Can suicide ever be rational?

To the Editor

Over the last century, the human life expectancy has increased as a result of medical advances. The increase in longevity and associated morbidity has emphasised the importance of maintaining a balance between an individual’s quantity versus quality of life (Van Wijngaarden et al., 2016). With the recent legislative changes in Australian state governments, healthcare professionals are now also faced with the challenge of considering suicide as a rational choice with a shift towards voluntary assisted dying (VAD). The following consultation liaison psychiatry case reflects the complexity of rational suicide.

Mrs A is an 80-year-old European woman referred following a temazepam overdose. This was her first suicide attempt and she had no past psychiatric history. Mrs A described having lived an active and fulfilling life. However, she emphasised that her quality of life had declined over the past 5 years due to the progression of her respiratory disease. Based on the opinion of the respiratory physician, her estimated life expectancy was less than 1 year.

To ease the process for her family, Mrs A had settled her legal, financial and health matters. Although her family was saddened by her decision, they were accepting of her wish to die with dignity before further loss of independence. After several days of assessment on the medical ward, the working diagnosis was of an adjustment disorder due to functional decline. An inpatient psychiatric admission was offered but both the patient and her family declined this option. Mrs A was referred to the palliative care team but she refused to engage with the service.

A collaborative decision was made to discharge her home with follow up by her general practitioner and the community psychiatric services. Following discharge, she refused to engage with the community psychiatric services. Further attempts made in collaboration with her family were also unsuccessful. One week following discharge, her family notified the psychiatric team that she had committed suicide at home.

Reflection on Mrs A case, VAD could have been an alternative pathway and this option may have protected her loved ones from the psychological impact following a suicide. VAD raises the question of how effectively and efficiently another individual or a group of individuals can assess a person’s suffering and exclude mental illness. As the Australian healthcare system explores the option of VAD, it is important to reflect on the potential issues and limitations that VAD may pose.