Many factors increase vulnerability to suicide in cancer patients. Uncontrolled pain and other physical symptoms, psychological distress, and existential suffering are related to suicide in oncology. There is a strong consensus that physicians and nurses are not adequately trained to manage the potential suicide patient. This paper offers suggestions for the early recognition of cancer patients at risk of suicide, for the planning of crisis intervention and a physician-patient communication strategy.
Methods
A review of the literature about suicide in cancer patients was carried out by MEDLINE and PSYLIT and peer contacts.
Results
Through a review of the literature and their clinical experience, the authors outline a number of vulnerability factors of suicide with the intention to help health professionals to face the dilemma of suicide in cancer patients. Clinical vignettes reveal how a patient may reject his/her suicidal intention if adequate pharmacological and psychosocial supports are offered. Other case reports of patients refusing cancer therapy show that suicide is a complex phenomenon touching ethical, sociological, medical and psychiatric issues.
Conclusions
Our findings support the hypothesis that improved patient-physician communication, to supply adequate psychological crisis intervention, respect for patient-centered care, familiarity with the tenets of palliative medicine alongside effective education in suicidology, and the routine use of teamwork may reduce the need of suicide in cancer patients and probably the need to hasten death.
MassieM.J., GagnonP., HollandJ.: Depression and suicide in patients with cancer. J Pain Symp Manag, 9: 325–340, 1994.
2.
MoscickiE.K.: Gender differences in completed and attempted suicide. Ann Epidemiol, 4: 152–158, 1994.
3.
HendinH.: Suicide, assisted suicide and medical illness. J Clin Psychiatry, 60: 46–50, 1999.
4.
FilibertiA., RipamontiC., TotisA., VentafriddaV., ContieroP., De ConnF., TamburiniM.: Characteristics of terminal cancer patients who committed suicide during a home palliative care program. J Pain Symp Manag, 22: 544–553, 2001.
5.
RipamontiC., FilibertiA., TotisA., De ConnoF., TamburiniM.: Suicide among patients with cancer cared for at home by palliative-care teams. Lancet, 914: 1877–1878, 1999.
6.
FilibertiA.: Il paziente oncologico ed il suicidio. Aspetti psicodinamici e psicosociali del suicidio in oncologia. Neurol Psichiatria, Sci Umane, 3: 406–418, 1992.
7.
MortensenP.B., JuelK.: Mortality and causes of death in first admitted schizophrenic patients. Br J Psychiatry, 63: 183–189, 1993.
8.
ConwellY., CaineE.D.: Rational suicide and the right to die. Reality and myth. N Engl J Med, 325: 1100–1102, 1991.
9.
WeismanA.: Coping with behavior and suicide in cancer. In: Cancer: the behavioral dimension, CullenG., FoxB., IsonR. (Eds), pp 321–341, Raven Press, New York, 1976.
10.
JohnsonP., FitchS., OltsonJ., McIntoshW.: Acceptance of conditional suicide and euthanasia among adult Americans. Suicide Life Threat Behav, 10: 157–167, 1980.
11.
SiegelK., TuckelP.: Rational suicide in the terminally ill cancer patients. Omega, 15: 263–268, 1984.
12.
AnnasG.: When the suicide prevention becomes brutality: the case of Elizabeth Bouvia. Hastings Center Report, 14: 20–21, 1984.
13.
HollandJ.: Psychological aspects of cancer. In: Cancer Medicine, HollandJ.F., FreyE. (Eds), pp 1175–1293, Lea & Febiger, Philadelphia, 1978.
14.
HietanenP., LonnquistJ., HenrikssonM.: Do cancer suicides differ from others?Psycho-Oncology, 3: 189–195, 1994.
15.
LevinD.N., CleelandC., DarR.: Public attitudes towards cancer pain. Cancer, 56: 2337–2339, 1989.
16.
DoukasD., WaterhouseD., GorenfloD., SeodJ.: Attitudes and behaviors on physician-assisted death: a study of Michigan Oncologists. J Clin Oncol, 13: 1055–1061, 1995.
17.
GanziniL., FennD., LeeM., HeinzR., BloomJ.: Attitudes of Oregon psychiatrists toward physician-assisted suicide. Am J Psychiatry, 153: 1469–1475, 1996.
18.
EmanuelE., FaircloughD., ClarridgeB., BlumD., BrueraE., PenleyC., SchnipperL., MayerR.: Attitudes and practices of US oncologists regarding euthanasia and physician assisted suicide. Ann Internal Med, 133: 527–532, 1996.
19.
Di MolaG., BorsellinoP., BrunelliC.: Attitudes toward euthanasia of physician members of the Italian Society for Palliative Care. Ann Oncol, 7: 907–911, 1996.
