Suicide and the HIV Positive Client Overview of Issues

By Tom Smith, Ph.D.

 

Sadly, as is the case with any terminal illness, but particularly with a stigmatic terminal illness like HIV/AIDS, suicide is always a possibility. Inquiry should be made into any self-destructive thoughts the client may entertain. In the early stages of the epidemic, many young men chose to end their lives before the disease inevitably ravaged their bodies. With the onset of a plethora of treatment options, this is somewhat less likely, but still possible, particularly if the client feels abandoned, lonely or has other psychological, social or financial problems.

Nevertheless, with assisted suicide now the law in Oregon, Washington State, Switzerland, Belgium and the Netherlands and more states in the U. S. considering making it legal, most recently in 2009 Montana, suicide cannot be discounted as an option in the face of HIV/AIDS. Moreover, it may be a rational as well as legal choice for those who are HIV positive. Attitudes towards end-of-life issues are changing rapidly as the baby boomer generation ages and as they watch their parents live longer, but with a lesser quality of life. Faced with a slow, degrading, insidious death accompanied by great suffering and indignity a person with HIV may plan for the future in a rational way to end their life when they have had it with all the suffering and see nothing else on the horizon.

This tremendous ethical dilemma ought to be explored with anyone with HIV, or at least, the question asked if they have thought about ending their life sooner or later. The problem is that an already disenfranchised stigmatic group may be encouraged to take such action so not to burden the healthcare system, family, friends or the society as a whole. Should one do everything medically and legally possible to postpone an inevitable, degrading death? Most people who have died of HIV/AIDS have died in bits and pieces an ugly death. The issue is very controversial and will not go away.

It must be in the front of every healthcare provider’s mind that a person who encourages or helps someone with or who is present at a suicide where it is illegal can be charged with assisting the suicide, manslaughter or even murder. Most recently, in February 2009, a group (not physicians as mandated by Oregon and Washington law) in Georgia have been collectively charged with illegally assisting a suicide. What to do if a client asks within the therapeutic alliance for the clinician to be present for their final exit? The competing values of client autonomy and keeping the client safe are brought to bear under these circumstances. In any case, mental health practitioners must take whatever reasonable action to prevent a patient from committing suicide. Their actions must be within the community standards of care to promote well-being or they may be liable for a wrongful death.

An experienced attorney’s view of the issue of assisted suicide was expressed as follows:

Aiding or abetting a patient or client to commit suicide, or simply providing supportive counseling or therapy, might likewise, depending upon the circumstances, constitute a crime.

In most states, therapists and counselors are permitted (sometimes required) to break confidentiality when the patient is a danger to self as the result of a mental or emotional condition. If the disclosure is required, the practitioner is expected to comply with the law. If the disclosure is permitted, the practitioner must make a very important judgment. In my view, that judgment should favor those disclosures calculated to prevent the threatened or imminent suicide or serious danger to self.

I would be uncomfortable taking the position (e.g., arguing in court) that since the practitioner was not mandated to warn, notify or alert anyone, he or she was therefore without blame when nothing was done to try to prevent the intended self-harm, or when supportive counseling was provided to assist the patient with his or her plans. I would much rather be defending the practitioner who made reasonable efforts to prevent the self-harm – including, if necessary, breaking the patient’s confidentiality. When states pass laws that allow people to take their own lives under specified circumstances, then mental health practitioners can perhaps more safely provide supportive counseling or therapy that is consistent with the terms and conditions of such a law. Until then, practitioners must be very cautious when confronted with this kind of a situation. (Retrieved from https://cphins.com/LegalResources/BulletinArchive/tabid/66/cid/123/sid/93/Default.aspx April 1, 2009)

Currently, in California, there is no “right to die”. At least, the therapist has a responsibility to remain neutral and help the client explore all of their thoughts and feelings about ending their life and all the alternatives available. Palliative care has come a long way over the years. As one nears death one does not have to suffer. There are many treatments available to ameliorate pain and suffering. Often, there are medical crisis that pass in which suicide is contemplated. The ethical question that arises is how far does one go in efforts to prevent a suicide if the clients choice seems thoughtful and at the right time; that is to say, after all medical alternatives have been exhausted and there is a sure determination that the situation will not improve and in fact deteriorate. What would be unethical is if the therapist’s countertransference issues or poor skills resulted in NOT fully exploring the patient’s thoughts, feelings and intentions.

So, some of the questions to be considered are: Has there been a thorough medical exam to rule out any physical or mental illness that is causing suicidal ideation? Is the suicidal ideation impulsive or well thought out over time in discussion with important people in the person’s life, including the therapist? Does the family know? Are there financial or other economic issues that may be instigating the ideation? Are there any spiritual implications that need to be considered? Would things be different if the client did not have HIV? What are the values and principles around life and death embraced by the clinician?Most of the time, suicidal ideation is the result of a medical setback or underlying undiagnosed situational or major depression and can be treated by taking the appropriate steps to keep the patient from harming themselves and prescribing medication.

