There is a lot of discussion about the right to die. Although most of these have to do with Physician Assisted Death (PAD). What about in those who are not dying but express a dire to end their lives in the absence of a diagnosable mental illness? Do they have the same right? Well, on today's podcast we are going to step into this tricky topic with our guest, Dr. Meera Balasubramaniam, a Geriatric Psychiatrist from NYU.
Meera wrote a paper for JAGS titled "Rational Suicide in Elderly Adults: A Clinician's Perspective". We talk with Meera about her article, including how she would define rational suicide, how can we help best explore these thoughts that patients consider rational, and how society and baby boomers are changing the way we think about this. We also dive into some other interesting topics include agism. I really love this quote from Meera, so I'll post it here, but for the full transcript read below or listen to the podcast:
Ageism is a very interesting and distinct concept. It's fear of growing old or fear of being in that state. It's so distinct from something like racism or sexism. If a person is racist about a certain other race, it's less likely that they are going to be part of the other race that they are having negative connotations about. Similarly, if you are sexist, it's less likely less likely that you are going to belong to the other gender. When it comes to age, it's quite fascinating that most of us are actually going to get to that stage that we're being ageist about. What it is about growing old and about being down in the future that scares most of us has been sort of the crux of part of my work from a society perspective.
by: Eric Widera (@ewidera)
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Eric: Welcome to the GeriPal Podcast. This is Eric Widera.
Alex: This Alex Smith.
Eric: Alex, who is our guest today?
Alex: Today we have Meera Balasubramaniam who is from NYU where she is Geriatric Psychiatrist, and she wrote a paper for JAGS titled "Rational Suicide in Elderly Adults, A Clinician's Perspective". Welcome to the GeriPal podcast Meera!
Meera: Thank you!
Eric: Before we get into the topic of rational suicide, we always start off with a little song. Do you have a request for Alex?
Meera: How about Bob Dylan's "Don't Think Twice"?
Alex: Terrific. The lyrics are sort of appropriate. We're just going to do a snippet of it at the beginning, and we'll have the complete song, or more of it, at the end.
Meera: Sounds good.
Alex: Just a little taste.
Meera: Thanks so much.
Alex: And more at the end.
Eric: Thanks for joining us, the topic of rational suicide. Before we get into the meat of what you talked about in the JAGS paper, how did you get interested in this as a topic?
Meera: Sure. I'm a geriatric psychiatrist, and in the context of my clinical encounters, I started coming across and hearing about a number of older adults. Many of them were in their late 80s, early 90s, and in the context of their interactions they would talk about, "You know, I've had a good life. I've lived well. I'm healthy. I'm relatively independent, and I think it's time for me to go. I don't want to be in a state where I'm bedbound or dependent on other people or have to go back and forth from nursing homes".
Now, for me as a psychiatrist, I found myself in a conundrum. On one hand, yes the idea of wanting to end their lives and suicide was clearly disturbing to me. But on the other hand, many of these individuals did not have a diagnosable mental illness. They did not appear clinically depressed. They did not have a psychotic thought process. Many of them were not even significantly cognitively impaired.
At that point in time, I started wondering, are we capturing a new clinical diagnosis? Is this something that doesn't exist in the DSM? Is it a problem with the nosology or are we going to increasingly encounter people like these as the life expectancy continues to increase?
The more I thought about it, I realized that there is not much out there in the literature in terms of how to proceed working with these individuals. How can I be of most help to them in sorting through any ambivalence they have or in helping them define their death wishes. So, that's how my interest in this topic took shape, from actual clinical encounters.
Eric: When we talk about rational suicide, can you just give us your working definition of what that is.
Meera: Sure. Just circling back a little bit, when I started thinking more about this topic as a psychiatrist, I think my goal was not primarily to determine if suicide can be rational or it cannot be rational. In fact, the term, "rational suicide" was told to me by some of my patients who insisted that their thoughts were rational, that their ideas of wanting to end their lives were purely rational, whereas I found myself debating if suicide can, indeed, be rational. A little bit more of digging into the literature gave me some cursory definitions like it meant the person should have a clear and coherent reasoning. There should be consistency. They should have realistic information and judgment about the life world. They should be in a lucid state of mind. Their death wishes should be congruent with their fundamental values.