20.
GrassiL., AgostiniM., MagnaniK.: Attitudes of Italian doctors to euthanasia and assisted suicide for terminally ill patients. Lancet, 914: 1876–1877, 1999.
21.
QuillT., CasselC., MeierD.: Care of the hopelessly ill-proposed clinical criteria for physician-assisted suicide. New Engl J Med, 327: 1380–1384, 1992.
22.
SiegelK.: Psychosocial aspects of rational suicide. Am J Psychotherapy, 40: 405–418, 1986.
23.
CasselC.R., MeyerD.E.: Morals and moralism in the debate over euthanasia and assisted suicide. New Engl J Med, 13: 750–752, 1990.
24.
LouhivuoriK., HakamaM.: Risk of suicide among cancer patients. Am J Epidemiol, 109: 59–65, 1979.
25.
FoxB., StanekE., BoydS., FlanneryT.: Suicide rates among cancer patients in Connecticut. J Chronic Dis, 35: 85–100, 1982.
26.
AllebeckP., BolundC., RingbackG.: Increased suicide rate in cancer patients. A cohort study based on the Swedish Cancer-Environment Register. J Clin Epidemiol, 42: 611–616, 1989.
27.
StormH., ChristensenN., JensenO.: Suicides among Danish patients with cancer: 1971 to 1986. Cancer, 69: 1507–1512, 1992.
28.
LeviF., BulliardJ., La VecchiaC.: Suicide risk among incident cases of cancer in the Swiss Canton of Vaud. Oncology, 48: 44–47, 1991.
29.
CrocettiE., ArnianiS., AcciaiS., BarchielliA., BuiattiE.: High suicide mortality soon after diagnosis among cancer patients in central Italy. Br J Cancer, 77: 1194–1196, 1998.
30.
BreitbartW.: Suicide in cancer patients. Oncology, 1: 49–54, 1987.
31.
BreitbartW.: Suicide. In: Handbook of psychooncology, HollandJ., RowlandJ. (Eds). Oxford Press, New York, 1989.
32.
BreitbartW.: Cancer pain and suicide. In: Advances in pain research and therapy, FoleyK.M., BonicaJ.J., VentafriddaV. (Eds), Vol 16, Raven Press, New York, 1990.
33.
BreitbartW.: Suicide risk and pain in cancer and AIDS patients. In: Current and emerging issues in cancer pain: research and practice, ChapmanC.R., FoleyK.M. (Eds), pp 49–65, Raven Press, New York, 1993.
34.
OlafsenO.M.: Suicide among cancer patients in Norway. In: Depression et suicide. Aspects medicaux psychologiques et socio-culturels, SoubrierJ.P., VedrinneJ. (Eds), pp 587–591, Pergamon Press, Oxford, 1981.
35.
HanashK., FurlowW., HarrisonE.: Carcinoma of the penis: a clinicopathological study. J Urol, 104: 291–295, 1970.
36.
BolundC.: Suicide and cancer. Medical and care factors in suicides by cancer patients in Sweden, 1973-1976. J Psychosocial Oncol, 3: 31–52, 1985.
37.
FarberowL., GanzlerS., CutterF., ReynoldsD.: An eight years survey of hospital suicides. Suicide Life Threat Behav, 1: 184–201, 1971.
38.
BreitbartW., HollandJ.: Psychosocial aspects of head and neck cancer. Semin Oncol, 15: 61–69, 1988.
39.
HietanenP., LonnquistJ.: Cancer and suicide. Annals Oncol, 2: 19–23, 1991.
40.
BolundC.: Suicide and cancer: demographic and social characteristics of cancer patients who committed suicide in Sweden. J Psychosocial Oncol, 3: 17–30, 1985.
41.
ConwellY., CaineE.D., OlsenK.: Suicide and cancer in late life. Hosp Community Psychiatry, 41: 1334–1339, 1990.
42.
FilibertiA., AudisioR.A., KaasaS.: Psychosocial issues in old cancer patients. Crit Rev Oncol Hematol, 27: 132–133, 1998.
43.
PerimanP.: Suicide among cancer patients. J Clin Oncol, 16: 2292, 1998.
44.
ShaffiM., CarriganS., WhittinghillJ.R., DerrickA.: Psychological autopsy of completed suicide in children and adolescents. Am J Psychiatry, 142: 1061–1064, 1985.
45.
ReichP., KellyM.: Suicide attempts by hospitalized medical and surgical patients. New Engl J Med, 294: 298–301, 1976.
KunkelE., WoodsC., RodgersC., MyersR.: Consultations for maladaptive denial of illness in patients with cancer: psychiatric disorders that result in noncompliance. Psycho-Oncol, 6: 139–149, 1997.
