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Suicide
Few patients with cancer commit suicide, but poorly controlled pain places them at increased risk. Table 23 and Table 24 list factors that predispose cancer patients to depression and increase risk of suicide.
Although fleeting or occasional thoughts of suicide probably occur commonly in those with advanced illness, persistent and intense suicide thinking is rare in the absence of depression or of uncontrolled physical symptoms such as pain.61 Suicide is often held as an option by the patient to sense of control. Fear of unacceptable pain was a major component of requests to physicians for assisted death200 and is so important to patients with cancer that 69 percent reported that they would consider committing suicide if their pain was not adequately treated.282 In another study, the majority of patients who committed suicide had severe pain that was inadequately controlled.53 Clinicians in a pain clinic report seeing many patients who considered suicide who changed their minds once given adequate pain relief.134 For at-risk patients, clinicians should be aggressive in the use of analgesics and other appropriate drugs as well as crisis intervention-oriented psychotherapeutic approaches that mobilize the patient's support system.
Although it is appropriate to intervene when medical or psychiatric factors are clearly the driving force in a suicidal cancer patient, overly aggressive intervention may be less helpful in patients with advanced illness when comfort and symptom managemen are the primary concerns. As an alternative to suicide, the goal of intervention should be to establish rapport, to develop an alliance, and to provide effective management of symptoms.
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