September 25, 2010 ✽ Vol. 32 ✽ No.

18
[ News ✽ Analysis ✽ Commentary ✽ Controversy ]
oncology-times.com

ONCOLOGY
Publishing for

32 Years

TIMES The Independent

Hem/Onc News Source

Helping Prevent Suicide in

Downloaded from https://journals.lww.com/oncology-times by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0hCywCX1AWnYQp/IlQrHD3GlzJh/RXoJ5eZ1s+Hn5W++tmjhVw9LJvRcjUU0FkoBE= on 09/12/2020

Cancer Patients
Those Thinking of It Won’t Tell Unless You Ask
BY ROBERT H. CARLSON

O ncologists who say they’ve never had a patient commit suicide simply might
not know. The patient who doesn’t return for treatment or reportedly died of
an accidental drug overdose could have decided, in their suffering, that life was not
worth living. Depression is a risk factor for suicidal ideation, and the only sure way
to detect either one is to ask—whether face to face or in a screening questionnaire
before the office visit, but the questions must be asked. Here are practical steps to
take now, every day.
Page 15

Preparation for Medical Coding Post-Transplant Lymphoproliferative Oncology Social Media Pioneer
Change Should Begin Now! p.4 Disease: Update on Current Anas Younes, MD p.27
Treatment Options p.8

[ A L S O ] LETTERS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
MIKKAEL SEKERES Reviews a New Biography of Henry Kaplan . . . . . . . . . . . . . . . . . . 21
Concerns about Ovarian Cryopreservation for Women with Leukemia. . . . . . . . . . . . . . . . 23
SHOP TALK . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30
Remembering Cancer Epidemiologist Frank Garland . . . . . . . . . . . . . . . . . . . . . . . . . . 31
Myelofibrosis: Promising Results with Oral INCB018424 JAK Inhibitor . . . . . . . . . . . . . . 32
WENDY HARPHAM: ‘OpenNotes and Me’ . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35

