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Having a terminal or life-limiting illness can increase a person’s risk of taking their own life. Find out how to have compassionate conversations and offer support
When Robin Walton was a nursing student on a London hospital ward in the 1960s, a patient climbed out of the window one day and jumped to his death.
Nursing Standard. 37, 8, 24-26. doi: 10.7748/ns.37.8.24.s14
Published: 03 August 2022
She remembers three consequences of this event.
‘It was traumatic. Nurses felt guilt and blame. And the window openings were reduced,’ she says.
What did not happen was any kind of counselling for the affected staff or training on how to support patients who felt suicidal.
Suicide had been decriminalised in 1961, but it was still ‘unmentionable’, says Ms Walton, who went on to become a psychotherapist and is now retired. Even in the 1980s when she was nursing at the Friarage Hospital in Northallerton, North Yorkshire, the idea that patients might want to take their own life was taboo – offensive even – to many of her colleagues.
‘I tried to discourage abrupt behaviour, but some nurses were judgemental and unkind towards patients who self-harmed or talked about ending it all,’ she says. ‘I suppose it’s a natural reaction. If you spend time saving people’s lives and they don’t want you to, it’s a bit confusing. And if you’re not getting emotional support from your colleagues or supervisors, you become inured, unable to respond appropriately.’
Suicide can still be taboo today but we now know that asking someone directly if they are thinking of taking their own life does not plant the idea in their head or make it more likely to happen. As part of a compassionate conversation, it is more likely to help them feel better about the future.
Nurses, in particular, need to be able to open this dialogue, given that patients with low-survival cancer, chronic heart disease or a life-limiting lung disease are at least twice as likely as the general population to take their own lives, according to Office for National Statistics (ONS) data.
Former health and social care secretary Matt Hancock asked the ONS to examine suicide rates in patients diagnosed and treated in England from 2017-2020 for:
» Chronic obstructive pulmonary disease (COPD).
» Chronic ischaemic heart conditions.
» Low-survival cancers– namely liver cell carcinoma, oesophageal, mesothelioma and malignant neoplasm of bronchus and lung, pancreas and meninges.
‘Ask the person what they’re looking forward to. If someone is no longer getting enjoyment from things or thinking about the future, that should ring alarm bells’
Sarah Holmes, Marie Curie UK medical director
The data show that one year after diagnosis, the suicide rate among patients with low-survival cancers is 22.2 deaths per 100,000 people – 2.4 times the rate among matched controls (people with similar sociodemographic characteristics not living with a severe health condition).
The suicide rate for patients with COPD one year after diagnosis was also 2.4 times that for matched controls. And for patients with chronic ischaemic heart conditions it was nearly twice the rate among matched controls.
British Heart Foundation senior cardiac nurse Sindy Jodar says: ‘It is devastating to hear that people living with heart disease are at increased risk of suicide. Everyone should have access to support and care that addresses their psychological needs, alongside treatment of their condition.’
It is normal for people with life-limiting conditions to feel anxious or low, says Ms Jodar. ‘We encourage them to talk to a loved one, ask their GP for advice, or contact us,’ she says.
The charities British Heart Foundation, Asthma + Lung UK, Cancer Research UK and Marie Curie UK all have helplines staffed by specialist nurses and offer many resources for individuals, including peer-to-peer support.
But Marie Curie UK medical director Sarah Holmes says it is not inevitable that patients with a terminal illness will be depressed or suicidal.
‘Depression is under-recognised and under-treated in palliative care. People often assume it’s normal for people to feel sad given the circumstances,’ says Dr Holmes. ‘But there is a difference between sadness and treatable depression. A patient with Parkinson’s disease came to see me with physical symptoms and feeling low. He said, “this is what I’ve got to face forever now. I know this condition is just going to get worse”.
‘Eighteen months on, he is loving life and that’s because we treated his depression and tackled his physical symptoms.’
Dr Holmes adds that sometimes healthcare professionals think there is not enough time to make a difference if the person has a short prognosis, but there are treatments for depression that work relatively quickly. ‘It’s important not to miss that opportunity because we don’t want to waste precious time,’ she says.
Patients with a life-limiting illness may express a ‘passive’ wish for death to come soon or say their symptoms are becoming too much. But that is different from actively planning to take their own life, though it is also a point where the patient needs help.
‘If someone talks about ending their life, it’s vitally important to ask if they have any active plans and if there is anything that is stopping them carrying out those plans,’ says Marie Curie UK medical director Sarah Holmes. ‘That way, you can put measures in place to keep that person safe.’
If a patient is actively expressing suicidal intent or you are in any doubt about their safety and well-being, then you must follow the relevant procedures in your organisation for a person at risk.
The National Institute for Health and Care Excellence has specific risk assessment and monitoring advice for healthcare practitioners about people with depression and chronic health conditions.
