Managing patients with palliative care needs who express a desire to die

The aim of managing patients with palliative care needs who express a desire to die is to ensure patients and their family and carers receive appropriate support and intervention.

A sensitive and open conversation about a patient’s fears, how the future may unfold, and identification of support available may be sufficient to reassure some patients and their carers and families—see also Discussing goals of care and Advance care planning. Reassure them that ongoing support can be provided. A multidisciplinary approach, involving suitably trained healthcare professionals, can facilitate optimal management. For patients with severe psychiatric disorders (eg treatment-refractory disorders, schizophrenia, bipolar disorder), continued mental health specialist monitoring and shared care arrangements are strongly advised.

As part of ongoing clinical care and support, identify opportunities to relieve physical, emotional or spiritual distress; look for potentially treatable conditions (eg pain, depression, anxiety) and ensure symptoms are well controlled.

For patients who wish to pursue voluntary assisted dying, see Voluntary assisted dying.

For patients at risk of suicide, see the Psychotropic guidelines for advice on developing a safety plan as well as a list of helplines and support services.

Suicidal ideation can be a marker of significant distress and must be managed in patients with palliative care needs. Suicide has major implications on the experience of grief and bereavement in family members and carers. If suicide risk is significant (eg current intent, a specific plan, access to means or previous suicide attempts), immediately consult with or refer to an acute psychiatric service or acute mental health team.

For patients who are acutely agitated, if possible, use nondrug measures; see the Psychotropic guidelines for management advice, including verbal de-escalation and psychological intervention to reduce the risk of harm. If the patient remains acutely agitated and is at risk of harming themselves or others, see Acute agitation in palliative care for drug regimens.

Expressions of a desire to die can be confronting and distressing for family and carers. Conflict can arise when the patient’s goals of care and preferences are at odds with those of family members and carers. For advice on providing support to families and carers, see Family support in palliative care and Support for carers in palliative care.

Caring for patients with palliative care needs who express a desire to die can be personally challenging for healthcare professionals. Healthcare professionals should monitor their own feelings and reactions, especially for difficulties coping with patient suffering, because this might influence their ability to effectively communicate, objectively assess patient needs and maintain accepted professional standards of practice—see Healthcare professional wellbeing in palliative care.