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

2. Hello!

3. Who I am? Why am I here?

4. Roadmap

5. 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?

6. Strategies for suicide prevention Ability to distinguish “tough cases” where suicidal ideation and patient autonomy seem to overlap

7. This is relevant --even in Missouri --even with population of “older Americans”

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

9. “Older Americans”

10. “Long-term Care Settings”

11. “Suicide”

12. Decision made by individual to take their own life Indication of underlying mental illness Treatable Possible to reverse desire to die

13. Obligation to do so Fulfilling life is still possible Professional mandate

14. Elder Suicide is a significant problem TK

15. This problem is magnified in long-term care settings

16. TK article on depression

17. Why do elderly people in long-term care settings commit suicide
Why do elderly people in long-term care settings commit suicide? TK causes

18. Unity underpinning disparate causes

19. What is to be done?

20. 2) What are strategies for suicide prevention?

21. Environmental Changes TK

22. Clinical Changes TK

23. Integration with Community TK

24. Working with families TK

25. Successful interventions TK

26. Underlying assumption

27. We should prevent people who want to die from doing so

28. 3) Is there a conflict between suicide prevention and “right to die” in these populations?

29. “Right to die”

30. 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”

31. In America it is both controversial and uncontroversial

32. Controversy

33. Medical Aid in Dying (MAID)

34. 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

35. Supreme Court has left legal status up to individual states
Eight states legal
Will continue to be an issue for rest of our lives

36. There’s a lot to talk about with this!

37. Just not now!

38. MAID is largely irrelevant to this talk

39. Likely won’t become legal here in near future
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”)

40. Ethically, legally, professionally obligated to practice suicide prevention

41. But while MAID is largely irrelevant (to this talk) right to die is not

42. Refusal of Life-Sustaining Treatment (LST)

43. 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”

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

45. Individual does choose to die But not considered suicide Individual is considered competent Decision is autonomous

46. So what’s the problem?

47. 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

48. Cite Longmore Article

49. But it can also be legitimate

50. 4) How do you distinguish legitimate desire to die (via refusal of LST) from suicidal ideation?

51. Cite Erica’s article

52. Tie back to earlier points about suicide prevention

53. In conclusion
Suicide prevention by TK
Be aware of potential tension with patient autonomy in cases of refusal of LST

54. Questions