Excerpt from Facing Death: Finding Dignity, Hope and Healing by Jim deMaine
Beyond the protocols for Medical Assisted Dying (MAID) and Voluntary Stopping Eating and Drinking (VSED), some argue that suicide may, at times, be rational. This is a difficult subject for me. Two of my friends killed themselves with handguns in recent years. One had a failing business venture. The other likely had a poorly managed manic-depressive disorder. In retrospect, it is clear that both of my friends had shown warning signs of depression. (The main risk factors for senior suicides are depression, debility, access to deadly means, and disconnectedness, known as “the four Ds.”). The scars left behind after deaths like these remain deeply imbedded in the psyches of surviving families and communities—a painful legacy.
Suicidal gestures are highest for young adults undergoing a crisis. But suicide rates are increasing across all age groups, particularly among the elderly, who commit suicide with a frequency more than four times the age-adjusted national average.[i] Suicide is now the tenth leading cause of death[ii] in the United States, more than double the number of homicides.
Suicide is always tragic and often preventable. But can it ever be rational? Kaiser News reports that small groups of seniors meet openly to discuss this question.[iii] A few hundred seniors each year commit suicide when transitioning either to or from long-term care facilities. It’s unclear how many were clear-headed when they made this choice. But it appears they wanted to be able to end their lives when circumstances came to feel unbearable. Among the elderly a major concern is the fear of progressive dementia, or an illness, that will seriously limit their ability to enjoy living—even if their disease is not terminal. “Heck, I’ve lived a full life. I’m basically falling apart,” they say. “There’s nothing to look forward to so I’m ready to die.”
This concept of “rational suicide” is worrisome to me. Dr. Yeates Conwell,[iv] a psychiatrist at the University of Rochester and leading expert on elder suicide, feels that widespread ageism is particularly dangerous in this regard. If ageism begins to normalize suicide among the elderly, it will profoundly change the way we look at aging and dying.
But then there are depictions of this struggle through films like Amour. If you haven’t seen it, I hope you get the chance. Amour starts and ends with love, but not in the usual, youthful fashion of a Hollywood romance. It focuses on death after a life of love, longtime care, and, finally, suffering.
The story begins in the apartment of two aging musicians. As the wife suffers a series of strokes, her mind and her will to live erode. Her life becomes agonizing, and her caregiver husband is exhausted. This painful circumstance, common to many real-life couples handling illness on their own, was dramatized so beautifully that Amour won the 2013 Academy Award for Best Foreign Language Film.
Was it reasonable for the wife to attempt suicide? Was it OK for her to make her husband promise never to take her back to the hospital? Could the couple’s daughter have been more supportive? What happens as the loving caregiver is finally at wits end? Amour left me full of lingering questions about the choices this couple made, yet admiration for the love between them as they navigated the process of dying.
In real life, sadly, the death of an elderly couple can be violent and abrupt. Not long ago, in a Seattle nursing, two residents in their nineties were found dead in their apartment, both from gunshot wounds, in an apparent murder-suicide. About twenty older Americans die in this manner each week in the United States, according to estimates.[v] I see nothing loving in those situations. Typically, a controlling husband shoots his wife in her sleep, then turns the gun on himself. There is often a history of domestic abuse. Most commonly, the underlying issue is depression. Families, physicians, and caregivers need to be on alert and unafraid to ask about mood changes and suicidal thoughts. There is no easy solution, but we can all reach out and, if there are concerns about potential self-harm, call 1-800-273-TALK (8255).
There certainly are actions that physicians and loved ones can take to help before things get that dire. We need to address loneliness, depression, spousal abuse, cognitive changes, and housing stability for the aging. We need to better ensure access to caregivers and loved ones. In my own retirement community, a friend observed, “I’m sure we live longer and happier lives here because of our connected community of people.” I believe this is true.
To my mind, the concept of rational suicide remains nuanced; it is certainly not black or white. For those who are not terminally ill, choosing VSED could be seen as an example of rational suicide, as it is a conscientious decision to stop eating and drinking made not out of depression or other mental illness, but as an option against enduring a deteriorated quality of life. For the terminally ill with severe suffering, I consider MAID a rational response, as long as patients are screened for mental health and legal safeguards are in place.
Both MAID and VSED remain uncommon although their rates are increasing. As death nears, it’s not uncommon for a patient to state: “I want no more pills or fluids or food.” This is likely much more common than reported. With the advent of hospice and palliative care, most of us will die naturally, hopefully without great discomfort, and ideally in a manner that allows for healing and a positive legacy for those we leave behind.
[i] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5916258/
[ii] https://www.cdc.gov/nchs/fastats/leading-causes-of-death.htm
[iii] https://khn.org/news/suicide-seniors-long-term-care-nursing-homes/
[iv] https://khn.org/news/rational-suicide-seniors-preemptive-death-medical-aid-in-dying/
Thanks Jim – so very well written. I am interested in talking points for conversations with someone who may be considering suicide but is not telling his loved ones. (Nor sharing with anyone else likely.)
A few years ago, I spent three days with my brother, traveling to visit relatives . His poor health was not the reason for our travel, but we discussed long term options along the way. He had just had two diagnoses of mild cognitive impairment – an obvious euphemism for dementia to all who were close to him. While I prattled on about the state of long term care, the prospect of my brother contemplating suicide was unthinkable, and not mentioned.
Three months later he took his own life – with no warning, according to his relatives. I wish I had been more circumspect as to the possibility of suicidal thoughts (plans?). His memorial service was an immense tribute to the communicator he had been in life. But those of us left to mourn would have fared so much better to not have the words “died unexpectedly” ringing in our ears ever since. We needed the words to say BEFORE the unexpected played out, as now happens increasingly.
Sylvia