But you know for each of these criteria, I found that it's never clear cut. For example, having realistic information, that can be debated. Is it that they're having anticipatory anxiety? For the example of the person I mentioned, "The idea that I'm going to be nursing home-bound. The idea that I'm going to be bedbound". None of these have happened to her. Yes, they are realistic, but none of them have actually happened. Are we dealing with someone who is anxious about something that has not happened? Would that be amenable to further investigation and treatment or is the fact that she is 91 today and having these thoughts like fairly consistent with what's happening to others of her age? I found myself feeling that what's out there in terms of definition of rational suicide is actually inadequate.
When I started working on this topic, my goal was less to define rationality and more to understand how can we help best explore these thoughts that patients consider rational.
Alex: It's interesting, this idea that you mention that older adults may think they have the information, but they haven't actually had the experience and that once they have the experience, they may well adapt to what they previously consider to be adverse circumstances, living in a nursing home, dealing with immobility, dependence on other people, the need for caregiver support. These are all things that many people fear but that once they enter those situations and are actually experiencing them, often adapt to. I think you're bringing up a really key point here about ... Some of this actually gets into society's portrayal of what it is like to be in that state, quality of life judgments about states of disability, dementia, etc. Is that sort of part of what the story is here with rational suicide?
Meera: Absolutely. I think how we as a society view the idea of growing old, how we view the idea of death, I think they have a lot to do with how older adults view the idea of themselves 10 years down the line. Over time this has changed, as I wrote in my article, as well. Ageism is a very interesting and distinct concept. It's fear of growing old or fear of being in that state. It's so distinct from something like racism or sexism. If a person is racist about a certain other race, it's less likely that they are going to be part of the other race that they are having negative connotations about. Similarly, if you are sexist, it's less likely less likely that you are going to belong to the other gender. When it comes to age, it's quite fascinating that most of us are actually going to get to that stage that we're being ageist about. What it is about growing old and about being down in the future that scares most of us has been sort of the crux of part of my work from a society perspective.
Eric: That's fascinating. I never thought about that before.
Alex: Yeah, I'd never thought about that way either. It separates ageism from sexism and racism.
Meera: Yes, but as a society we tend to view good health. We tend to view the idea of being young, the idea of being vital. So, using a walker, having to use somebody's help are all considered sort of negative, and we grow old with these notions, so it's understandable that as a 75 year old, somebody is going to be concerned about being in that state when they've been ingrained to that notion that being dependent or using assistance or having to acclimatize to a slightly different state of being is quite negative.
Eric: You also describe a little bit about some other influences including the baby boomer generation in your article. Can you talk a little bit about that.
Meera: Absolutely. I think it's critical to understand more about the baby boomer generation because most of the patients who we are going to come across us geriatricians or geriatric psychiatrists are going to be people that belong to the baby boomer generation, so as we know, baby boomers are people who were born between the time of 1940s and early 60s or so. These are individuals who form a large chunk of the US population today.
Now, the reason I talked about it in the form of a generation is because social events as we're growing older tend to inform our individual and societal notions. So, why baby boomers? This was the generation that, say, saw the end of the Vietnam War. They had more exposure to sexual freedom or the use of drugs. As a group, they were a little bit more different from the cohort that was before them. They have a sense of sort of mistrust in authority. They have a greater reliance on, say, the need for control. They place a greater importance on independence.
In terms of how they're doing today, this is the group that is, say, less likely to be married compared to their predecessors. They are more likely to be living alone. This was the group that has more individualistic notions of death in the sense that, "You know, I want it this way. It is not as though death comes upon me. Partly, it's death coming upon me, partly, I want death to look like this for myself."
Historically, I found it interesting that the group, which was more open to experimenting with drugs, now we're exposing them to increasing use of analgesics and benzos. So we're dealing with a population that probably socially somewhat more isolated than people before them, greater reliance on ... Greater emphasis on individualism and control and also greater access to means for ending their lives.
With this kind of cohort in mind, how is the notion of death going to look, say, now and in the next 20 years? I think it remains to be seen, but we're also going to find ourselves increasingly encountering people like the patient I mentioned in my paper who wanted to end his life on his own terms.
Alex: I love the way that you present this article. You start off with a case much like one of the cases that you described in the beginning of this podcast and then you talk about all of the many influences that brought this person to this point including, as you just mentioned, the fact that this person's a baby boomer, he's 72 years old, former businessman. You talk about contemporary society and the historical context, who this person is as a patient, aging and bodily changes, relational changes. I wonder if you could speak more ... We've talked a little bit about the baby boomer, and we've talked a little bit about some of the historical context. Are there other of these factors that you think it's important to really draw out for our listeners here, that might influence the patients they're seeing towards expression of desire for suicide?
