Assessing patients with palliative care needs who express a desire to die
Balaguer, 2016Hudson, 2006Rodriguez-Prat, 2017
Patients with palliative care needs experience a variety of emotional responses to their condition, ranging from a strong will to live through to a desire to die. These feelings can fluctuate throughout the course of life-limiting illnesses, and reflect the changing nature of the illness and decline in function and quality of life.
Patients may explicitly state their desire to die or hint at it. Statements that can indicate a desire to die include:
- ‘I can’t do this anymore.’
- ‘I wish things would hurry up.’
- ‘Why am I still here?’
- ‘This is not a life.’
- ‘I wish I could go to sleep forever.’
- ‘I want this over.’
Alternatively, the desire to die may be expressed behaviourally (eg refusing food, drink, investigations, treatment, or to engage with healthcare professionals).
Expressions of a desire to die can have many different meanings. Do not make assumptions or jump to conclusions about a patient’s feelings or intent. Expressions of a desire to die may be:
- transient and indicate acute distress
- a plea for help and support
- a wish to regain dignity and control
- an indirect request to withdraw or withhold life-sustaining measures (eg ventilation support, dialysis, transfusions)
- an indirect request for voluntary assisted dying
- indicative of suicidal ideation.
Key aspects of assessing patients who express a desire to die include:
- exploring concerns that have contributed to the desire
- actively listening to their thoughts, feelings, attitudes and beliefs about death and dying
- establishing the intensity, duration and nature of thoughts (eg intermittent and modifiable, or persistent and intrusive)
- determining the intent to die, degree of planning, and access to means
- identifying risk factors for suicidal ideation
- identifying potential protective factors (eg connections to friends, family and community support, cultural or religious beliefs that discourage suicide) or coping methodsCenters for Disease Control and Prevention (CDC), 2021.
The Psychotropic guidelines provide further information on assessing suicide risk, including questions to guide assessment.
In addition to general risk factors for suicidal ideation listed in the Psychotropic guidelines, specific risk factors for suicidal ideation in patients with a life-limiting illness include:
- patient perception of treatment failure
- poorly controlled physical and psychological symptoms (particularly depression and anxiety)
- functional decline with reduced quality of life
- concerns of being a burden to others
- relationship conflict
- fears of the future
- fears of the process of dying
- fears of abandonment (including by healthcare professionals)
- a lack of meaning and purpose
- loss of dignity
- demoralisation.
NB1: Assessing suicide risk is a standard and crucial component of psychiatric assessments and mental health plans, but it is inherently difficult to reliably predict an individual’s risk of suicide.
NB2: Patients with intense or intrusive thoughts of suicide who have a specific plan and access to means are at significant risk (unless the plan and means are as a result of an approved voluntary assisted dying process)—immediately seek advice from or refer to a specialist service (eg specialist palliative care service, acute psychiatric service, mental health team).