Oncologists who say they've never had a patient commit suicide simply might not know. The patient who doesn't return for treatment or reportedly died of an accidental drug overdose could have decided, in their suffering, that life was not worth living.
Depression is a risk factor for suicidal ideation, and experts say the only sure way to detect either one is to ask. The questions can be in a screening process, either face to face or in a questionnaire before the office visit, but they must be asked.
“Suicide is a very hidden problem,” says Matthew J. Loscalzo, LCSW, the Liliane Elkins Professor in Supportive Care Programs and Executive Director of the Department of Supportive Care Medicine at City of Hope. “You can't look at a person and know they are suicidal.”
The risk factors are well known: a sense of hopelessness, depression, pain not adequately managed, confusion as a side effect of the drug or the cancer. “Most people cope well [with these factors], but there is a subset of patients who don't, and they need special attention—and you cannot do that by guesswork.”
More than Managing Symptoms
Richard M. Goldberg, MD, Distinguished Professor of Clinical Research in Hematology/Oncology at the University of North Carolina at Chapel Hill, said that suicide by a patient has happened twice in his 30-year career that he is aware of.
Dr. Goldberg said he asks about depression and suicidal intent in his practice. But sometimes patients have reasons for not being completely frank with their physician, he said, so if he is worried about despair he will also talk to family members and friends.
“I consider it a personal failure when a patient of mine chooses suicide as a way to end their ordeal with cancer, in part because we can always manage and nearly always successfully control cancer-related symptoms, whether they are physical or psychological. If somebody is depressed, we can use antidepressants; if they're in pain, we can use pain medicines.
“But when somebody takes their own life, it means to me that I didn't do an adequate job dealing with the consequences of their disease,” Dr. Goldberg said.
“While that kind of decision may take great courage, it also can be a sign of isolation for the individual facing this ordeal that is exactly what those of us who devote our lives to caring for patients with cancer are striving to avert.”
The key question, Mr. Loscalzo said, is simply: “Do you have serious thoughts of ending your own life?”
Screening in City of Hope's outpatient cancer clinic is done with sophisticated touch-screen tablets with questions about many facets of the patient's life besides depression and suicidal thoughts, including pain levels, talking to a child about cancer, money problems, and the adequacy of support at home.
When the patient says yes to a question in this screening system, an e-mail is automatically sent out to the appropriate service, to triage in real time.
Mr. Loscalzo, who is also Administrative Director of City of Hope's Sheri & Les Biller Patient and Family Resource Center, said that 1% to 2% of patients screened say they do have serious thoughts of suicide.
“We go and meet those patients right in the clinic.” But screening can be as low tech as pencil and paper, he added. And there is no harm in asking.
“I've been doing this screening and asking the question about suicide for about 15 years, have screened about 15,000 patients, and no patient has ever come to me saying ‘you know, I had no thoughts of ending my life but now [after you asked], I do.’ And I've never had a patient or a family member complain because we asked.”
Mr. Loscalzo said patients with cancer can get scared, agitated, feel vulnerable or hopeless or trapped, and then ask themselves “is this worth it?”
“And then, if they do make the decision to kill themselves they can become optimistic because they feel the weight is off of them,” he said.
The patient may be sitting calmly in the clinic listening to the doctor focus on pain and cancer and treatments, when the patient has already made up his mind to end his life.
“You've got to talk about it,” Mr. Loscalzo repeated, to understand if the patient is coping well or has become comfortable with the idea of suicide.
He admits it can be difficult for a physician to fit yet another task into such a brief encounter as an office visit.
“If you ask doctors how long they think office screening would take, they'll roll their eyes and say forever,'” he said. “Male doctors may especially have issues about talking with the patient about feelings, but both male and female physicians are under such time pressures.”
But asking patients about suicide actually normalizes the situation, “because then we can tell them it's okay if they have these thoughts—we can help you.”
It also demonstrates that the physician cares about the patient, “that you have confidence in yourself as a physician or you wouldn't even ask.”
Before becoming President and Chief Executive Officer of the National Hospice and Palliative Care Organization, J. Donald Schumacher, PsyD, ran hospice programs for almost 30 years. He has had patients in hospices make suicide attempts, with one actual act of suicide, a patient with a history of depression, he said.
“The concerns with cancer patients are how well their treatment is going, is the patient feeling desperate, and with that desperateness is there a history we have to pay attention to. Those would be key indicators. And some kind of depression assessment or substance abuse assessment would be critical.”
Dr. Schumacher advises asking about the patient's social support at home: “Many people are alone, and this might be a candidate who needs a little more attention.”
