From time-to-time in my work with patients and caregivers, someone will raise the issue of suicide, sharing their own suicidal thoughts or talking about those of a loved one. As disturbing as it can be, it is always helpful to create the emotional space for patients and caregivers to discuss these painful feelings.
When we are open to their expressions of emotional pain and acknowledge the fact that suicidal feelings are not uncommon in cancer patients, we make it possible for patients to speak openly. They may or may not choose to disclose such thoughts, but having those sometimes terrifying, sometimes oddly comforting thoughts and feelings placed in context and validated can be a tremendous step toward healing.
When a patient does express suicidal impulses, we need to acknowledge them and begin a conversation about the patient's experience that is candid and clear. We want to avoid being judgmental or argumentative, trying to convince them that life is worth living. This is a profoundly painful and isolating experience; we want to avoid offering cliché reassurances that “Things will be OK.”
We need to ask them how often they think about suicide, if they have a plan and, if so, to tell us about it. We need to assess the plan for detail, to consider how realistic and feasible it may be (the more realistic, the more specific, the more likely the patient is in danger of acting). We need to find out if they have anything or anyone meaningful in their lives, any goals that they are living for or working towards, and, as we gather this information, we need to consider next steps. Is this person an imminent danger to himself? And, if so, who is the psychiatrist on-call, or where is the nearest psychiatric emergency facility?
Often, our assessment will point towards someone depressed but not immediately in danger, someone who needs a mental health referral, but who also simply needs support. They need to know that there is nothing unusual about wanting to "get away" from situations that cause distress, to consider the tremendous difference between wanting to die and wanting to put an end to the suffering. It is so important for patients to know that they are not alone when these thoughts do emerge. It is crucial for them to know that there are ways to feel better even in the midst of such pain and despair and to know that their medical team can point them in the right direction for help.
With any patient who is struggling with depression and thoughts of suicide, we need to contract with her, to make an agreement that, if she is feeling suicidal and is in immediate danger of hurting herself, she will call 911, stay on the line, and wait with the operator for help to arrive.
For those who experience suicidal ideation, but are not in immediate danger, there are options for help. If they have a therapist/psychiatrist, they should contact them. For those who don't yet have mental health support (and also for those who do), it can be a good idea to call the national suicide hotline to get connected with a crisis center and/or hotline in their community.
With my own patients, I strongly recommend that they call this number as soon as possible to find out about services in their area. In my experience, there can be a long wait for connection to a person when calling the national number, so it is best to call before there is a problem and to get information about a local resource that can be more immediately available. They can also check-out websites, like Suicide Hotlines, which provide links to phone numbers for many crisis intervention centers across the country.
I wonder how situations like this are handled at your cancer center. Are any members of your cancer care team screening patients and caregivers for suicidal tendencies?
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