Meera: Absolutely. I think in addition to the more societal factors, what we need to talk about are the quality of one's relationships as well as how one is acclimatizing to the process of aging. Both of these are significant, but I don't think we stress upon them enough in the context of evaluation or in the context of thinking about people, leave alone patients. One important aspect to discuss is the relational aspect. Shneidman, who is considered the father or suicidology, he described suicide in the form of dyadic event. There's always the other. It's imperative that in the context of an evaluation or even while talking to an older person about death, it's important to try to understand who the others are in their lives. As a psychiatrist, I've always found it helpful to ask my patients, "Who are the people in your life?" It's a very broad question, but the answers are often quite enlightening.
A few things that come to mind here would be, "What is it like for this person to grow old, and how has that impacted their relationships?". A few things of relevance could be, has it affected friendships? If this was someone who thrived on having coworkers and having people report to them, what's it like to have that missing in one's life?
I've come across patients in whom there's a very different or very disparate process of aging so the husband and the wife might just have an age difference of two or three years, but they come into your office and one of them looks so much more old and frail. This may not be subconscious, may not be consciously expressed or verbalized, but it's something to keep in mind, like what's it like for 80-year-old Mr. X to feel like he is functioning at a level that's 10 years older than Mrs. X who is actually just 78. Similarly, what's the quality of adult relationships with their children?
One important distinction to make is the actual support versus the perceived support. In some instances, the actual support may not be very great, but when you ask someone, "Do you feel well supported?" They may actually say, "You know what? I'm fine. I feel well cared for and this is what matters to me". Whereas certain others you might get the semblance that the entire family is coming with them for the visit and they seem very invested, but when you ask the individual, they may feel like, "You know, I don't feel well supported. All these people are wanting to be a part of my life, but I just feel like I'm alone all the time".
I think drawing the distinction is quite important, and we fail to miss that in the context of when we actually see patients and families or interact with them.
Alex: You touched on something, I think, critically important here, well several things. In that last comment about relationships and the importance of relationships and how we exist in relation to others. There seems to be a theme here about loneliness and isolation and getting back to societal causes of the desire for suicide or expressed wish for suicide. It seems that there are trends towards more and more older adults living alone and dying alone, being isolated from family and friends. That might be part of kind of the social underpinnings of why we're seeing an increase in these requests as geriatricians.
Eric: Can I go back to the ageism aspect of this? There was an accompanying editorial called "Social Causes of Rational Suicide in Older Adults," by Liz Dzeng and Steve Pantilat. In the end of their article, they say, "Acceptance of the idea of rational suicide in older adults is in itself ageist. It implicitly endorses a view that loss is associated with aging resulting in a life that is not worth living." I want to hear your thoughts. Would you agree with that statement?
Meera: I think yes, and my opinion is that the idea of rational suicide it ought to be complex, it ought to be challenging because I think we're not being fair to our older adults if we either completely agree or completely disagree, and I can elaborate on that. For example, if we were to say suicide in the older adults can be rational. If people are tired of living, they ought to have the right. We are setting ourselves up for a slippery slope from, say, euthanasia to physician-assisted death, which involves death in the case of terminal illness, to now people who are old and weary of life. We think, okay, they need to have the right to die, but it's only going to be a matter of time before an age of society transforms the right to death into a duty to die where someone who is old and likely to require assistance from others, there's this expectation that this person needs to make this decision. I absolutely caution against hastily making this judgment of rational suicide in the elderly.
That being said, if we are conclusively saying that rational suicide in the elderly cannot exist, it's irrational. This person ought to be mentally ill. If we are to adopt that stance in a more strict and stringent way, we may be at risk of shutting down some of our older adults who want to talk to us about the sense of ambivalence they have about life. My take as an individual clinician is to position myself in a place of curiosity. We need more research in this area to try to understand what it's like to grow old, what it's like to be dependent, what it's like to have this anxiety about what's going to happen. We need to hear about it from people who are in that place. We're far, far away from that position of saying rational suicide can exist as an entity or it cannot. I think at this point what we need to do, though, is we need to start actively thinking about it. We need to start confronting it because our patients have started talking about it, so we cannot be lagging behind them which would be a disservice to them.