He said he doesn't like to characterize, but a diagnosis of throat cancer or oral cancer is often associated with alcohol and smoking, which might be associated with depression.
And cancer patients often times have more access to narcotics, so if the tendency for suicide is there, the opportunity may be greater.
Dr. Schumacher encourages any physician or nurse practitioner in the field to do a psychological assessment on anyone newly diagnosed, to look for potential key indicators.
In an oral interview, the practitioner can ask the patient how they have dealt with loss, whether they have had traumatic health issues in the past, and ask for the patient's own perspective on their situation.
And instead of asking if they have any thought of suicide, the practitioner might ask what solutions the patient has for dealing with depression or discomfort. They could mention suicide.
Have a conversation with family members as well, Dr. Schumacher advised.
“Every time there is a treatment, ask not only how the patient is doing physically, but also what is it like at home, what kind of support they have, and are they experiencing pain—pain is a very major issue, poorly controlled pain or nausea or vomiting. Make sure that hasn't gotten the better of the patient.”
Tell the Truth
But will the patient tell the truth?
“The relationship with the physician is very important in getting an honest answer from a suicidal patient,” Dr. Schumacher said. “The best oncologists I've worked with are very attentive and emotionally supportive, and have developed a very high level of sensitivity.”
The suicide Dr. Schumacher recalled was a very difficult case, in that the patient was expecting a visit from the hospice physician, who when she got to the house found the patient had shot himself. The patient probably wanted her, and no one else, to find him first, Dr. Schumacher said.
“That was really difficult for the doctor, and very, very difficult for the nursing staff, because one might think ‘if only I'd gotten there an hour earlier…,” he said. “All the what-ifs.”
Dr. Schumacher said he gave himself a reality break there, realizing that if someone is very determined to commit suicide, they eventually will.
“We try and find ways to intervene as best as we possibly can, but generally, even if you stop them once, somebody who is determined will make another attempt.”
Mr. Loscalzo said oncologists must have an action plan for dealing with suicidal patients. It is crucial to have a contact with a psychiatrist who can see an actively suicidal patient quickly, whether the oncologist is in private practice or in a large cancer center.
“With an actively suicidal patient, only a psychiatrist will do. I cannot imagine any oncologist who does not have a contact with a psychiatrist, psychologist, or social worker to assess some of these patients, a backup team of mental health professionals.”
In the Hospital: Plan at OSUCC-James
Joyce Hendershott, LISW-S, ACSW, Clinical Program Manager of Nursing Staff Development & Patient Education at Ohio State University James Cancer Hospital and the Solove Research Institute, notes that research indicates that with hospitalized patients, agitation, depression over a recent diagnosis or chronic illness, impulsivity, unrelieved pain, substance abuse, and/or immediate relationship issues, are more predictive of suicidal behavior in the acute population. (See “References” box on page 19—specifi cally Bostwick and Rackley 2007 [#5] and Wint and Akil 2006 [#9]).
A suicide assessment is done for these patients by an oncology social worker or mental health clinical nurse specialist, and if the assessment identifies a suicide risk, the physician is notified.
Suicide precautions are initiated by a physician's order, including creating a safe environment for the in-patient and a consult to the psychiatry team, said Ms. Hendershott, a member of OT's Editorial Board.
The health care team and physicians determine the need for continued precautions with the psychiatry team, and a physician order is required to discontinue suicide precautions.
“In the outpatient setting, if a patient is identified as at risk, an oncology social worker or mental health clinical nurse specialist is contacted who will complete an assessment to make the appropriate referrals.”
* Joyce Hendershott, LISW-S, ACSW, Clinical Program Manager of Nursing Staff Development & Patient Education at Ohio State University James Cancer Hospital and the Solove Research Institute, recommends as especially helpful for health care professionals an article on the NCI site, “Evaluation and Treatment of Suicidal Patients with Cancer—Effects of Suicide on Family and Health Care Providers,” which addresses many common questions and provides statistics on the incidence of the problem: http://www.cancer.gov/cancertopics/pdq/supportivecare/depression/Patient/page5
* And the National Association of Social Workers Code of Ethics includes ethical standards, including those specific to self harm or harm to others. These are listed under Section 1, Social Worker's Ethical Responsibilities to Clients: http://www.socialworkers.org/pubs/code/code.asp
* Ms. Hendershott also pointed to the National Suicide Prevention Lifeline at 1-800-273-TALK (8255), a free, 24-hour suicide prevention hotline available to anyone in suicidal crisis or emotional distress. The national prevention center routes the call to the crisis center nearest to the caller.
* Matthew J. Loscalzo, LCSW, Professor and Executive Director of the Department of Supportive Care Medicine at City of Hope, also recommends the American Psychosocial Oncology Society (www.apos-society.org), which connects cancer patients and their families with mental health professionals in their area.
