I have worked in acute and community mental and physical health care settings for the past 23 years. I was promoted to NHS consultant clinical psychologist in 2004, and then to specialist care pathway lead for clinical health psychological services in 2013. I continue to work in this role as a clinician, line manager and clinical supervisor for psychologists and psychotherapist.
I am very interested in the development of best practice for patients who reach a palliative and end of life diagnosis. It is a very important area for psychological care and resonates with my wish to support patients through the trajectory of life, especially at such a vulnerable and significant period in their life. I have also had a long-standing interest in suicide risk management, and ways to support patients, their loved ones, communities and health services in ways to reduce this risk. I have been active in the areas of risk assessment and management, and was a member of the Department of Health working groups for psychiatric intensive care, as well as community suicide assessment toolkits. I chaired the NELFT clinical risk advisory group into suicides and sudden unexplained deaths for several years, and have also branched out to contribute to the growing field of psychological and mental health discourse in the areas of digital and social media risk. I have presented at several national and international conferences, and have co-authored a paper, ‘Digital lives in psychotherapy; ‘the other in the room’. Kingsley, M, Stockmann, & Wright, D.
The risk of suicide in the palliative care patient group remains an underreported yet highly significant concern. Receiving a palliative diagnosis can be a shock and a distressing experience for many people. It can happen quite suddenly, or after years of chronic health difficulties. Either way, it often heralds a life-changing process, in which the reality of living with an incurable illness, as well as facing death and dying become tangibly apparent.
Suicidal ideation is common in terminally ill patients, but is usually fleeting in nature, and often associated with psychological distress of the unknown, and fear of loss of function and independence, as well as uncontrolled pain. The prevalence of depression and anxiety, often in mixed states, are well reported. Distinguishing the clinically depressed patient from the person overwhelmed or despairing of their illness and circumstances may not be easy, and the two states can often accompany each other through the palliative journey. Specific risk factors in this population, such as time since diagnosis, and illness type, are crucial to consider. For example, the highest risk phase for suicide in palliative patients has been identified as the acute phase after diagnosis. In cancer patients, this has been placed at the first 3 months after receiving the diagnosis. The risk then increases again in advanced stages of the illness, perhaps due to complications such as difficult to manage pain, reduced mobility, increased dependency and the shame and despair associated with loss of dignity. Patients with delirium may also become more vulnerable to suicidal feelings,
In order to help best support patients through the psychological distress associated with a palliative condition, it is important to spend quality time assessing and understanding the subjective feelings and concerns associated with living with a life-limiting condition. This is something that I continue to do whenever I meet both new and existing patients, as well as through supporting my colleagues in palliative care clinical discussion groups, and in individual supervision. For some patients, being able to share their concerns of losing their dignity and independence along with practical support with care plans and concrete steps to aid independent choice and reassurance of how dignity will be managed, can be enough to alleviate psychological suffering, and reduce the wish for a hastened death. For others, the psychological distress runs deeply and is associated with lost opportunities, unmet needs and failed relationships. Psychotherapy and especially meaning-centered approaches have been associated with a reduction of psychological symptoms in this group, and often an ability to live life more fully, even in the end stages (Breitbart, 2017).
It is my hope that raising awareness of the risks of suicide in palliative and end of life groups will help to assist in reducing the risks associated with this patient group. For many patients who I have spoken with, the relief that they have felt in being able to share their distress, and find ways to manage some of their fears and concerns about death and dying, have reduced their wish for a hastened death, or to end their lives. This active engagement with psychological distress and low mood can enable people to focus on the here and now, and give them the chance to live life for as long as is possible.