Last month, we delved into the dark, but real topic of suicide. Because there is an increased incidence of this act in the cancer population, and because the slant of this blog has thus far been toward cancer related matters, I took the liberty of writing about a topic on which I am not an expert – no official training in psychiatry and psychology, save medical school. In last months essay, I mentioned that my childhood had been severely altered by a suicide, and as a result, I have always had a special interest in the topic. More importantly, my life as a surgical oncologist has led me into the realm of dealing with the issue on a number of occasions. Surgeons are sometimes stereotyped as insensitive psychologically – perhaps true, but as with most acts of stereotyping, probably exaggerated. Speaking for myself, I have spent my career trying not to be part of the “insensitive” crowd. So bear with me as I talk about something that is of great interest to me.
Last months blog was an overview of suicide – data, and risk factors – and in developing this topic in greater depth, I certainly will repeat certain things. My goal in doing so, however, is not to ignore redundancy, but rather to lend continuity to the two pieces.
It is important to recognize that the oncologist is often the patient’s first outlet for his or her most intimate thoughts; therefore, when suicidal ideations surface, no matter how subtly verbalized, the physician should respond by encouraging, rather than discouraging, dialogue with the patient. Lest oncologists underrate the importance of this moment in time, I draw attention to the fact that a substantial number of cancer patients who commit suicide visit their cancer physician in the last month of their life. The state of alertness to the likelihood of suicide should be heightened even more in individuals with malignancies of certain select organ sites—breast, prostate, and head and neck cancers all seem to be associated with higher rates of suicide than other sites. The patient’s “overture”—no matter how subtle, represents an important juncture, essentially, a reaching out for help. From this point on, the oncologist must uncouple morality (if it is an issue for the doctor) from suicide and react as a physician, rather than a theologian. In my opinion, it’s dismissive and condescending to respond to such a trial balloon with triteness: “it’s not a good idea,” “it’s morally wrong,” “that won’t solve anything” – all examples of dismissiveness. Most unforgivable is to avoid the discussion altogether. Following such a nonproductive visit with the physician, a cancer patient is left with the same questions, the same motivations, and the same sense of desperation that he or she came in with. The major change that results from such psychiatric myopia is that the physician has largely lost the confidence of the patient and has probably squandered any hope of influencing the course of events. One of the early lessons in psychiatric training is to never underestimate the significance of a patient talking about suicide, no matter how innocent sounding. While not always a prologue to action, it must always be taken seriously.
On several occasions, I have had the sad experience of patients actually taking their own life, and even though I recognized their rationale, each evoked within me a sense of having failed in my leadership and guidance of a desperate patient. After the fact, I pondered whether if I had established the correct relationship with the patient or perhaps picked up on certain signals, this might not have happened. For the compulsive, the sense of failed responsibility is pervasive and long-lived. On the other hand, I am conflicted by my ambivalence in this matter. Vivid recollections of a number of patients linger within me, but two in particular reverberate in my memory. Each was dying of refractory head and neck cancer that was creating unspeakable misery and degradation—odor, drooling, embarrassment and pain. When they ended their own lives I felt relief; at a minimum, I understood their reasons. This confession may be good for my psyche, but forgetting is another matter.
The mandate for heightened alertness to suicide prevention should be keener in patients with favorable situations and can ethically be looked at with different standards than patients like the ones I just cited with refractory terminal cancer. Regarding the attention given to those with a favorable prognosis, it is important to note that the prevalence of suicide is probably highest in the first three months following diagnosis of cancer, and then peaks again at about one year after treatment. Additionally, there are data suggesting that, for unexplained reasons, the risk for adult survivors of childhood cancer is elevated. More understandable is that the risk factor for suicide in cancer patients is higher in the elderly. Finally, we cannot loose sight of the threefold increase in suicide rate among cancer-afflicted widowed men compared with those who are married.
The take-home message here is that in dealing with this matter, the oncologist should individualize the situation and tailor the response by considering the risk factors and characteristics that have been referred to in the preceding paragraphs. Of course, all of these considerations should include appropriate psychiatric consultations and care. In several of my essays, I’ve stated that psychological support given to the cancer patient should be delivered circumferentially—from all members of the team, but especially from the oncologist to whom the patient extends the overture. Essentially, that team member has a greater responsibility in the process by virtue of the fact that the patient apparently feels a stronger connection with them. The involvement of a psychiatrist and the psychological support of the oncology team are not, however, mutually exclusive. To reemphasize the alarm issue, suicidal ideations and true suicidal thoughts of a cancer patient are usually first encountered by a member of the treatment team; and this critical moment in time should lead to psychiatric consultation.