Alex: I wanted to push a little bit to talk about initial steps that clinicians should take when a patient expresses a desire…an older adult comes to them who does not have a terminal illness and expresses a desire to commit suicide. What are the first, sort of off the top of your head, questions or domains that the clinicians should address in this case. And is this something that geriatricians and primary care physicians can handle on their own and at what point should they consider referral to a psychiatrist or geriatric psychiatrist for assistance?
Meera: Great question. From my perspective, when there's a mention of death or when an older adult says, "You know, I'm tired of life, and I've been thinking about death". One important thing to remember is that the desire for death exists along a very wide spectrum. It can be, on one hand, the wish that death should come soon, or it can be a curiosity about what death is going to look like or it can be fleeting thoughts of what it's going to be like if "I was dead," or actually making a plan to end their lives and having made attempts and active measures to end their lives. First of all, it's important to remember that just because someone mentions death, it doesn't mean that they're going to commit suicide the very next day. I think we have to be attune to the idea of a spectrum.
The second thing to remember is as clinicians we should not be fearful or concerned about having these discussions. It's only imperative that we show curiosity, a certain open mind and compassion while having these conversations. If somebody was to come to me and say, "You know, lately I've been thinking about death," my approach should be, "Yes, let's talk about it. What about death have you been thinking? What is it about your life that you want to end? When you think about death, what questions or images come up for you? Have you been actively talking about, thinking about ways to end your life? If you have been thinking about ways to end your life, what's come in the way of following through on those plans?".
In my experience, that question can be really enlightening because if someone says, "You know, I have been thinking about overdosing on my pills”, and if you ask them, "Why haven't you followed through on it?" and if they say, "It's because the minute I think about it, I think about my grandchild. I think about my wife. I think about my son. I think about this friend". This gives you an idea that this person already has many people or many protective factors. But if they were to say, "You know, I didn't overdose on these pills because I was out of pills. I didn't have the money to go and buy them", that would be someone you should be a little bit more concerned about.
Then if someone says, "You know, I want to die because the idea of being wheelchair bound or the idea that it takes me five minutes to walk from one corner of my apartment to another is really sad for me. It's really crippling for me" then that gives you some hooks to explore further.
In terms of your question about can geriatricians handle these alone or should be referred to geriatric psychiatrists, I think one rule of thumb is if anything makes you uncomfortable, it's fine to take help. Never worry alone. That is, I think, a general dictum for any clinician. I do think as geriatric psychiatrists or a psychiatrist we are trained to deal with more ambivalence to explore in depth about some of these aspects, but treatment works best when there's a bind from the individual concerned. I think for a geriatrician it might be important to say, "You know, what you're saying is important and what you're going through is something that a lot of people go through. I think there might be value in talking to a geriatric psychiatrist, someone who's trained to talk with you about these elements. Would you be interested in that?". These would be some general, some broad strokes that I hope would be helpful.
Alex: That's very helpful. I wonder also ... Maybe I'll just summarize that, if I could. First step is to evaluate what is the immediacy of this request? Do they actually have a plan and intention? Are they going to do it tomorrow? Or is this sort of a other end of the spectrum, a general musing about something that may or may not occur in the future? Then, taking an attitude of curiosity, being nonjudgmental and comfortable with what may be a very ambivalent position for them. Third, really asking a whole range of open-ended questions to try and understand the context in which this request comes up. Does that sort of capture?
Alex: I wonder if you could say something as a clinician what it's like for you. I'm sure you've had patients who have committed suicide. What is that like for you and are there some times when you know a patient is going to commit suicide or might be committing suicide but you don't have enough to, say, commit them to the hospital? What is this like for you as a clinician to experience this with your patients?
Meera: That's a great question. I think as a psychiatrist and as someone who trained to be one, along the way I've heard in the field that psychiatrists can be divided into two categories. The first category is those who have lost patients to suicide and those who will lose patients to suicide. Suffice to say that this is not uncommon, sadly not uncommon for psychiatrists to go through this. When one experiences this, it brings up a whole gamut of emotions, a sense of helplessness, a sense of guilt. You find yourself thinking about, "What could I have done differently? Is there something I could have done for this person?". Something to remember during these stages is to seek support, is to talk to someone who's gone through this and to never worry alone. One other thing to remember is it always helps to talk to families, convey your sense of loss. That goes a long way in reestablishing a place of trust.
