Ending One's Life at the End of Life: Ethical Considerations of Suicidality

• Published in: Journal of pain and symptom management 2024-05, Vol.67 (5), p.e644-e644
• Main Authors: Ramos, Jacob, Gula, Annie L., Simpson, Jane M., Stafford, Jensy
• Format: Article
• Language: English
• ISSN: 0885-3924
• DOI: 10.1016/j.jpainsymman.2024.02.087

1. Discuss key ethical considerations around suicidality in patients with terminal illness and understand the role of routine psychosocial assessments in patients receiving hospice care. 2. Differentiate between the desire to end one's life and incomplete management of unbearable symptoms at the end of life. Suicidality is not uncommon, particularly in older patients with chronic illness. While palliative care may alleviate symptoms that contribute to suicidality and offer psychosocial support, patients with a desire to end their life warrant an ethical discussion on a case-by-case basis. Suicidality is not uncommon and is “associated with functional disability and numerous specific conditions including malignant diseases, neurological disorders, pain, COPD, [and] liver disease…”(1) The wish to end one's life at the end of life raises ethical concerns around autonomy, non-maleficence, and justice. We describe a patient who attempted suicide while receiving hospice services for terminal illness. This patient lived in Rhode Island, a state where patients do not have access to Medical Aid In Dying. Mr. B is a 102 year old man with a primary hospice diagnosis of chronic kidney disease. He presented to the hospital after slicing his wrists with a razor. Further investigation revealed that his cost of living expenses were more than anticipated and he “no longer wanted to be a burden.” Mr. B revoked his hospice benefit and was admitted to the inpatient psychiatric unit until living accommodations were arranged with a family member. This case raises the ethical discussion of who gets to choose when to die. While high-quality hospice and palliative care can minimize distressing symptoms and obviate the need to intentionally end one's life, others contend that suicidality can be rational in the setting of terminal illness and unbearable suffering. In this case, the principles of autonomy and non-maleficence are in direct conflict with each other; however, one must also consider the unintended consequences of involuntary psychiatric care. The principle of justice is also highly relevant in this case when considering social support networks, inpatient hospice care, and medical aid in dying providers as limited resources. Ethical / Legal Aspects of CareExistential / Humanities / Spirituality / Religion