Rational Suicide in the Elderly (eBook)

Robert E. McCue, M.D. Clinical Associate Professor of Psychiatry; Program Director, Fellowship in Geriatric Psychiatry; New York University School of MedicineMeera Balasubramaniam, M.D., MPH Clinical Assistant Professor of Psychiatry, New York University School of Medicine

Contents 5
Contributors 7
Introduction 9
1: Can Suicide in the Elderly Be Rational? 12
1.1 Introduction 12
1.2 Suicide, Mental Illness, and Rationality 14
1.3 The Meanings of Suicide 20
1.4 The Paradigm of Terminal Illness Making Suicide Rational 22
1.5 Assessing Rationality in the Elderly 24
1.6 Cases and Commentary 27
References 31
2: Would This Be Rational Suicide? 33
2.1 Introduction to Mr. D 33
2.2 Criterion 1: The Ability to Demonstrate Rationality 35
2.3 Criterion 2: Realistic Information and Judgment About the Lifeworld 36
2.4 Criterion 3: Lucid State of Mind, Intelligible Emotion, and Authentic Will 37
2.5 Criterion 4: Congruence with Fundamental Values and Critical Interests 38
2.6 Conclusion 39
References 41
3: Rational Suicide and the Law 43
3.1 Introduction 43
3.2 Legal Background 43
3.3 Assisting a Suicide 44
3.4 Legalized Physician-Assisted Suicide 46
3.5 Civil Liability and Treating the Suicidal 48
References 53
4: Refractory Depression and the Right to Terminate Active Treatment 55
4.1 Introduction 55
4.2 Treatment-Resistant Depression (TRD) 56
4.3 Terminal Depression and the Case of Mr. A 57
4.4 Biological Substrates of TRD 60
4.5 Novel Antidepressant Approaches to TRD 61
4.6 Decision-Making Capacity 63
4.7 End-of-Life Decisions in Psychiatric Patients in Europe 65
4.8 Discussion 66
References 67
5: A Psychological History of Ageism and Its Implications for Elder Suicide 72
5.1 Traditional History of Ageism: The Lens of Social Gerontology 74
5.2 Psychological History of Ageism 75
5.2.1 Ageism as Rooted in the Fear of Death 75
5.2.2 Ageism as Rooted in Perception 76
5.2.3 Ageism as Rooted in How We Think 77
5.3 Implications for Elder Suicide 78
5.3.1 A Brief History of Attitudes Toward Suicide 79
5.3.2 Elder Suicide in Our Contemporary World 79
5.4 Conclusion 81
5.5 Notes 81
References 82
6: Rational Suicide in the Elderly: Anthropological Perspectives 84
6.1 Introduction 84
6.2 Suicide and Culture 85
6.3 Historical Perspectives 86
6.4 Anthropology and Rational Suicide 87
6.5 Conclusion 90
References 91
7: Life’s Meaning and Late Life Rational Suicide 92
7.1 Introduction 92
7.2 Two Questions About the Meaning of Life 94
7.3 Can a Human Life Have Meaning? 95
7.4 What Makes a Human Life Meaningful? 100
7.5 Life’s Meaning and Suicide 103
7.6 Conclusion 105
References 106
8: Baby Boomers and Rational Suicide 108
8.1 Introduction 108
8.2 What Is so Special About the Baby Boomers? 109
8.3 Attitudes Toward Youth and Aging 110
8.4 Baby Boomers and Death 112
8.5 Baby Boomers and Suicide Risk in Late Life 113
8.5.1 Social Isolation 113
8.5.2 Substance Use 113
8.5.3 Chronic Illnesses 114
8.5.4 Financial Difficulties 115
8.6 Conclusions 116
References 117
9: Who Are the Elderly Who Want to End Their Lives? 121
9.1 Definition of Rational Suicide 122
9.2 Epidemiology 123
9.3 Age and Ageing 123
9.4 Gender 125
9.5 Marital Status 125
9.6 Ethnicity 126
9.7 Religion 126
9.8 Spirituality 127
9.9 Education 128
9.10 Social Support 128
9.11 Physical Problems and Ill Health 128
9.11.1 Cancer/Malignancy 128
9.11.2 Pain 129
9.11.3 Alzheimer’s Disease/Cognitive Impairment 129
9.11.4 Sensory Impairment 130
9.12 Depression and Euthanasia/PAS 130
9.12.1 Depression/Depressive Symptoms in the Context of Medical Problems 130
9.12.2 Depression in the Context of Terminal Illness 130
9.12.3 Depression and Stability of Attitudes Towards Euthanasia/PAS 131