* Also very helpful is CancerCare (www.cancercare.org), which offers free telephone counseling.
* Both Ms. Hendershott and Mr. Loscalzo and other experts, though, strongly urge that any suicidal individual should be taken to an emergency room or to an emergency community mental health center for evaluation and treatment.
Oncologist Felt He ‘Dropped the Ball’
A Nebraska farmer in his late 70s with end-stage lung cancer took his own life shortly after that diagnosis was made.
Peter M. Townley, MD, a partner at Nebraska Cancer Specialists in Omaha, was the oncologist who made the diagnosis.
It was Stage 4 disease, but with no bone or brain metastases, only some liver metastasis, Dr. Townley recalled in relating the sad situation to OT. The patient presented with no symptoms other than cough, and his only complaint was feeling more tired than usual.
Dr. Townley said the man never returned to discuss treatment before he shot himself.
“I had no warning at all that he was depressed,” Dr. Townley said. “I felt like I had somehow dropped the ball, that I should have seen some clue that something was going to happen.”
He said patients at the Omaha clinic fill out questionnaires before visits and are asked how they are handling the diagnosis. Counselors are available, and they make it a point to engage family members and ask how the patient is doing emotionally.
“We try to give patients several chances [to talk about emotional issues], we get to know them fairly quickly and get a sense” of the patients' state of mind. But in this case, I was caught off guard.”
Dr. Townley said the experience has made him much more sensitive about the risk of suicide.
He said he has a patient, a man in his late 40s, very recently diagnosed with metastatic lung cancer. The man appeared very despondent when told the cancer was incurable.
“He had his girlfriend with him, and I asked him several times how worried he was about this, what did he think he was going to do, but he didn't want to talk,” Dr Townley said. “I reassured him that if pain becomes a problem we could control that, tried to reassure him on many levels, but he just wanted to leave.”
This could have been a warning sign, Dr. Townley said, but he continued to talk to the patient's girlfriend, and the man stayed.
Dr. Townley then asked the man directly if he was thinking about hurting himself.
“He told me he was terribly depressed by the news, but no, he had just had enough information for the day.”
The patient lived quite a distance from Omaha and Dr. Townley referred him to oncologists in his area. He followed up on the patient and found that the man did start treatment there.
Dr. Townley compared this patient with the farmer who did commit suicide. The farmer “was just very matter of fact, didn't come across at all as being depressed.” He said he learned from the patient's longtime family physician that the man had committed suicide.
“The family doctor was not as surprised about the suicide as I was,” Dr. Townley said. “He said the man had always worked on the farm and was familiar with the cycle of life, and perhaps just thought his time had come.”
Joyce Hendershott, LISW-S, ACSW, Clinical Program Manager of Nursing Staff Development & Patient Education at Ohio State University James Cancer Hospital and the Solove Research Institute, also recommended the following references for further helpful information for cancer care and other health care professionals:
1. American Psychiatric Association: Assessing and Treating Suicidal Behaviors, a Quick Reference Guide, 2003.
2. Billings C: Close observation of suicidal inpatients. Journal of the American Psychiatric Association 2001;7(2):49-50.
3. Joint Commission on Accreditation of Healthcare Organizations. Sentinel Event Alert—Inpatient Suicides: Recommendations for Prevention, Suicide Precautions Divisional Standard of Practice Page 5 of 5 December 2008. Available at: http://www.jointcommission.org/AccreditationPrograms/BehavioralHealthCare/Standards/09_FAQs/NPSG/Focused_risk_assessment/NPSG.15.01.01/Suicide+risk+reduction.htm Accessed May 2009.
4. Logue EM, Parrish RS: Suicide precautions in a medical/surgical unit. Nursing Management 1998;29(10):33-34.
5. Bostwick J, Rackley S: Completed suicide in medical/surgical patients: who is at risk? Current Psychiatry Reports 2007;9:242-246.
6. Farrow TL, O'Brien AJ: “No-suicide contracts” and informed consent: An analysis of ethical issues. Nursing Ethics 2003;10:199-207.
7. Farrow TL: “No Suicide Contracts” in Community Crisis Situations: A Conceptual Analysis. Journal of Psychiatric and Mental Health Nursing 2003;10:199-202.
8. Tishler C, Reiss N: Inpatient suicide: preventing a common sentinel event. Department of Psychology, The Ohio State University. General Hospital Psychiatry 2009;31:103-109.
9. Wint D, Akil M: Suicidality in the General Hospitalized Patient. Hospital Physician 2006;42:13-18.