Most cancer victims are frightened, and not surprisingly, this vulnerability often leads the patient to develop extraordinary dependency and reliance on their oncologist. It is not unusual for such a patient to look to that physician for advice and counsel on a variety of health-related matters—psychiatry, nutrition, their aunt’s migraines—you get the picture. Importantly, the role of the “perceived expert” on all matters medical must be handled with tact, realism, humility, and always with graciousness and generosity. It’s a simple thing to disavow expertise but show interest by offering suggestions on some questions and by promoting appropriate referrals when indicated. In this day and age of super-specialization, it’s important for doctors to remind themselves that they are still physicians and should still attempt to look after, and care for the “whole patient.”
At a minimum, simply talking about suicide gives a cancer patient the reassurance of autonomy, that is, jurisdiction over his or her body—something that may actually have therapeutic emotional value. The quotation in my previous essay of the brilliant German philosopher, Nietzsche**, suggests exactly this and should provide an imperative for the alert and mature cancer physician to encourage and engage, rather than discourage a suicide dialogue when a patient brings the matter up.
** ”The thought of suicide is a great consolation: by means of it one gets successfully through many a bad night”. Friedrich Wilhelm Nietzsche (1844-1900)
In the past, I’ve dealt with suicide queries from doomed patients (failed treatment) in a variety of ways, but the theme common to my response has always involved a reassurance that I would be available until the end, and that I would exercise a very liberal use of medications for sedation and pain. Regarding this latter statement, the concept of terminal sedation is introduced, and the patient is allowed to rely on anything short of outright overdosing. The physician must keep in mind the consistent fear that is common to most cancer patients of being abandoned by their doctor or their family. Since terminal sedation is within our legal and ethical capabilities if the legal criteria are followed, and since today’s pain control is so effective, physicians are able to mitigate the agony of cancer-related terminal life more than ever before. More will be devoted to this concept in a future blog on euthanasia. Regarding pain, it is important to note, however, that pain alone does not frequently explain the motivation to end one’s life. In fact, there is survey data from the Dutch experience that shows pain is responsible for only 5 percent of the inquiries about that country’s euthanasia program. The same is probably true among those who consider suicide in the United States. Motivation is neither clear nor singular in most cases, but instead amorphous and broad based. Consider, if you will, the enormity of what the cancer patient faces –the forces of depression/anxiety, discouragement, fear, concern for financial and family compromise, a desperate concern for privacy, dignity, autonomy and lastly the journey of the general misery during the terminal period—all come together in an avalanche of psychic and physical forces. Some patients simply say to themselves, “Who needs all of this?”
Depression alone is an insidious but powerful enemy that can emotionally consume a terminal cancer patient, and often it is accompanied by anxiety. Fifteen to twenty-five percent of cancer patients are affected substantially by depression. Anxiety is a relentless partner of depression, and both have been studied independently and together. Depression and panic attacks seem to be more prevalent in the younger population. This association tends to decline with age, so that the elderly handle the situation better. When unrelenting pain is thrown into the mix, the perfect psychiatric circumstances exist to overwhelm a cancer patient. I think of this as a circle of torment that feeds itself—depression and anxiety enhanced by pain, which leads to a sense of hopelessness and deeper depression, and so on. Even in non-cancer patient, the duality of depression and anxiety occurs; one can only imagine how much more intense the syndrome is when the fear of cancer and death enter the picture. Thankfully, antidepressant and anti-anxiety medications have come of age and especially in the patient destined to die of cancer, when this new pharmacopoeia is combined with proper pain management, the all-important involvement of a psycho-oncologist, and the diligence and staying power of the alpha oncologist, the terminal phase of the disease is dramatically improved over previous times.
In my experience, a majority of cancer patients who have suicidal thoughts ultimately decide against it when the “the circle of torment” is treated and the alpha oncologist has engaged in forthright dialogue about the subject. Having said this, I should point out that until relatively recent times, cancer physicians and even cancer teams have not done a very good job in dealing with this syndrome of depression, pain, and anxiety. Fortunately, as the concept of the functional cancer team matures, we are getting better at it.
Most patients abhor the thought of committing suicide, many for religious reasons. It is fundamental to Judeo-Christian, Islamic, and Hindu theology that death should come at God’s will, rather than one’s own. These philosophies teach that life is a gift from God and to arbitrarily end it usurps the power of the creator. Those that follow these tenets feel that the will of God with respect to this matter must be taken on faith. It follows, then, that since killing is intrinsically wrong and suicide is self-killing, to commit suicide is wrong. It’s an extraordinary contradiction that jihadists in the news of today justify suicide bombing by religious authority despite the fact that the Holy Koran does not condone suicide. Roman Catholic traditions are based on specific doctrine that not only condemn the actual act of suicide but also consider it wrong for someone to aid in the act of another’s suicide. I’ll speak more of this latter fact in a subsequent blog. In point of fact, in Roman Catholic history, the most stringent of interpretations of the transgression of suicide prevented persons who had taken their own lives from being embraced in the after-death rituals of the Church. Modern adaptation does grant the concession that those who have committed suicide are often emotionally disturbed and not in possession of full reason; therefore, contemporary practice usually allows full ritual performance. Until this recent flexibility of the Church’s previous attitude, this was an area of some sensitivity and resentment among those Catholics who are family members of suicide victims. But basically, despite this modification, the Church has been consistent in its teachings since suicide was formally banned in the sixth century. Other religious philosophies—Jewish and Christian alike—are more lenient and tolerant in dealing with this issue than is Roman Catholic orthodoxy.
