Navigating Suicidality in Palliative Care: A Multi-dimensional View

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From being just a specialty to being an emerging field in care provision, and to now having specialist and sub specialties, palliative care has come a long way from the hospice movement back in 1980’s. (Salins et al., 2022). Palliative care addresses suffering beyond the physical symptoms and includes caregivers and the treating medical team under its ambit. Unlike the myth that palliative care is only for cancer or HIV/AIDS, the definition and inclusivity offered by palliative care is unmatched from cardiovascular (38.3%); cancer (34%); chronic respiratory disease (10.3%), AIDS (5.7%) and diabetics (4.6%) patients seeking palliative care support globally (WHO).

The broadening of care from the biomedical model into the bio-psycho-social-spiritual-sexual-financial model has nudged the seeping of mental health services into palliation (Farre & Rapley., 2017). September commemorates world suicide prevention month and hoists us towards hope when we are unable to see it and brings realistic hope to those seeking it. Understanding some of the triggers and the ways in which individuals incline towards suicidality and how its impacts the caregivers will be dealt with in this article.

Well, the question remains, “If they are already diagnosed with a life limiting / chronic illness, then why would they want to hurt themselves?”

The answer to this question has been beautifully illustrated by the NCCN, Distress Thermometer, which highlights the aspects that could influence or trigger any individual diagnosed with an incurable illness. These triggers are multimodal and these patients experience higher rates of distress (Leung et al., 2013). There are however 3 parts to how the suicidal ideation escalates; from death ideation, to suicidal active ideation, to finally suicidal behavior (Sveticic and Leo, 2012). We, as health care professionals could use the well validated Socratic method of questioning, and probe gently into the thoughts, feeling and behaviors of our patients and caregivers to gain a better understanding of their ideations (Van et al., 2013).

Enlisted below are a few warning signs and triggers exhibited by patients who might be suicidal:

  1. Unbearable pain or physical symptoms of pain
  2. Loss or perceived loss of autonomy
  3. Gradual or sudden reduction in quality of life
  4. Heightened distress (physical, social, financial, sexual, spiritual)
  5. Existential crisis or loss of faith
  6. Being withdrawn and giving away precious possessions
  7. Speaking of ending, closure or washing hands from responsibilities
  8. Overwhelming sense of helplessness and hopelessness
  9. Feeling of being dependent or a burden on their families
  10. Depression, anxiety, fear and other overwhelming feelings

Whether heard or observed subtly, or in the most obvious forms or methods, immediate action for safety planning must be done and openly kept instruments must be removed and well hidden under lock and key.

Medical and nursing curriculums are gearing up to offer communication skill trainings as a part of their training. Additionally, we must keep upgrading and learning continuously to keep ourselves abreast to bridge the gap between mental and physical wellbeing.

Below are a few strategies or simple guidelines to help us remember and act immediately to address the ideation and to reduce the implementation of these thoughts by our patients / caregiver.

  1. Create open communication channels: Support and encourage patients / caregivers to express their inner fears, thoughts, apprehensions, and confusions uninhibitedly
  2. Conduct regular screening: Nurses and medical care providers can use the distress thermometer (DT) everyday as a check-in and as an indicator to screen patients for suicide risk (Chiang et al., 2022).
  3. Create intradisciplinary teams: Integrate psycho-social care providers into the team to build robust mechanisms to recognize distress and provide immediate assistance and support
  4. Provide adequate symptom management: Another significant way to reduce the risk towards suicidality or ideation is effective pain management, ensuring adequate sleep, maintenance fair score on appetite scale, and management of other symptoms such as bowl obstruction, foul smell, oedemas, and fluid retentions will certainly alleviate distress
  5. Offer Psycho-oncologist interventions: Providing psychological care as a part of holistic wellbeing from the beginning allows for the patient-caregiver-health care team to receive timely interventions, strengthen coping strategies, and improve the overall wellbeing and quality of life for everyone involved in care provisioning and care receiving.

Caregivers also need to be cared for as they are the decision makers, care providers and the link between a patient and the health care team. Most often, caregivers make difficult choices as the patient’s choices could be dynamic and fluid. Caregivers therefore end up experiencing distress which is similar to their loved ones (except for the physical symptoms and their illness perceptions), resulting in their own health issues and reduced quality of life (Bijnsdorp et al., 2021).