Reprehensibly, socioeconomic status may determine what treatment is available to the suicidal, physically debilitated patient. People who are poor, unschooled, lack health insurance or live on the margins of society are often discriminated against in the healthcare industry. No money, no treatment. Usually, an indigent person needs to have actually attempted to kill themselves to gain access to emergency psychiatric hospitalization. Sadly, the attempt may be more than an attempt, but a successful suicide. The ethical problem is that if one does not make a concerted effort to get the impoverished individual treatment, no matter how frustrating or unsuccessful, accusations, unfounded or otherwise, may be made that the clinician failed in their ethical responsibility to get the patient treatment even though the system made a judgment based on socioeconomic status rather than genuine medical need. It is not unheard of to hear that poor patients died on the emergency room floor, found only when their body grew cold and staff finally noticing.

Best Practices regarding determination of potential for suicide.It is important to continually assess for suicide once it is determined that the thought has crossed the client’s mind.

It cannot be emphasized enough to document all questions asked of the potentially suicidal client and their answers. Document your next steps or how the treatment plan is to be altered or why it will remain the same.Be aware of all your client’s relations with allied health care providers. If they need to rehearse interactions with their primary care physician or other health care provider, walk them through it … role play interactions. Let them know that you are their ally and that they are not alone.HIV/AIDS remains a disease with no cure and eventually will result in death sooner or hopefully, later. Talking about dying and death is something from which all people could benefit. Talking about dying early in the therapeutic alliance removes some fear of that unknown and may need to be initiated by the clinician. Once the subject is broached and the door opened, the client may express some relief that it is okay to talk about their end. Do not wait for the client to bring the subject up. It may be helpful to ask the client about how and where they may want to die and who they would want to be present, if anybody. If in Oregon or Washington, ask the client if they have thought about assisted suicide. Considering the legal circumstances in those states, this is not an inappropriate line of inquiry. Be aware of countertransference issues regarding death, suicide or assisted suicide. These conversations are best had long before it is necessary because death is imminent. If they are thinking of asking their primary care physician for lethal drugs, the clinician may be required to be particularly careful about documenting the client’s state of mind and may need to facilitate the conversations with the physicians.

If the client is bordering on or is having a psychiatric emergency, they are not likely to call 911. Make sure that if the client needs to be referred, that the clinician is fully familiar with all of the resources available in their respective community to immediately get the client the help they need. Know the contact person at local facilities and the protocols required to receive service or gain access to a psychiatric bed.For a fact, HIV positive individuals who are asymptomatic or who have only experienced minor health setbacks think about what circumstances regarding the quality of life that they will not tolerate. For example, some may say that they will consider suicide if they can no longer walk; others may say that if they lose control of their bathroom functioning, they will think of killing themselves; others may think that when they can no longer care for themselves or must go to the hospital that they might commit suicide. Explore with the client what disabilities might provoke suicidal thinking. Talk about their issues regarding independence and control over their life. Ask them if they want to prepare an advance directive or write a will or what other concrete steps they would like to take to maintain control as long as possible or to simply shore up their sense of having control. One of the greatest fears at the end of life is losing control and independence.

Work the therapeutic alliance to the maximum. Support the client’s reality testing; that is, if the system is treating them unjustly, acknowledge that; if the highly active antiretroviral therapy is no longer effective, acknowledge that. Do not engage in wishful thinking with the client. If family is present, let them know that you are on their team. Engage all of the client’s support systems.

Most importantly be informed, thoughtful, as part of your ethical decision-making consult, as necessary, with expert colleagues, informed ethicists, and knowledgeable attorneys before engaging in assisted suicide with an HIV/AIDS client.

Resources

APA (2009). End-of-life Issues and Care (Resources Page). Retrieved from https://www.apa.org/pi/aids/programs/eol/index.aspx

Battin, Margaret P., Rhodes, Rosamond, and Silvers, Anita, eds. Physician assisted suicide: expanding the debate, NY: Routledge, 1998.

Coombs Lee, B. & Werth, J. L., Jr. (in press). Observations on the first year of the Oregon Death with Dignity Act. Psychology, Public Policy, and Law.

Forstein M. 1994. Suicidality and HIV. In: Cadwell S, Burnham R, Forstein M, editors. Therapists on the frontline: psychotherapy with gay men in the age of AIDS. Washington (DC): American Psychiatric Press. p 111–45.

Haley, W., Larson, D., Kasl-Godley, J., Neimeyer, R., & Kwilosz, D. (2003). Roles for Psychologists in End-of-Life Care: Emerging Models of Practice. Professional Psychology: Research and Practice, Vol. 34, No. 6, pp. 626-633.

Kleespies, P. (2004). Life and death decisions: Psychological and ethical considerations in end-of-life care. Washington, DC: American Psychological Association.

Smith, T., End-of-Life Issues and Care: Arguments in Support of and Opposition to Assisted Suicide in End of Life Issues: Managing Dying, Death & Beyond. 2008. Zur Institute.

Werth, Jr., Ph.D., James L.; Richmond, Jessica; Counseling those near the end of life, The National Psychologist, p. 23, May/June 2007

Wood, G., Marks, R., and Dilley, J. (1992) AIDS Law for Mental Health Professionals. Berkeley, Celestial Arts.