are cancers that begin in the cells of the immune system. Central nervous system cancers are cancers that begin in the tissues of the brain and spinal cord.

To adjust to new situations and overcome problems.

The methods a person uses to deal with stressful situations. These may help a person face a situation, take action, and be flexible and persistent in solving problems.

Immediate, short-term counseling (talking with a professional counselor) to stop a critical emotional incident (e.g., attempted suicide or drug overdose) from getting worse. Crisis intervention is not meant to solve the problem that led up to the crisis.

To heal or restore health; a treatment to restore health.

Dead.

A mental state in which a person is confused, disoriented, and not able to think or remember clearly. The person may also be agitated and have hallucinations, and extreme excitement.

In psychiatry, a state in which a person is unable or unwilling to see the truth or reality about an issue or situation.

A mental condition marked by ongoing feelings of sadness, despair, loss of energy, and difficulty dealing with normal daily life. Other symptoms of depression include feelings of worthlessness and hopelessness, loss of pleasure in activities, changes in eating or sleeping habits, and thoughts of death or suicide. Depression can affect anyone, and can be successfully treated. Depression affects 15-25% of cancer patients.

The process of identifying a disease by the signs and symptoms.

Extreme mental or physical pain or suffering.

Any substance, other than food, that is used to prevent, diagnose, treat or relieve symptoms of a disease or abnormal condition. Also refers to a substance that alters mood or body function, or that can be habit-forming or addictive, especially a narcotic.

An easy or painless death, or the intentional ending of the life of a person suffering from an incurable or painful disease at his or her request. Also called mercy killing.

A record of a person's current and past illnesses, and those of his or her parents, brothers, sisters, children, and other family members. A family history shows the pattern of certain diseases in a family, and helps to determine risk factors for those and other diseases.

Infected with the human immunodeficiency virus (HIV), the cause of acquired immunodeficiency syndrome (AIDS).

A loss of part or all of a physical or mental ability, such as the ability to see, walk, or learn.

The number of new cases of a disease diagnosed each year.

A method of putting fluids, including drugs, into the bloodstream. Also called intravenous infusion.

State of being separated from others. Isolation is sometimes used to prevent disease from spreading.

A type of cancer characterized by the abnormal growth of blood vessels that develop into skin lesions or occur internally.

Cancer that forms in tissues of the lung, usually in the cells lining air passages. The two main types are small cell lung cancer and non-small cell lung cancer. These types are diagnosed based on how the cells look under a microscope.

A legal drug that is used to prevent, treat, or relieve symptoms of a disease or abnormal condition.

Cancer that forms in tissues of the lip or mouth. This includes the front two thirds of the tongue, the upper and lower gums, the lining inside the cheeks and lips, the bottom of the mouth under the tongue, the bony top of the mouth, and the small area behind the wisdom teeth.

An amount of drug that is more than what should be taken at one time.

Loss of ability to move all or part of the body.

Cancer that forms in tissues of the pharynx (the hollow tube inside the neck that starts behind the nose and ends at the top of the windpipe and esophagus). Pharyngeal cancer includes cancer of the nasopharynx (the upper part of the throat behind the nose), the oropharynx (the middle part of the pharynx), and the hypopharynx (the bottom part of the pharynx). Cancer of the larynx (voice box) may also be included as a type of pharyngeal cancer. Most pharyngeal cancers are squamous cell carcinomas (cancer that begins in thin, flat cells that look like fish scales). Also called throat cancer.

Medical doctor.

The likely outcome or course of a disease; the chance of recovery or recurrence.

A severe mental disorder in which a person loses the ability to recognize reality or relate to others. The person is not able to cope with the demands of everyday life. Symptoms include being paranoid, having false ideas about what is taking place or who one is, and seeing, hearing, or feeling things that are not there.

A device that is used to give a controlled amount of a liquid at a specific rate. For example, pumps are used to give drugs (such as chemotherapy or pain medicine) or nutrients.

In medicine, an improvement related to treatment.

Something that may increase the chance of developing a disease. Some examples of risk factors for cancer include age, a family history of certain cancers, use of tobacco products, certain eating habits, obesity, lack of exercise, exposure to radiation or other cancer-causing agents, and certain genetic changes.

A drug or substance used to calm a person down, relieve anxiety, or help a person sleep.

A network of family, friends, neighbors, and community members that is available in times of need to give psychological, physical, and financial help.

The extent of a cancer in the body. Staging is usually based on the size of the tumor, whether lymph nodes contain cancer, and whether the cancer has spread from the original site to other parts of the body.

In medicine, a family of drugs used to treat depression, attention-deficit disorder (a common disorder in which children are inattentive, impulsive, and/or over-active), and narcolepsy (a sleep disorder that causes uncontrollable sleepiness). Stimulants increase brain activity, alertness, attention, and energy. They also raise blood pressure and increase heart rate and breathing rate.

The use of illegal drugs or the use of prescription or over-the-counter drugs or alcohol for purposes other than those for which they are meant to be used, or in excessive amounts. Substance abuse may lead to social, physical, emotional, and job-related problems.

The act of taking one's own life on purpose.

A group of people with similar disease who meet to discuss how better to cope with their disease and treatment.

One who remains alive and continues to function after overcoming difficulties or life-threatening diseases like cancer.

An indication that a person has a condition or disease. Some examples of symptoms are headache, fever, fatigue, nausea, vomiting, and pain.

The hollow tube inside the neck that starts behind the nose and ends at the top of the trachea (windpipe) and esophagus (the tube that goes to the stomach). The throat is about 5 inches long, depending on body size. Also called the pharynx.

A plant with leaves that have high levels of the addictive chemical nicotine. The leaves may be smoked (in cigarettes, cigars, and pipes), applied to the gums (as dipping and chewing tobacco), or inhaled (as snuff). Tobacco leaves also contain many cancer-causing chemicals, and tobacco use and exposure to secondhand tobacco smoke have been linked to many types of cancer and other diseases. The scientific name is Nicotiana tabacum.