Background    Chronic or advanced medical illness is a significant risk factor for suicidality (1).  This Fast Fact discusses evaluating and responding to suicidality in patients with life-limiting diseases.  Note:  this Fast Fact does not address cases of ‘physician assisted suicide’ which have occurred after a deliberative process including psychiatric screening such as in Oregon in the US (2).   

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). For this patient population, 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 (5,6). In these situations, clinicians are advised to: 
  • Verify the certainty of the short prognosis, utilizing consultants liberally,  
  • Discuss with proxy decision makers possible treatment plans including, when feasible, less-invasive supportive care options with treatment limitations (e.g., ICU monitoring, gastric lavage for an overdose, but establishing a DNR/DNI order even if the patient deteriorates). 
  • Seek ethics consultation.   
• Advance Directives (ADs):   ADs 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. ADs specifying treatment limitations should be re-evaluated if it is suspected it was completed during a period of undetected depression (7,8). 

Epidemiology and risk factors    There have been limited research into ‘terminally ill’ populations, hence the rate of suicide in the terminally ill is unknown.  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 (9,10).  Cancer patients have nearly twice the incidence of suicide than the general population (rate of 31.4 vs. 16.7/100,000 patient-years) and the first year after diagnosis carries a higher risk (9,11).  Lung, prostate, pancreatic, and head and neck cancers have the highest suicide rates among all cancer types (11).  Up to 8.5% of terminally ill cancer patients express a sustained and pervasive wish for an early death, and in one survey 10% of terminally ill patients reported “seriously pursuing” physician assisted suicide (12,13).  Rates of actual 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, 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, 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 seriously ill patients who express a desire for death are simply communicating unresolved emotional and existential concerns about dying. See Fast Facts #156 & 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 mental health provider (14).  Immediate resources depend on local availability and can include prompt evaluation by an established psychiatrist, medical or psychiatric urgent care clinics or emergency departments, or even voluntary hospital admission. Care 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 patients close to death, removing the means of self-harm (e.g., limit access to pain medications if a reliable family member can administer them) and providing close supervision through, for instance, hospice services are often sufficient and minimally restrictive.  

References 

1. Hendin H.  Suicide, assisted suicide and medical illness.  J of Clin Psychiatry.  1999; 60 Suppl 2:46-50. 
2. Death With Dignity Act Report 2007.  State of Oregon Department of Human Services.  Available at:  http://www.oregon.gov/DHS/ph/pas/index.shtml.  Accessed November 10, 2008. 
3. Lo B.  Resolving ethical dilemmas: a guide for clinicians – 3rd Edition.  Lippincott Williams & Wilkins, 2005: 256-9. 
4. Miller RD.  Need-for-treatment criteria for involuntary civil commitment: impact in practice.  Am J Psychiatry. 1992; 149:1380-4. 
5. Campo-Engelstein L, Jankowski J, Mullen M.  Should health care providers uphold the DNR of a terminally ill patient who attempts suicide. HEC Forum 2015; 28:169-174. 
6. Marks S, Heinrich TW, Rosielle D. Case report: are clinicians obligated to medically treat a suicide attempt in a patient with a prognosis of weeks?. Journal of Palliative Medicine. 2012; 15(1):134-7. 
7. Ganzini L, Lee MA, Heinz RT, et al.  The effect of depression treatment on elderly patients’ preferences for life sustaining medical therapy.  Am J of Psychiatry. 1994; 151:1631-6. 
8. Sontheimer D.  Suicide by advance directive.  J Med Ethics. 2008; 34:e4; doi:10.1136/jme.2008.025619. 
9. Farberow NL, Banzler S, Cutter F, Reynolds D.  An eight-year survey of hospital suicides.  Suicide and Life-Threatening Behavior. 1971; 1:184-201. 
10. Rabins PV.  Prevention of mental disorder in the elderly: current perspectives and future prospects.  J Am Geriatric Soc. 1992; 40:727-33.
11. Anguiano L, Mayer DK, et al. A literature review of suicide in cancer patients. Cancer Nursing 2012; 35:E14-E26. 
12. Chochinov HM, Wilson KG, Enns M, Mowchun N, Lander S, Levitt M, et al.  Desire for death in the terminally ill.  Am J Psychiatry. 1995; 152:1185-91. 
13. Emanuel EJ, Fairclough DL, Emanuel LL. Attitudes and desires related to euthanasia and physician-assisted suicide among terminally ill patients and their caregivers.  JAMA. 2000; 284:2460-2468. 
14. Block SD.  Chapter 6: Assessing and managing depression in the terminally ill patient.  Physician’s Guide to End of Life Care.  Snyder, Lois ACP Press; 2001.

Author Affiliations:  Medical College of Wisconsin, Milwaukee, WI (SM), University of Minnesota Medical School & Fairview Health Services, Minneapolis, MN (DAR).  
Version History:  Published November 2008. 2nd edition published in June 2012; 3rd edition in July 2015; 4th edition in January 2024. 
Conflicts of Interest: None to report