What is hopelessness? What does it mean to feel needed or that one is a burden? These are intense and profound emotions that contribute to diagnoses of depression and for some, thoughts of suicide. Words mentioned by individuals are “I might as well just disappear from life,” or “I don’t think there’s any meaning to my life,” or I wanted to “leave the box of evil thinking.” These are difficult words to hear as clinicians, and even more difficult to assess as to sincerity and plan. Typically, we go to our standard tool box to assess: Have you wished you were dead? Do you have a plan? Have you made steps or acted on this plan? But what if we used another set of tools and began exploring the relationships each person has in her present life and probed into answering the question “Who are you?” Who are you now that you have a terminal disease? Who are you now at 93 years old? Who are you as independence diminishes? Who are you and what is your place in the world and the meaning of your relationships?
Does the language of ideation – to disappear or be hopeless – express a sincere wish to die or is it an effort to say I am lonely, I wish I weren’t a burden and I miss all my loved ones? Does our assessment of suicidal ideation change depending on the age of the individual? Mustn’t we consider that thoughts of ending life differ depending on your age – 60 years old compared to 90?
For clinicians working in a hospital setting the Death With Dignity option became a focus of the Round Table Discussion Group. One hospital social worker expressed the opinion that culturally in the United States we are not well equipped to talk about death. Unlike in some health care systems where medical care is more heavily cost controlled, doctors do address palliative care, withdrawing treatment and quality of life more easily than here in the United States. It was commented that when a patient voices the wish to die there is often an immediate assumption they must be clinically depressed, medicated and convinced otherwise. But for those working in community and home-based services the discussion has a different meaning. As mandated reporters, any mention of ending life or suicide raises alarms; homecare workers can be most affected by this language. These caregivers are often the closest eyes and ears of the frail and chronically ill who may likely express a wish to die. Though the skills of these caregivers are not directly meant to address suicidal ideation, a homecare worker must become knowledgeable about when to refer, when to report and, most importantly, to be offered support when hearing an expression about a wish to die, because of cultural or religious taboos against suicide and the strong relationships and connection they have made with that frail individual.
The journal articles speak to strengthening protective factors when thoughts of suicide are expressed, such as self-forgiveness or creating a more fulfilling life. No matter the clinical setting, an expression of suicidal ideation deserves attention and dignity. As clinicians our role is to evaluate, assess intent and listen with intention and compassion.
The Round Table Discussion Group meets monthly for an interdisciplinary conversation with experienced professionals in the field of aging. Each conversation uses one or two journal articles as reference points. The articles read for this discussion were:
Incorporating Resilience Factors in the Interpersonal Theory of Suicide: The Role of Hope and Self-Foregiveness in an Older Adult Sample, Chevens, et al, Journal of Clincal Psychology, Vol 72(1), 58-69 (2016).
Influencing & Protective Factors of Suicidal Ideation Among Older Adults, Huang, et al, International Journal of Mental Health Nursing, (2017) 26, 191-199.