Contact: Karin Eskenazi
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ADVICE FOR CAREGIVERS WHEN PATIENTS REQUEST ASSISTANCE WITH SUICIDE
NEW YORK, NY, January 28, 1998 -- When a patient makes a request for assistance with suicide, the physician's response should not be a simple yes or no. Instead, the caregiver should engage the patient in a dialogue that explores the possible meanings behind the stated wish to die. Only then can the physician determine whether the request is "rational" or driven by other, possibly resolvable factors, such as depression or inadequately treated pain.
This and other advice is offered to doctors in an article in today's issue of the Journal of the American Medical Association. The article, by Philip R. Muskin, MD, Associate Professor of Clinical Psychiatry at Columbia-Presbyterian Medical Center, goes well beyond the usual discussion of patients who request to die. To date, the medical literature on this topic has focused almost entirely on whether the patient is competent to make such a request, "which is too simplistic an approach for so complex a matter," he writes.
Physician-assisted suicide is illegal in all but one state (Oregon), and the Supreme Court ruled last year that it is not a constitutional right. Nonetheless, there is substantial support for physician-assisted suicide. Studies have shown that 55 percent of people with HIV and 25 percent of those with cancer have contemplated physician-assisted suicide. How many patients actually make such a request and how often it is granted by caregivers are not known. But assisted suicide does occur. In a survey of critical-care nurses, 16 percent reported that they assisted in a patient's death, and 4 percent acknowledged that they expedited a patient's death by pretending to deliver vital treatment ordered by a doctor.
However, Dr. Muskin writes, "The issue to be addressed in this article is not one of ethics or law.... Regardless of the outcome of the societal and legal debate regarding physician-assisted suicide, physicians should recognize that patients who make a request to die deserve a compassionate and comprehensive evaluation." The doctor's first answer "should not be a simple yes or no," Dr. Muskin elaborates. "An initial response might be, 'That is a serious request; before we can know what would be the best way to proceed, let's talk about why you are asking me to help you die now.'"
Dr. Muskin advocates a "psychodynamic" approach to these patients. In modern psychodynamics, he writes, one seeks to find "important hidden meanings within emotion, thought, and behavior rather than searching for a singularity, a core unit, or a 'truth.'" Thus, the request to die may in fact be a communication to the physician, for example, an appeal to be given a reason to live.
According to Dr. Muskin, some terminally ill patients want to commit suicide for perfectly rational reasons, such as intractable pain or extremely poor quality of life, and there may be little that can be done to change their minds. "Not every request for physician-assisted suicide indicates complex unspoken psychodynamics," he admits, "but that cannot be known until the physician and patient talk."
In many cases, the patient's thinking is colored by other factors, most often pain or depression, but also sadness, rage, hopelessness, guilt, or self-punishment. In some cases, a request to die may be a last-ditch attempt to regain control over their lives or a way to get revenge against a doctor who has failed to help. Still others experience "a split in the experience of self" and believe that suicide can rid themselves of their sick half.
More often than not, when the underlying problem is treated, patients decide that they do not want to die after all, says Dr. Muskin. He cites the case of a 92-year-old woman who was admitted to the hospital after a fall and was found to have congestive heart failure. Although she was expected to recover, she asked to die, stating strongly that she was "old and had lived long enough." During a psychiatric consultation, it was learned that she was once a professional dancer and had suffered many recent losses, including the use of her legs, suggesting a clinically significant depression. After antidepressant treatment, she realized she would regain the ability to walk and pressed for more aggressive physical therapy and to return home.
"You don't need to be a psychiatrist or a psychoanalyst to initiate this kind of dialogue," says Dr. Muskin. "Most people, even if they are not physicians -- social workers, nurses, laypeople -- can engage in these kinds of conversations." However, a psychiatric consultation is often warranted. "[S]ome of the skills required for the in-depth exploration are not those of the primary care physician, the oncologist, or the surgeon," he writes. "These are the skills of the psychiatrist..."
The title of Dr. Muskin's paper is "The Request to Die: Role for a Psychodynamic Perspective on Physician-Assisted Suicide."
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