These caregivers also go through phases of depression, anxiety, insomnia, and restlessness along with caregiver distress, burden and burnout, which often goes unaddressed as the focus is purely on the patient (Antony et al., 2018). It is important to note that caregivers need to be supported beyond just palliation extending into bereavement also. A few caregivers never recover from the loss of their loved ones, resulting in the need for continued psycho-social support and a safety planning exercise to avoid suicidality amongst them as well. A caregiver’s lived experiences also alters their perspectives, perceptions and outlook towards life and also brings with it some permanent cognitive changes into their lives (Bijnsdorp et al., 2022).

To conclude, integrating psychosocial care within palliative care allows one to address distress, suicidality and suicidal ideation, which definitely occurs in the silence of the hospital wards. Bear in mind that suicidal ideation doesn’t necessarily need to look like self-harm; it can also show up as starving oneself to death, refusing treatment or allowing the disease to overtake them, or even refusing treatment all together. Adequate training to recognize triggers, signs and symptoms among patients, caregivers, and among those healthcare professionals who deal with significant distress on a daily basis is crucial. A perspective shift towards holistic well-being (including mental healthcare) to focus on improving the quality of life for all groups of stakeholders builds a culture of compassion, understanding and healing for everyone involved in the palliative care community.


World health organization., Palliative care, accessed on September 10, 2023.

Salins, N., Bhatnagar, S., Simha, S., Kumar, S., & Rajagopal, M. R. (2022). Palliative care in India: Past, present, and future. Indian Journal of Surgical Oncology, 13(Suppl 1), 83-90.

Farre, A., & Rapley, T. (2017, November). The new old (and old new) medical model: four decades navigating the biomedical and psychosocial understandings of health and illness. In Healthcare (Vol. 5, No. 4, p. 88). MDPI.

Leung YW, Li M, Devins G, Zimmermann C, Rydall A, Lo C, Rodin G. Routine screening for suicidal intention in patients with cancer. Psychooncology. 2013;22:2537–2545. doi: 10.1002/pon.3319. 

Sveticic J, De Leo D. The hypothesis of a continuum in suicidality: a discussion on its validity and practical implications. Ment Illn. 2012;4:e15. doi: 10.4081/mi.2012.e4

Van Orden KA, Simning A, Conwell Y, Skoog I, Waern M. Characteristics and comorbid symptoms of older adults reporting death ideation. Am J Geriatr Psychiatry. 2013;21:803–810. doi: 10.1016/j.jagp.2013.01.015.

Chiang, Y. C., Couper, J., Chen, J. W., Lin, K. J., & Wu, H. P. (2022). Predictive value of the Distress Thermometer score for risk of suicide in patients with cancer. Supportive care in cancer, 30(6), 5047-5053.

Bijnsdorp FM, Onwuteaka-Philipsen BD, Boot CRL, Beek AJvd, Klop HT, Pasman HRW. Combining paid work and family care for a patient at the end of life at home: insights from a qualitative study among caregivers in the Netherlands. BMC Palliat Care. 2021;20(93):1-13.

Antony, L., George, L. S., & Jose, T. T. (2018). Stress, coping, and lived experiences among caregivers of cancer patients on palliative care: A mixed method research. Indian journal of palliative care, 24(3), 313.

Bijnsdorp, F. M., Onwuteaka-Philipsen, B. D., Boot, C. R., van der Beek, A. J., & Pasman, H. R. W. (2022). Caregiver’s burden at the end of life of their loved one: insights from a longitudinal qualitative study among working family caregivers. BMC Palliative Care, 21(1), 1-22.


About the Author:

Dr Sravannthi Maya is a Psycho-Oncologist, Health & Counseling Psychologist, Mental Health Lead & Consultant. She is also the Founder of The Raft, Counseling & Psycho-social support center at Hyderabad.

She also works with chronic illnesses and metabolic disorders amalgamating into Health and Medical psychology. Her keen interest lies in navigating difficult communications, complex PTSD, trauma, death and dying, teaching and training, developing modules in counseling skills for health and medical psychology professionals.

She works at the intersection of health and community very actively. Her larger aim is to normalize mental health occurrences and make help and support accessible to the vulnerable populations, and to bring in awareness and normalize conversation around death and dying in the Indian population.


Note: This article is a republication from the October edition of the Indian Association of Palliative Care‘s free monthly e-newsletter.

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