Rational Suicide in Elderly Adults: A Clinician's Perspective

Meera Balasubramaniam, MD, MPH

Disclosures

J Am Geriatr Soc. 2018;66(5):998-1001. 

In This Article

The Case of Mr. A

Mr. A was a 72–year–old retired businessman who was admitted to a teaching hospital for treatment of Stage 1 colorectal adenocarcinoma. He underwent resection of the tumor and was deemed not to require adjuvant chemoradiation. He was informed that he would need ongoing periodic follow–up at the gastrointestinal clinic. Mr. A casually mentioned to his nurse that he had always entertained the idea of ending his life "while I'm still doing well." He said that should his health show signs of failing or the process of follow–up become arduous, he would consider suicide. He denied thoughts of wanting to hurt himself at the present time. He suggested that he would do it on his own terms when he felt that it was about time. He did not specify a timeline, stating, "I've lived a good life. I'll see how it goes, but it's better to die well in my early 70s than have a life in which I have to be anxious before every doctor's visit or have repeated surgeries or end up in a nursing home." Mr. A's medical history included diabetes and hypertension that were well controlled with medications. He also had bilateral knee osteoarthritis, used a walker to ambulate, and had recently been recommended for total knee replacement surgery.

Psychiatry was consulted to evaluate Mr. A. He appeared lively and well spoken. He reported that he had been widowed for the last 10 years and that his 2 adult children lived in a neighboring state. He shared that he socialized with friends at a local senior center a few times every week. His score on the Montreal Cognitive Assessment scale was 28 out of 30, excluding significant cognitive impairment.[1] He was not found to meet diagnostic criteria for any mood, anxiety, or psychotic disorder. His primary care physician, the surgeon, and the psychiatrist in the hospital discussed Mr. A's thoughts about ending his life, which he had long considered but was not imminent. They wondered whether Mr. A was safe to be discharged home. Mr. A insisted that his thoughts were "rational" and that he had a "right" to decide when he should die.

As a geriatric psychiatrist, I often come across older adults expressing death wishes. Some express a sense of hope that death will arrive soon, others express a wish to shorten the dying period, and others explicitly verbalize a desire to kill themselves. Suicide has historically been considered pathological, preventable, and within the purview of psychiatry. This is generally justified, because most suicide attempts are in the context of mental illnesses that are usually treatable. As a field, we are particularly attentive to suicidal thoughts expressed by older adults, an age group associated with high rates of completed suicides,[2] but geriatricians are increasingly encountering older adults like Mr. A who express the desire to end their lives in the absence of a diagnosable mental illness. Many of them have medical illnesses that affect their quality of life but who are by no means terminally ill. Such individuals insist that their thoughts are rational. Physician–assisted death for terminal illnesses has been legalized in 6 U.S. states and the District of Columbia. This has not only led to a growing interest in the idea of controlling the time and manner of one's death, but has also brought physicians into the mainstream of the right–to–die discussion. Additionally, there are organizations such as My Death My Decision that support the idea that mentally competent older adults should have the right to a dignified death rather than face an uncertain life that may be fraught with frailty and dependence.[3]

The topic of rational suicide among non–terminally ill elderly adults like Mr. A is complex. We need to explore whether ethical arguments in favor of physician–assisted suicide apply to elderly adults who are tired of living but are not terminally ill. Another angle to examine is philosophical: whether and how aging changes one's perception of the meaning of life and suicide. A changing society and its relationship with aging and death is another important dimension to consider.

In this article, I will examine the topic of rational suicide in elderly adults primarily from the perspective of a clinician to whom an elderly adult has disclosed death wishes that he or she deems rational. I do not seek to espouse a view on whether suicide in non–terminally ill elderly adults can be rational. My experience as a psychiatrist has led me to believe that any decision that is complex and personal is fraught with conflicts and ambivalence, and I see my role as helping people work through their conflicts. I will first briefly discuss how contemporary societal perspectives influence older adults and their death wishes. I will then discuss rational suicide with reference to the baby boomer generation. After this, I will discuss how medical illnesses, functional losses, and feelings of dependence can collectively affect an older adult's desire to die.

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