May 15 2008

Suicide, ethics, and end of life care dilemmas for families

Please note: This is a fictionalized case-study. I have created this case scenario to stimulate thought and discussion about the complicated clinical and ethical dilemmas related to end of life care for patients and their families.

I will be very happy if this case is used for study purposes in an ethics or clinical therapy class.
Susan came to see me about a year after her brother Bob’s complicated death related to cancer. She had been referred by a friend who knew that I worked with many adults with life threatening illnesses and their families.

At her first session, Susan was depressed and tearful. She described in great detail the loving care that she and her mother had provided for her brother who began to suffer a lot of pain at the end of his struggle with his cancer. He had begun to actively die.

During the next session, Susan was visibly upset. With some difficulty, she confided in me that the real reason she was suffering so much right now was because she felt guilty that she had she had entered into a secret pact with her brother to help him take enough pain medicine to “speed up” his dying process and help him avoid a long, protracted and painful death.

Susan did this at a point that her brother had decided that he would only be in and out of consciousness and in a great deal of pain anyway. He began to spend a lot of time with his friends and other family members during the days leading up to his death. No one else knew of his plans and Susan kept her end of the agreement and did not disclose to anyone of their plans.

She described this time as very upsetting in that she knew she would lose her brother to death in a short time. She understood that his cancer would result in his death anyway, but she had mixed feelings about her agreement to keep his plan to end his life on his own terms a secret.

They talked about it as his way to decide when to die with as much dignity as possible. Yet, she still had conflicts about whether this was the best plan. She was also unsure about how she would feel after his death. She described in detail the circumstances around his death. Her brother decided it would be best to do later at night after his mother went to bed.

Susan reported that her brother had the usual intimate good night with his mother and felt in his heart that his relationship with her was in a good place. Susan knew that her brother and mother had had many good conversations about their relationship. He felt ready to die and felt that while there may not be any good time for his mother, family and friends for him to die, this was the time it would happen.

Her brother prepared his medication mix. He had done all the research he needed to know the dosage of the usual medications he took to ensure his death during the night. He and Susan spent time with their goodbye, he took the medication, she held his hand, and with many tears she watched as he slowly closed his eyes, and later died.

There were many other details about her brother’s death, his funeral, and she and her family’s grieving process. All through this time, she maintained her promise to her brother to keep the actual cause of his death secret. Susan felt good about this and grateful she was able to help her brother at a time in his life when he needed her support in a profound way.

However, recently she began to have second thoughts about her role in her brother’s suicide. She wondered if she had done the right thing. She believed that her brother would not have lived for much longer and that they talked for a long time about his choice to decide the time and manner of his own death. But now, during the therapy, she revealed guilt, confusion and fear about the complexity of her brother’s death.

I began to help her explore her feelings about this complex event. I understood that my role was not to make any judgements about what she had done. It was already completed. Her brother’s death was in the past. Nothing would ever change this.

In considering the ethical challenge here, I knew that my priority was to help Susan continue her grieving process and heal from the death of her brother. Her complicated feelings about her perceived role, passive as it was, in this death was part of the grieving process for her.

I knew my role as Susan’s therapist was not to be a judge or jury for her and her decisions. Whatever my personal judgements, injecting them into the therapy process would not be appropriate.

I wondered what I would have done. I wasn’t sure what I would do if placed in a similar situation. I really do not know what choice I would make. I just knew that my responsibility was to help her move forward and complete the grieving process. I had enormous compassion and empathy for Susan. She had made her decisions based on a deep love for her brother.

Susan understood that her feelings were mixed in with the normal grief she would experience as a result of her brother’s death. She was very sad and was able to grieve more openly during our therapy time together. She had taken me into her trust, like her brother had taken her into his trust and the context of our therapy relationship was a safe place for to open her heart more fully and release the depth of her grief.

During later sessions, she began to talk about her wish that she could really know that she had done the right thing by not stopping her brother’s plan. She knew that no matter what she did, if he was truly determined, he would have found some way to take his life, even if she tried to stop him.

She also understood that his dying process was complicated and difficult enough for everyone. If she tried to intervene, his dying process would have been more about her feelings of fear or her judgements that he was making the wrong decision.

In her mind, she felt confident she made the right choice to stand beside her brother. In her heart, though, she had other powerful feelings.

We had used some relaxation and imagery exercises as part of the earlier therapy sessions. I explained to her that there was an imagery exercise that might be helpful in addressing her concerns about her brother’s death. I gave her some details of the imagery exercise.

She readily agreed.

Case continued in the next post.

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