9.13 Personality Factors 131
9.14 Psychological Factors: Life Satisfaction and Burden on Others 132
9.15 Conclusions 133
References 134
10: Psychological Issues in Late-Life Suicide 137
10.1 Introduction 137
10.2 Psychological Theories of Suicide 138
10.3 Rational Suicide Risk Assessment 139
10.3.1 Traditional Suicide Risk Assessment 139
10.3.2 Motivational Interviewing 140
10.3.3 Self-Determination Theory 141
10.3.4 Collaborative Assessment and Management of Suicidality (CAMS) 142
10.3.5 Structured Assessments 142
10.3.6 Medical Decision-Making Capacity 143
10.4 Lessons from Psycho-Oncology 143
10.4.1 Desire for Hastened Death 144
10.4.2 Hopelessness 145
10.4.3 Burdensomeness, Helplessness, and Loss of Control 146
10.4.4 Social Support 147
10.4.5 Existential Distress 147
10.5 Practice Guidelines 148
10.5.1 Interdisciplinary Intervention 150
10.6 Conclusion 150
References 150
11: A Psychodynamic Perspective on Suicidal Desire in the Elderly 156
11.1 The Case of Ms. A 156
11.2 Theories of Suicide: Freud and Beyond 157
11.3 Revisiting the Case of Ms. A 160
11.4 Conclusion 164
References 164
12: Impact of Psychotherapy on Rational Suicide 166
12.1 Introduction 166
12.2 Motivational Interviewing 168
12.2.1 Empirical Research 170
12.2.2 Application to Rational Suicide 170
12.3 Safety Planning 171
12.3.1 Empirical Research 172
12.3.2 Application to Rational Suicide 172
12.4 Cognitive-Behavioral Therapy 173
12.4.1 Empirical Research 173
12.4.2 Application to Rational Suicide 174
12.5 Dialectical Behavior Therapy 175
12.5.1 Empirical Research 176
12.5.2 Application to Rational Suicide 176
12.6 Mindfulness and Acceptance 176
12.6.1 Empirical Research 178
12.6.2 Application to Rational Suicide 178
12.7 Existential Therapies 179
12.7.1 Empirical Research 179
12.7.2 Application to Rational Suicide 180
12.8 Psychodynamic Therapy 181
12.8.1 Empirical Research 181
12.8.2 Application to Rational Suicide 182
12.9 Interdisciplinary Collaboration 182
12.10 Practice Guidelines 183
12.10.1 Prevent Impulsive Behavior 183
12.10.2 Nonjudgmentally Explore Suicidality and Values 183
12.10.3 Cognitive-Behavioral and Mindfulness Skills Can Be Helpful 184
12.10.4 Existential Concerns are Important 184
12.10.5 Collaboration with Patients’ Systems Is Critical 185
12.10.6 Some Things Are Not Recommended 185
12.10.7 Be Mindful of Own Values 185
12.11 Conclusions 186
References 186
13: Spirituality, Religion, and Rational Suicide 193
13.1 Introduction 193
13.2 Engaging Religion and Spirituality: The FICA Spiritual History Tool 194
13.3 Religion, Spirituality, and Rational Suicide, with Focus on Christianity 195
13.4 Historical Christian Perspectives on Suicide 196
13.5 Contemporary Christian Perspectives on Suicide 197
13.6 Two Affirmations Behind Modern Christian Objections to Rational Suicide 198
13.6.1 Affirmation 1: “Autonomy” and “Rationality” Are Modern Constructions 198
13.6.2 Affirmation 2: Vulnerability Is Normative, and Christians Belong to God and to Each Other 199
13.7 Two Christian Objections to Rational Suicide 201
13.7.1 Objection 1. Suicide Addresses Suffering by Eliminating the Sufferer 201
13.7.2 Objection 2. Suicide Diminishes the Role of Community in Bearing the Burdens, and Vulnerability, of Those Who Suffer 203
13.8 Conclusions: Practical Recommendations for Clinicians 206
References 207
14: Classic Psychedelics and Rational Suicide in the Elderly: Exploring the Potential Utility of a Reemerging Treatment Paradigm 209
14.1 Introduction 209
14.2 Sociopolitical History of Classic Psychedelics 209
14.3 Empirical Findings with Classic Psychedelics: Implications for Rational Suicide 211
14.4 Conclusion 214
References 214
15: Epilogue 217
Index 224