Co-authored by Ora Nakash, PhD
Does a cancer patient with a good prognosis who shoots himself constitute a suicide? What about a cancer patient near the end of life who refuses treatments? How do we classify a request for palliative sedation, which doesn’t hasten death, but will put a terminal cancer patient in a comma that they will never wake up from? These, and other philosophical questions, are among the life and death decisions that oncologists struggle with on a daily basis in their clinical practices.
In a set of papers published in Supportive Care in Cancer and in Psycho-Oncology, we examined how oncologists, nurses, and social workers identify suicide risk in their cancer patients. The project was funded by the American Foundation for Suicide Prevention and was the first research project to examine how healthcare workers see this issue. We know that cancer patients are at an increased risk of thinking about, and committing suicide compared to the rest of the population. For example, in England, 70% of cancer patients considered taking their own lives compared to 20% of the general population. In the United States, cancer patients are twice as likely to take their own lives compared to those who are disease free. Given the astronomically high rates of suicidal thinking and suicidal acts among cancer patients, we were interested in finding out how healthcare professionals who work in in the oncology field identify who is most at risk.
The study involved interviews with 61 oncologists, nurses, and social workers that work at academic cancer centers across Israel. Using a qualitative method known as grounded theory, we analyzed the data by systematically coding each interview transcript line by line for themes to see which themes stood out most robustly across the interviews. Over half of the oncologists and nurses encountered at least one patient who had committed suicide during their professional careers. Thoughts of suicide were also common, with healthcare workers reporting that approximately 75% of cancer patients under their care expressed thoughts of taking their own life.
While we often think of suicide in black and white terms – someone either takes their life or doesn’t – the most important finding from our study is the discovery of a nuanced spectrum when it comes to suicide in the cancer context. There was remarkable consistency among oncologists, nurses, and social workers when it came to identifying four phases falling on a continuum that included a strong will to live in phase A, a decreasing will to live in phase B, a readiness to die in phase C, and a will to die in phase D. There were, however, competing definitions of what defines suicidal thinking and suicidal acts in these different categories of the spectrum. For example, while some defined ‘stopping or rejecting treatment’ as suicidal behavior, others thought that choosing to stop treatments could be a rational decision depending on the circumstances of the patient. Importantly, the most robust factor affecting the patient’s will to live was how much they were suffering, physically and mentally. At every point along the spectrum, regardless of the prognosis or stage of the disease, the healthcare providers pointed to the strong relationship between the patient’s physical and mental suffering and their wish to keep living.
Our results highlight two important points. First, is the dire need for psychosocial intervention and palliative care during the entire cancer treatment trajectory and not only at end of life, or when patients are diagnosed with mental health distress. There is robust evidence that early integration of psychosocial and palliative care can substantially reduce cancer patients’ physical and emotional suffering, and yet it still unavailable for many patients. These interventions are essential in promoting the well-being and quality of life of cancer patients, and as our study findings pointed out, this support can potentially prevent suicidal thinking and suicidal acts in cancer patients.
Second, our study exposed a philosophical question about a cancer patient’s right to end their lives. Given the tremendous complexity of defining suicide in the cancer context, the question of what defines a rational choice when it comes to taking one’s own life needs to be rethought. In Israel, as in most of the United States, euthanasia is illegal, leaving some patients who are suffering and wish to end their lives frustrated with their inability to determine their own faith. The healthcare provider who wants to help these patients but needs to stand by and witness this suffering is also frustrated and alone in facing these ethical dilemmas. There are no easy answers when it comes to matters of life and death, but one thing is clear, this is a discussion that needs to move beyond the individual patient and healthcare provider to a national forum.
If you or someone you know needs help, call 1-800-273-8255 for the National Suicide Prevention Lifeline. You can also text HELLO to 741-741 for free, 24-hour support from the Crisis Text Line. Outside of the U.S., please visit the International Association for Suicide Prevention for a database of resources.