What was your second question? Sorry.
Alex: I think that answers my question and what does this feel like going through this experience as a clinician when your patient ... I can imagine it must be so sad knowing that your patient might be committing suicide and feeling like, as you said, "I wish I could have done more".
Meera: I want to actually circle that back. What I mentioned about feeling guilty, feeling helpless, it translates more when you actually already lost a patient to suicide. But if you're dealing with someone who you're concerned may be at risk of ending their lives, my recommendation would be to tread on the side of caution and to encourage them to get hospitalized or to be in a more supportive setting. If you're in a position where you feel like someone is about to end their lives, I wouldn't recommend sort of sitting on it. I would definitely recommend taking a more cautious approach. If the hospital is not willing to admit them, then certainly taking the buy in of another colleague, making sure they get a second opinion, I think those steps are absolutely important, but I would never recommend not doing anything when you feel like someone is at high risk for ending their lives.
Alex: One last question here. It seems to me that there are things society should be doing to counteract this trend, this concerning trend towards increased request for suicide that we're seeing clinically in that we have more to do to combat ageism, to increase mechanisms that provide social support for older adults who are increasingly feeling disconnected, to improve quality of life, to depict images of older adults who are disabled, and so we have positive messaging around aging rather than the constant bombardment of aging is to be avoided and the worshiping at the altar of youthful culture.
Meera: Absolutely. I think the changes have to be brought about both at a conceptual fundamental level as well as the more instrumental level. The conceptual changes would be some of those you mentioned in terms of not portraying growing old as something that's necessarily negative or doing aging in a more potentially positive light. The more instrumental logistical changes we can make would be to do very tangible changes like improving the condition of assisted living facilities and nursing homes or making the hospital experience a little bit more personalized for the older adults, if possible. I think one of the fears of going to a nursing home, part of it is actually the experience of what nursing homes look like today, despite best efforts. If as a society something could be done in terms of funneling more funding or improving their condition, I think that may go some ways in altering this experience of being under the care of a nursing home.
Eric: Ya and I really like in Liz Dzang and Steve Pantilat's paper, they also talked about combating loneliness, giving examples of the campaign to end loneliness in the UK, that combines both research, education and outreach for older adults.
Meera: Absolutely, and there have been efforts. I think the UK is definitely at the forefront of that, but even in the US there have been organizations that are coming up lately that are talking more about the issue of loneliness. In fact, I recently heard about a group called Clatch which is an upcoming startup which is talking about some sort of meetup.com specifically for older adults where you have this select group of people that are interested in it and then they have a bunch of activities to choose from and the idea is to have a cohort of people who are engaging with each other in activities that they find meaningful. I do think aging should not just be associated with being informed with being alone and being dependent. It may involve redefining of notions but, hey, I think it's certainly possible to get there.
Eric: Last question on my end is that in the paper you describe a case of Mr. A who is a 72 year old who had a request for suicide despite not being terminally ill. What actually happened to him?
Meera: Yeah, great question. Mr. A, as I describe in the paper, said that, "You know, I don't want to have to go through the scare of coming repeatedly for appointments knowing if my cancer is going to recur. Instead, I'll just end my life, and it's about time". Then psychiatry was consulted, that's when my team and I had a chance to speak with him. What we noticed was a sense of ambivalence. Yes, being independent, being healthy was part of his fundamental views that he's long had, but there's also the sense of ambivalence because if he was sure about this, he may not have mentioned this in a very unsolicited way. So, a longer conversation with him showed that this was someone who has been thinking about this, was also more open to discussing it, so he was referred to a psychotherapist in the community. From what I last heard, he is continuing to see this therapist. He is alive. He is attending his appointments. The cancer hasn't recurred. He is now at least a year older from the time I wrote the paper, but alive and well.
Eric: Wonderful. Well, I want to thank you for joining us for this podcast.
Alex: Thank you so much, Meera.
Meera: Thank you! It was my pleasure.
Eric: Alex, do you want to send this off with a little bit more of a song?
Alex: Sure. A little bit more of "Don't Think Twice, It's All Right". I think this song is actually about a breakup, but you could think about it as somebody who might be committing suicide, maybe? I don't know. Think about it as you listen to this. [Singing]
Eric: I want to thank all our listeners for joining us for this podcast. We look forward to our next podcast next week.
Alex: Bye folks.