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

2. Hello!
Who I am, and why I am here

3. 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?

4. 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”

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

6. “Long-term Care Settings”
“Suicide”
“Older Americans”
“Long-term Care Settings”

7. 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

8. Elder Suicide is a Significant Problem
TK (article on depression) This problem is magnified in long-term care settings

9. Why do Elderly People in Long-Term Care Settings Commit Suicide?
Unity underpinning disparate causes

10. What is to Be Done? What are strategies for suicide prevention?
Environmental Changes
Clinical Changes
Integration with Community
Working with Families

11. Successful Interventions
(TK)

12. Underlying Assumption
We should prevent people who want to die from doing so Is there a conflict between suicide prevention and “right to die” in these populations? “Right to Die”

13. 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

14. Medical Aid in Dying (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

15. There’s a Lot to Talk About With This!
Just not now!
MAID is largely irrelevant to this talk

16. 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

17. But while MAID is largely irrelevant (to this talk) Right to Die is not

18. 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”

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

20. If an Individual Does Choose to Die…
But not considered suicide Individual is considered competent Decision is autonomous …So what’s the problem?

21. 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

22. Cite Longmore Article But it can also be legitimate

23. How Do You Distinguish Legitimate Desire to Die (via Refusal of LST) From Suicidal Ideation?

24. Cite Erica’s article
Tie back to earlier points about suicide prevention

25. In Conclusion…
Suicide prevention by TK Be aware of potential tension with patient autonomy in cases of refusal of LST

26. Questions