Handling hospice patient with suicidal thought or requesting euthanasia

1. Handling hospice patient with suicidal thought or requesting euthanasia

2. Incidence of suicide among cancer patients - men with cancer with relative risk as high as 2.3 of the general populations (Motto et al.,1981) - among the committed suicide: 50% of women & 25% of men use drugs, while men tend to use more violent methods such as hanging, jumping & shooting

3. Reasons for suicide among palliative patients - meaningless suffering - hopelessness - fear of painful death - fear become disabled and dependent - loss of body functions and appearance - means to regain control - securing a ‘dignified death’ - wish to punish others or to be punished - to draw attention or manipulate others - cry for help

4. Suicidal risk factors in cancer patients -mental state: -suicidal ideation, lethal plan -depression & irrational thinking -delirium & psychotic features -history: -prior attempts -psychopathology -substances abuse -recent loss, poor social support -older male -family history of suicide

5. -physical: -uncontrolled symptom(s), fatigue -poor prognosis -use of steroids -loss of body image or function

6. In a HK study (Chiu et al., 2004) 86% of old age suicide case have >= 1 type of psychiatric illness e.g. depression, schizophrenia Increase risk of suicide by -depression: 60 times (Chiu et al., 2004) while in north Europe: 160 and in New Zealand: 185 (Waern, 2002) -eyesight affected (7), stomach disease (6.4), stroke (4), cancer (3.4) (Waern, 2002) -heart failure (1.7), COAD (1.6), epilepsy (3) -chronic pain (20) (Chiu et al., 2004)

7. Management for suicidal patients: -rapport building (empathetic approach) -explore reasons for the suicidal thought -assess risk factors -evaluate need for hospitalization or companion at home -maintain a sense of control -improve quality of life -making referral if indicated -facilitate social support & watch for family exhaustion (avoid possible harm than good)

8. Effect of regular contact to suicidal person Motto et al. (1981) 3 hypothesis: 1) patient’s sense of isolation decrease by regular & long-term contact 2) contact must be initiated by concerned individual & put no demands on suicidal person 3) systematic program of this kind will exert suicide-prevention influence of high-risk persons

9. - 3005 hospitalized persons of high suicidal risk (862 declined on-going treatment after discharge) - randomly divided into ‘contact’ & ‘no contact’ group - ‘contact’ group: monthly x 4, bimonthly x 8, 3-monthly x 48 (total 5 years) - Result: ‘contact’ group had significant lower (p=0.043) suicide rate, especially in the 1st two years

10. Request for euthanasia: Presentation: to ask if there is measure to hasten death Interventions: acknowledge unbearable & avoid value judgement encourage sharing of nature, intensity of suffering explain what we can do and cannot do to euthanasia acknowledge feeling and reflect our feeling as well explore what is still meaningful to him reassure our support and help strengthen social support & refer to expert if indicated

11. End