Right to Die and Suicide Prevention in Older Populations Harold Braswell Assistant Professor Health Care Ethics Saint Louis University

Hello!

Who I am? Why am I here?

Roadmap

Why do elderly people in long-term care settings sometimes want to commit suicide? What are strategies for suicide prevention? Is there a conflict between suicide prevention and “right to die” in these populations? How to practice suicide prevention while being mindful of patient autonomy at the end of life?

Strategies for suicide prevention Ability to distinguish “tough cases” where suicidal ideation and patient autonomy seem to overlap

This is relevant --even in Missouri --even with population of “older Americans”

1) Why do elderly people in long-term care settings sometimes want to commit suicide?

“Older Americans”

“Long-term Care Settings”

“Suicide”

Decision made by individual to take their own life Indication of underlying mental illness Treatable Possible to reverse desire to die

Obligation to do so Fulfilling life is still possible Professional mandate

Elder Suicide is a significant problem TK

This problem is magnified in long-term care settings

TK article on depression

Why do elderly people in long-term care settings commit suicide Why do elderly people in long-term care settings commit suicide? TK causes

Unity underpinning disparate causes

What is to be done?

2) What are strategies for suicide prevention?

Environmental Changes TK

Clinical Changes TK

Integration with Community TK

Working with families TK

Successful interventions TK

Underlying assumption

We should prevent people who want to die from doing so

3) Is there a conflict between suicide prevention and “right to die” in these populations?

“Right to die”

Ability of individuals to voluntarily end their lives with medical assistance This can be interpreted in very different ways in many different countries What “individuals” What is “medical assistance”

In America it is both controversial and uncontroversial

Controversy

Medical Aid in Dying (MAID)

MAID Prescription of life-ending substance to terminally ill individual who has requested it MD prescribes, individual ingests Not considered a “suicide”— “natural death” Exempt from suicide prevention

Supreme Court has left legal status up to individual states Eight states legal Will continue to be an issue for rest of our lives

There’s a lot to talk about with this!

Just not now!

MAID is largely irrelevant to this talk

Likely won’t become legal here in near future Why irrelevant? Likely won’t become legal here in near future Location (Missouri) Even if did would not apply to majority of individuals who are subject of this talk Population (“Older Americans”)

Ethically, legally, professionally obligated to practice suicide prevention

But while MAID is largely irrelevant (to this talk) right to die is not

Refusal of Life-Sustaining Treatment (LST)

Refusal of Life-Sustaining Treatment (LST) Individual asks to be removed from treatment that is keeping them alive Die as a result Cause of death considered underlying disease “Natural death”

Refusal of life-sustaining treatment is legal everywhere Can apply to older Americans

Individual does choose to die But not considered suicide Individual is considered competent Decision is autonomous

So what’s the problem?

Refusal of life-sustaining treatment can be an expression of suicidal ideation Should be treated as mental health issue In such cases, decisional autonomy would be impaired

Cite Longmore Article

But it can also be legitimate

4) How do you distinguish legitimate desire to die (via refusal of LST) from suicidal ideation?

Cite Erica’s article

Tie back to earlier points about suicide prevention

In conclusion Suicide prevention by TK Be aware of potential tension with patient autonomy in cases of refusal of LST

Questions