48.
ColleoniM., MandalaM., PeruzzottiG., RobertsonC., BredardtA., GoldhisrchA.: Depression and degree of acceptance of adjuvant cytotoxic drugs. Lancet, 356: 1326–1327, 2000.
49.
FawcettJ.: Suicidal depression and physical illness. JAMA, 219: 1303–1305, 1972.
50.
BrownJ., HenteleffP., BarakatS., RoweC.: Is it normal for terminally ill patients to desire the death?Am J Psychiatry, 143: 208–211, 1986.
51.
OwenC., TennatC., LeviJ., JonesM.: Suicide and euthanasia: patient attitudes in the context of cancer. Psycho-Oncol, 1: 79–88, 1992.
52.
ChochinowH.M., WilsonK.G., EnnsM.: Desire for death in the terminally ill. Am J Psychiatry, 152: 1185–1191, 1995.
53.
WilsonK., ScottJ., GrahamJ., KozakJ.F., ChaterS., ViolaR.A., De FayeB.J., WeaverL.A., CurranD.: Attitudes of terminally ill patients toward euthanasia and physician assisted suicide. Arch Intern Med, 160: 2454–2460, 2000.
54.
EmanuelE., FaircloughD., EmanuelL.: Attitudes and desires related to euthanasia and physician assisted suicide among terminally ill patients and their caregivers. JAMA, 284: 2460–2468, 2000.
55.
BreitbartW., RosenfeldB., PassinH., KaimM., Funesti-EschJ., GaliettaM., NelsonC.J., BresciaR.: Depression, hopelessness, and desire for hastened death in terminally cancer patients with cancer. JAMA, 284: 2907–2911, 2000.
56.
ChochinowH., WilsonK., EnnsM., LanderS.: Depression, hopelessness, and suicidal ideation in the terminally ill. Psychosomatics, 39: 366–370, 1998.
57.
FisherB., HaythornthwaiteJ.A., HeinbergL., ClrkM., ReedJ.: Suicidal intent in patients with chronic pain. Pain, 89: 199–206, 2001.
58.
SullivanM., RappS., FitzgibbonD., ChapmanC.R.: Pain and the choice to hasten death in patients with painful metastatic cancer. J Palliat Care, 13: 18–28, 1997.
59.
FilibertiA., RipamontiC., SaitaL., De ConnoF.: Frequency of suicides of cancer patients in the National Cancer Institute of Milan over the period 1986-1990. Ann Oncol, 2: 610, 1991.
60.
HeavenC., MaguireP.: The relationship between patients' concerns and psychological distress in a hospice setting. Psycho-Oncol, 7: 502–507, 1998.
61.
SilberfarbP.M., MaurerL.H., CronthamelC.S.: Psychosocial aspects of breast cancer patients during different treatment regimens. Am J Psychiatry, 137: 450–455, 1980.
62.
Acte'K.A., VanhkouenM.L.: Cancer and the psyche. Omega2: 46–56, 1971.
63.
PasacretaJ.V., MassieM.J.: Nurses' reports of psychiatric complications in patients with cancer. Oncol Nurs Forum, 17: 347–353, 1990.
64.
Fusco-KarmanC., TamburiniM.: Volunteers in hospital and home care: a precious resource. Tumori, 80: 269–272, 1994.
65.
DrussR.: Psychotherapy of patient with a serious intercurrent medical illness (cancer). J Am Acad Psychoanal, 14: 459–472, 1986.
66.
SneidemanE.: The psychological autopsy. Suicide Life-Threat Behav, 11: 325–340, 1981.
67.
BongarB.: Consultation and the suicidal patient. Suicide Life-Threat Behav, 23: 299–306, 1993.
StiefelF.: Psychosocial aspects of cancer pain. Support Care Cancer, 1: 130–134, 1993.
72.
BottomleyA.: Depression and cancer patients: a literature review. Eur J Cancer Care, 7: 181–191, 1998.
73.
StiefelF., TrillM.D., BerneryA., OlarteJ.M., RazaviD.: Depression in palliative care: a pragmatic report from the Expert Working Group of the European Association for Palliative care. Support Care Cancer, 9: 477–488, 2001.
74.
BaileW.F., DiMaggioJ.R., SchapiraD.V., JanofskyJ.S.: The request for assistance in dying. The need for psychiatric consultation. Cancer, 72: 2786–2791, 1993.
75.
KugayaA., AkechiT., NakanoT., OkamuraH., ShimaY., UchitomiY.: Successful antidepressant treatment for five terminally ill cancer patients with major depression, suicidal ideation and a desire for death. Support Care Cancer, 7: 432–436, 1999.
