Death wish in patients with advanced incurable diseases

Patients with incurable disease, such as cancer and AIDS, may wish to die when they are at the final stages of their illness. The expression of this wish may be suicide ideation, a suicide attempt, a request for euthanasia or refusal to follow a treatment regimen which might increase survival.

Elements of the underlying illness may make patients vulnerable to the desire of death: uncontrolled pain, depression, delirium, loss of control, advanced illness and poor prognosis, exhaustion and fatigue.. They may even exaggerate a pre-morbid psychopathology and prior suicide history (1). Such vulnerability factors are frequent among patients with cancer, and increase with the stage of their illness: 15-90% have severe pain (2,3), 23-77% have significant depression symptoms (4,5), and 25-85% have delirium (6,7). The prevalence of symptoms is also high in the case of AIDS, and some authors indicate that the incidence of premorbid psychopathology is also higher (8,9).

The impact of both physical and psychological symptoms reduces the quality of life. Suicide ideation with no intention to attempt suicide is prevalent in 17% of cancer patients; in AIDS patients it is reported as 40% (10). The incidence of suicide in patients with cancer varies between 2 and 10 times that of the general population (11). The relative risk of suicide in patients with AIDS is 36-66 times that of the general population (12). These factors must be taken into account in order to detect and treat these patients, and to offer alternatives to death as a method for alleviating their suffering.

The purpose of this paper is to provide a theoretical discussion of actual clinical cases. We describe four cases of patients with different degrees of death wish and we analyse the various factors relating to vulnerability, therapeutic approach and prognosis.