Are suicide prevention efforts missing older adults?
Older adults account for nearly one-fifth of all deaths by suicide and chances are they used a firearm, according to the American Association for Marriage and Family Therapy.
But for those 65 and older, longstanding suicide prevention approaches may not be capturing their needs, letting elder deaths by suicide fall through the cracks.
“We struggle with the understanding that anyone who is rational would want or hope for their own death,” said Jennifer Herbst, a professor of law and medical sciences at Quinnipiac University’s School of Law and Frank H. Netter MD School of Medicine. Herbst’s research includes medical ethics, patient decision-making and law.
Data obtained by Hearst Connecticut Media from the state Office of the Chief Medical Examiner lists 321 people 65 and older who shot themselves to death between 2010 and August of this year. This group made up more than 15 percent of the 2,056 total deaths during that time frame.
Ninety of these individuals were 80 and older, with all but 18 being men. The list includes 13 people of color, all men.
Several family members of older adults who died by suicide whom Hearst Connecticut Media contacted said their parents or siblings didn’t have diagnosed mental health conditions or show other indicators that they might take their lives.
Some said their elder family members expressed wanting choice and control over how they died when they felt it was their time. These families did not want to be named.
“I think to the extent that folks have decided that their life is done, I don’t know if we have any good treatment for folks who are not clearly clinically diagnosable as depressed or bipolar or schizophrenic or any other mental health disorder or with dementia,” Herbst said. “We don’t have a good treatment for it.”
In Connecticut, legislation on physician assisted dying, also known as medical aid in dying or death with dignity, hasn’t been signed into law. However, a bill concerning aid in dying for terminally ill patients was introduced again this legislative session.
Tim Appleton, Connecticut organizer for Compassion and Choices, has advocated for medical aid in dying for people who are terminally ill to be available in Connecticut the way it is in neighboring states.
“Expanding autonomy in the end of life for people who are faced to have this terrible choice of ending their life afraid and alone, that’s what we’re fighting for,” Appleton said.
The legislation would allow mentally capable adults with fewer than six months to live and approval from a physician, to seek a prescription patients administer themselves to accelerate their death.
In states where medical aid in dying legislation exists, suicide rates have also decreased, according to the Centers for Disease Control and Prevention.
“Options like this increases conversations around end of life care and hospice care so we would see more people having conversations with their doctors and families about it,” Appleton said.
Appleton said he believes it’s just a matter of time before this legislation exists in Connecticut but questions how many people will suffer until then. Ninety percent of people who choose medical aid in dying are in hospice, he said.
Part of the legislation’s safeguard against misuse is its specificity for only those
who are terminally ill.
Herbst said dementia is a large element of aging and end of life choices sitting unaddressed.
Herbst said early signs and symptoms of dementia might leave people scared of what their lives will become. Even if they can keep up a front to everyone else, inside they’re struggling.
Those ideas might transform into depression, but Herbst said it might also become a calculated decision to end their lives because of the belief that so much of who they are is their cognitive functioning.
Dementia is not a terminal illness, so people living with it couldn’t leverage a medical aid in dying prescription, or by the time the disease becomes terminal, a person has lost the mental capacity to avail themselves of it.
“I think there may be some folks for whom life just hurts too much — it just does — and we have not come up with a good way to treat it,” Herbst said. “I do think you should try to treat it, but it’s not always treatable.”
Herbst said in that framework, death can be a goal of patient care, but usually only in extreme hospice situations.
Herbst said some argue that since people already have the right to end their lives, physicians don’t need to play a role in aiding that. However, if a care goal is to die with dignity, “very few people would perceive the mess left behind after a suicide by a firearm as dignified,” she said.
“The difference between who finds you and who needs to clean up after that I think is still an issue for folks,” Herbst said. “For those who are seeking greater clarity and greater access to medical aid in dying, they are thinking of the others they anticipate they are leaving behind and trying to reduce the burden and the harm and the trauma to them.”
Firearms account for about 50 percent of deaths by suicide, according to the American Association of Suicidology, and people who use a gun are less likely to have attempted suicide before by any method.
“Suicide prevention strategies are great tools but not the right ones for this particular issue because they often aren’t going to capture the folks most likely to die by firearm suicide,” said Michael Anestis, a clinical psychologist and co-chair of the American Association of Suicidology firearms and suicide committee.
Intervening at the moment of crisis is already too late to prevent a suicide by firearm, Anestis said, so looking for mental health warning signs will leave many people who are at risk unnoticed.
According to the Centers for Disease Control and Prevention, 54 percent of people who die by suicide did not have a known mental health condition and those people were also more likely to die by a firearm than any other method.
“It (mental illness) has very little to do with whether someone thinking about suicide will attempt it,” he said. “More often than not the folks left behind were likely to not see it coming.”
Anestis said suicide prevention fails in identifying people who need it because it doesn’t address environmental interventions, such as firearm access.
Shifting social norms about firearms and suicide — safe storage and suicide risk education for firearm owners — is step one in prevention because of those who attempt suicide using a firearm, between 85 percent and 95 percent complete it, according to the AAS.
A person who wishes to voluntarily surrender their firearms may make arrangements with Connecticut State Police.
Herbst said instead of trying to decide whose life is worth living, we should reframe the conversation as one asking to what extent people should have control over what their death looks like and whether the tools of medicine should be available as a means for their death.
That could in turn result in fewer firearm suicides, she said.
In addition to that conversation, Herbst said society needs to do better caring for aging people and supporting caregivers as people especially 65 and older talk about not wanting to be a burden, she said.
Providing and funding better support and care at the beginning of someone’s perceived decline could alleviate such feelings and suicidal ideations, she said.
“With better paid health care, families can maintain their loving relationships because nothing is done out of obligation,” she said.
Anyone in crisis can call the National Suicide Prevention Lifeline at 1-800273-8255 or visit suicidepreventionlifeline.org for online emotional support.