For patients with a life-limiting illness, it can be helpful to discuss their end of life concerns, even if they are many years from dying.
According to RCN guidance on responding to a request to hasten death, this can lessen fears that might otherwise evolve into a belief that suicide is the only way to maintain dignity and control.
Healthcare practitioners should ask patients with depression and a chronic physical condition directly about suicidal ideation and intent, as set out in the National Institute for Health and Care Excellence (NICE) guidance.
People with terminal illnesses are often remarkably resilient, but those who are in a lot of pain, have lost their independence or are in advanced stages of an illness are at risk of having suicidal thoughts.
Diagnosis itself can also be a trigger, as can a sudden, sharp decline in health.
One of the challenges for nurses and other healthcare professionals is that some of the common physical signs of depression, such as fatigue, weight changes, loss of appetite and sleep problems, may also be symptoms of the illness itself.
‘It’s important to pick up on cues that patients give about their mood and to explore that further,’ says Dr Holmes. ‘It can be difficult for people to open up. One way in is to ask them what their life was like before their illness and what they used to enjoy. Ask them what they’re looking forward to. If someone is no longer getting enjoyment from things or thinking about the future, that should ring alarm bells.’
Patience is key, adds Dr Holmes. ‘When someone is depressed it can slow down their thought processes. Allow silence; leave space for people to talk. Gently ask questions and show that you are okay to take time and hear things that might be difficult.’
Show empathy rather than sympathy, because you cannot know what someone is feeling but you can acknowledge how hard it must be for them. Gently but directly reflect back what you have heard, avoiding metaphors to clarify understanding.
A helpful video devised by consultant nurse Chris Hart and mental health nurse colleagues at South West London and St George’s Mental Health NHS Trust shows examples of poor and good practice in these kinds of conversations.
Helping or encouraging someone to die by suicide is against the law in England, Wales and Northern Ireland and carries a maximum penalty of 14 years in prison. Although there is no specific crime of assisted suicide in Scotland, it is possible that helping a person to die could lead to prosecution.
The RCN has guidance for nurses on what to do if someone asks for your assistance to die.
It is normal for people with life-limiting or terminal conditions to feel low or anxious, but not inevitable that they will be depressed or suicidal
‘Make it clear you cannot do anything that would shorten life, but neither would you do anything that is against their wishes,’ the guidance says.
‘You must ensure you document all conversations and share any insights with colleagues and other members of the multidisciplinary team.’
The guidance draws a clear distinction between therapeutic decisions made as part of palliative care, such as withholding of life-sustaining treatment (which may be lawful), and actively helping or encouraging someone to bring about their own death (which is unlawful).
The UK parliament in Westminster and the Scottish parliament are examining bills that would legalise assisted dying in specific circumstances. The bills contain proposals for an ‘opt-out’ clause, which means that nurses who strongly opposed the practice would not be obliged to participate.
The RCN has held a neutral position on assisted dying since 2014 and will soon be consulting members again to ensure it remains aligned with their views. RCN professional lead for mental health Stephen Jones says: ‘The private members’ bill that is being examined in Westminster is a highly emotive and sensitive issue, and it is right the RCN understands the opinions of its members regarding our current position.
‘We must also consider the health and well-being of our members. It is vital that appropriate psychological support is in place to address any emotional distress that a change in the law could bring about.’
» The Samaritans – for everyone samaritans.org
» The Campaign Against Living Miserably (CALM) – for everyone thecalmzone.net
» Papyrus – for people under 35 papyrus-uk.org
» Childline – for children and young people under 19 childline.org.uk
» SOS Silence of Suicide – for everyone sossilenceofsuicide.org
Things have come a long way since Ms Walton’s days as a nursing student, but suicide is still a difficult and complicated subject. Last year, one of her friends, a senior psychotherapist with terminal cancer, took her own life. ‘She left a suicide letter for me and all the therapists who knew her, explicitly detailing her thought processes,’ says Ms Walton.
‘We were grateful for her letter and respectful of her choice, but also shocked and dismayed by her suicide and deeply sad that she died alone.
‘The thing I’ve learned is that it’s crucial to support each other. As a nurse, you need lots of supervision and peer support to protect you from vicarious trauma. It’s only by looking after your own mental health that you can help others.’
Further information
NICE (2019) Suicide prevention. nice.org.uk/guidance/qs189
NICE (2009) Depression in adults with a chronic physical health problem. tinyurl.com/NICE-depression-chronic
RCN (2016) When someone asks for your assistance to die. tinyurl.com/RCN-assisted-death
South West London and St George’s Mental Health NHS Trust (2015) Video: How to undertake a suicide risk assessment in an inpatient setting. tinyurl.com/video-suicide-risk-assess