In addition to the religion-based objections to suicide, other arguments for its wrongness are used, especially those that relate to the emotional impact of the act on the family, friends, and colleagues left behind. Not infrequently there is an enormous effect following suicide, and the long-term physic influences can be especially harmful to young children.
Suicide among cancer victims should be thought of differently from those without cancer. There is inevitability and the dread of tangible suffering and a waiting killer for the cancer victim, and even in those who are emotionally sound prior to the development of their cancer, the compounding effects of depression and anxiety frequently emerge as a result of the malignancy. On the other hand, the non-cancer related suicide is a different and perhaps sadder matter—another topic for another book that is composed by an expert in these matters. These are topics of profound importance to psychiatrists, and the management of patients who suffer from clinical depression, drug dependency, and other discouraging problems present challenges unique in medicine, although obviously such mental illnesses are not mutually exclusive from the emotional burdens of the cancer patient. But at the risk of oversimplifying a complex topic, the psychodynamics that lead to suicide in the general population are generally different from those of cancer patients. In cancer patients the psychiatrist seems to face three separate forces, albeit blended together: first, the patient’s fear of dealing with a relentless downhill journey to death; secondly, an organic depression-anxiety syndrome that is often present; and finally, fear of the unknown, of nothingness, and in many individuals, fear of the end of existence.
The reader should be clear that I am not advocating that oncologists attempt to manage the suicidal thoughts and inclinations of cancer patients. However, neither should they shy away from engaging the patient in unflinching dialogue. Psychiatric consultation and management is vital to the modern cancer team, but the process starts with a mature cancer physician who is not intimidated by the suicide word; and I repeat what I wrote earlier, the psychological involvement of the oncologist taking care of the cancer is in no way mutually exclusive from that of the psycho-oncologist. Even while the psychiatrist is doing what they do, there should be no prohibition of the oncologist to engage in intimate conversation with the patient.
It is worth noting that throughout history other cultures have looked at suicide differently; and even in the United States today, there is reasonable support for the individual’s right to decide when and how death should come. So after all of the considerations, we are left to deal on a practical level with a segment of the population who face the finality of uncontrolled cancer, who are unencumbered either by religious inhibitions or family matters, who are not worried about the afterlife, and who do not wish to be terminally sedated lest they lose the ability to alertly deal with their own demise. When such a patient says to me, “I want to be in control of my own death”—a statement that I view as meaning a desire for autonomy—I respond, “Even though I can’t help you do the deed, you have my understanding and best wishes for whatever awaits you.” This statement is not one of advocacy, but merely an articulation of my belief that a person not restricted by those factors that I have mentioned should indeed have control over their own destiny. The stoic philosophy of life and death of the ancient Greek philosophers promoted the notion that a person should be responsible for the timing and character of his or her death. Later, the Romans espoused and even encouraged suicide. Mind you, I do not advocate this somewhat cynical view of exiting life; but in this writing, I seek to defend the right of those that do.
One cannot avoid discussing the matter of physician assistance in suicide, and in this regard, oncologists and anyone else seeking to care for cancer patients must have their standards clearly established. The alertness of a cancer physician to the patient’s signals differs from the less subtle circumstance in which a patient actively seeks help in ending his or her life. No matter how heart-wrenching a patient’s misery or how compelling the appeals from the patient or family, a physician’s involvement in a suicide is prohibited by law, except in Oregon, Washington State, Vermont, New Mexico, and Montana. To step outside of legal restrictions is foolish and irresponsible. I speak of this with no moral overtone whatsoever—it’s simply not permitted. How a physician personally feels about it or how much one might disagree with the restrictions on one’s freedom to respond to these desperate requests are both irrelevant issues. In the final analysis, such active involvement is in violation of the law except in these states. I’ll explore these and related issues on a global basis in a future essay. The subject is dynamic and changing as we speak. California has recently approved physician-assisted suicide, but it is yet to be signed by the governor, and there the act remains illegal.
Roy B. Sessions, MD, FACS
Seabrook Island, SC