What to do when your resident's death wish seems 'rational'

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Marty Stempniak, Staff Writer
Marty Stempniak, Staff Writer

Suicide — a shadowy issue that most would prefer to ignore — is seemingly a hot topic in the news these days.

Hawaii, for instance,  just became the seventh state to legalize medically assisted suicide. This grants adults with less than six months to live an avenue to take their own lives, with the help of a doctor. California's own aid-in-dying law, meanwhile, is on hold, after a judge recently overturned the measure, citing a technicality. Several high-profile celebrity deaths in recent years have further thrust suicide into public discourse.

One could argue that aid in dying might be an easier matter to address with the terminally ill, where there is seemingly less gray area to debate. But what about cases of what researchers are calling “rational suicide,” where the individual is not dying, nor is he or she grappling with mental health issues?

That was the topic of a fascinating conversation, recently shared by the Annals of Long-Term Care. In the podcast, two geriatrics professors spoke with Meera Balasubramaniam — an M.D., geriatrics researcher and professor of psychiatry at New York University — about this topic of rational suicide. That was prompted by a piece she wrote in the Journal of the American Geriatrics Society in March.

Balasubramania said she is increasingly coming across able-bodied older individuals, many in their 80s and 90s, who expressed a desire to die, while at the same time not appearing to be clinically depressed, or displaying any signs of mental illness. This led her to ask some important questions: Is this a new clinical diagnosis? Will providers in long-term care and other settings see an increasing number of these individuals in their facilities, and if so, what should they do? I'll summarize a few of the key points, but would recommend giving the full 31-minute GeriPal (short for Geriatrics and Palliative Care) podcast a listen.

Balasubramaniam defines such rational suicide as occurring in a person with “clear and coherent reasoning,” displayed with “consistency,” based on “realistic information and judgment” about the world. They're in a “lucid state of mind,” too, and “their death wishes should be congruent with their fundamental values.”

She believes that grasping baby boomer dynamics is essential to understanding those who are grappling with such thoughts. Boomers mistrust authority, need control, covet independence, and are less likely to be married than the previous generation and more likely to live alone, she tells the interviewers. Plus, they experimented with substance use in the '60s, and have greater access and openness to drugs. All that adds up to what Balasubramaniam believes will be an increasing preponderance of these patients to go with the impending “silver tsunami.”

“With this kind of cohort in mind, how is the notion of death going to look, say, now and in the next 20 years? I think it remains to be seen, but we're also going to find ourselves increasingly encountering people like the patient I mentioned in my paper who wanted to end his life on his own terms,” she said, referring to a 72-year-old patient who wanted to die, though he was without a terminal or mental illness.

Balasubramaniam offers three steps that eldercare professionals can take when confronted with such thoughts from their residents. And one of the interviewers, Alexander Smith, M.D., a geriatrics researcher and associate professor with the University of California San Francisco, nicely summarizes those during the podcast: (1) “Evaluate what is the immediacy of this request? Do they actually have a plan and intention? Are they going to do it tomorrow? Or is this sort of a other end of the spectrum, a general musing about something that may or may not occur in the future?” (2) “Taking an attitude of curiosity, being nonjudgmental and comfortable with what may be a very ambivalent position for them. And, (3) “Asking a whole range of open-ended questions to try and understand the context in which this request comes up.”

The geriatrics psychiatrist also talks about the role ageism plays in fueling this trend, with folks feeling fearful of growing older, and ashamed when they have to use a walker or ask their adult children for help taking out the garbage. She speaks directly to our audience about the importance of improving the conditions at nursing homes and assisted living communities so that they are not places the elderly come to dread.

“If as a society something could be done in terms of funneling more funding or improving their condition, I think that may go some ways in altering this experience of being under the care of a nursing home,” Balasubramaniam said.

Loneliness is another aspect, and the doctor said it's important that nursing homes find creative ways to address such isolation in their resident populations. And on the flipside, eldercare providers should always seek help from peers when faced with those having thoughts of rational suicide. “One rule of thumb is, if anything makes you uncomfortable, it's fine to take help,” she said. “Never worry alone.”

Follow Staff Writer Marty Stempniak @mstempniak.

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McKnight's Daily Editors' Notes features commentary on the latest in long-term care news and issues. Entries are written by Editorial Director John O'Connor, Editor James M. Berklan, Senior Editor Elizabeth Newman and Staff Writer Marty Stempniak.

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