Twitter.com/OncologyTimes
PERIODICALS bitly.com/oncologytimes

LWW-OTUS_SEP25-10-0903-BM.indd 1 9/21/10 9:41:01 PM


Helping Prevent Suicide in
Cancer Patients
Those Thinking of It Won’t Tell Unless You Ask
BY ROBERT H. CARLSON
O
ncologists who say they’ve never
had a patient commit suicide
simply might not know. The
patient who doesn’t return for
treatment or reportedly died of an acci-
dental drug overdose could have decided,
in their suffering, that life was not worth
living.
Depression is a risk factor for suicidal
ideation, and experts say the only sure
way to detect either one is to ask. The
questions can be in a screening process,
either face to face or in a questionnaire
before the office visit, but they must be
asked.
“Suicide is a very hidden problem,”
says Matthew J. Loscalzo, LCSW, the
Liliane Elkins Professor in Supportive Care
Programs and Executive Director of the
Department of Supportive Care Medicine
at City of Hope. “You can’t look at a per-
son and know they are suicidal.”
Depression is a risk factor for suicidal ideation, and
experts say the only sure way to detect either one
is to ask. The questions can be in a screening
process, either face to face or in a questionnaire
before the office visit, but they must be asked.
The risk factors are well known: a
sense of hopelessness, depression, pain not
adequately managed, confusion as a side
effect of the drug or the cancer. “Most
people cope well [with these factors], but
there is a subset of patients who don’t, and
they need special attention—and you can-
not do that by guesswork.”
In the Hospital: Plan at OSUCC-James
J oyce Hendershott, LISW-S, ACSW,
Clinical Program Manager of
Nursing Staff Development & Patient
Education at Ohio State University
James Cancer Hospital and the Solove
Research Institute, notes that research
indicates that with hospitalized pa-
tients, agitation, depression over a
recent diagnosis or chronic illness, im-
pulsivity, unrelieved pain, substance
abuse, and/or immediate relationship
issues, are more predictive of suicidal
behavior in the acute population.
(See “References” box on page 19—
specifically Bostwick and Rackley 2007
[#5] and Wint and Akil 2006 [#9]).
A suicide assessment is done for
these patients by an oncology so-
cial worker or mental health clinical
nurse specialist, and if the assessment
LWW-OTUS_SEP25-10-0903-BM.indd 15
More than Managing Symptoms
Richard M. Goldberg, MD, Distinguished
Professor of Clinical Research in
Hematology/Oncology at the University
of North Carolina at Chapel Hill, said that
suicide by a patient has happened twice in
his 30-year career that he is aware of.
Dr. Goldberg said he asks about depres-
sion and suicidal intent in his practice. But
sometimes patients have reasons for not be-
ing completely frank with their physician, he
said, so if he is worried about despair he will
also talk to family members and friends.
“I consider it a personal failure when a
patient of mine chooses suicide as a way
to end their ordeal with cancer, in part
because we can always manage and nearly
always successfully control cancer-related
symptoms, whether they are physical or
psychological. If somebody is depressed,
we can use antidepressants; if they’re in
pain, we can use pain medicines.
“But when somebody takes their own
life, it means to me that I didn’t do an ad-
equate job dealing with the consequences
of their disease,” Dr. Goldberg said.
“While that kind of decision may take
great courage, it also can be a sign of isola-
tion for the individual facing this ordeal
that is exactly what those of us who devote
JOYCE HENDERSHOTT, LISW-S, ACSW
15
oncology times
•
september 25, 2010
our lives to caring for patients with cancer
are striving to avert.”
Key Question
The key question, Mr. Loscalzo said, is
simply: “Do you have serious thoughts of
ending your own life?”
Screening in City of Hope’s outpatient
cancer clinic is done with sophisticated
touch-screen tablets with questions about
many facets of the patient’s life besides de-
pression and suicidal thoughts, including
pain levels, talking to a child about cancer,
money problems, and the adequacy of sup-
port at home.
When the patient says yes to a ques-
tion in this screening system, an e-mail is
automatically sent out to the appropriate
service, to triage in real time.
Mr. Loscalzo, who is also Administrative
Director of City of Hope’s Sheri & Les
Biller Patient and Family Resource Center,
said that 1% to 2% of patients screened say
they do have serious thoughts of suicide.
“We go and meet those patients right
in the clinic.” But screening can be as low
tech as pencil and paper, he added. And
there is no harm in asking.
“I’ve been doing this screening and ask-
ing the question about suicide for about 15
years, have screened about 15,000 patients,
and no patient has ever come to me saying
‘you know, I had no thoughts of ending
my life but now [after you asked], I do.’
And I’ve never had a patient or a family
member complain because we asked.”
Hopeless Optimism
Mr. Loscalzo said patients with cancer
can get scared, agitated, feel vulnerable or
continued on page 16
identifies a suicide risk, the physician
is notified. “You’ve got to
Suicide precautions are initiated by talk about it, to
a physician’s order, including creating
a safe environment for the in-patient understand if the
and a consult to the psychiatry team,
said Ms. Hendershott, a member of patient is coping
OT’s Editorial Board. well or has become
The health care team and phy-
sicians determine the need for comfortable with the
continued precautions with the psy-
chiatry team, and a physician order idea suicide.”
is required to discontinue suicide
precautions.
“In the outpatient setting, if a pa-
tient is identified as at risk, an oncol-
ogy social worker or mental health
clinical nurse specialist is contacted
who will complete an assessment to
make the appropriate referrals.”
9/21/10 3:06:46 PM
 16
september 25, 2010
➞SUICIDE
continued from page 15
hopeless or trapped, and then ask them-
selves “is this worth it?”
“And then, if they do make the decision
to kill themselves they can become opti-
mistic because they feel the weight is off of
them,” he said.
•
The patient may be sitting calmly in
oncology times
the clinic listening to the doctor focus on
“We try to find ways pain and cancer and treatments, when the
patient has already made up his mind to
to intervene as best end his life.
as we possibly can, “You’ve got to talk about it,” Mr.
Loscalzo repeated, to understand if the
but, unfortunately, patient is coping well or has become com-
fortable with the idea of suicide.
generally even if He admits it can be difficult for a physi-
you stop them once, cian to fit yet another task into such a brief
encounter as an office visit.
somebody who is “If you ask doctors how long they think
office screening would take, they’ll roll
determined will make their eyes and say forever,’” he said. “Male
another attempt.” doctors may especially have issues about
talking with the patient about feelings, but
both male and female physicians are under
such time pressures.”
But asking patients about suicide ac-
tually normalizes the situation, “because
then we can tell them it’s okay if they have
these thoughts—we can help you.”
It also demonstrates that the physician
cares about the patient, “that you have
confidence in yourself as a physician or
you wouldn’t even ask.”
Key Indicators
Before becoming President and Chief
Executive Officer of the National Hospice
and Palliative Care Organization, J. Donald
Schumacher, PsyD, ran hospice programs
for almost 30 years. He has had patients in
hospices make suicide attempts, with one
J. DONALD SCHUMACHER, PSYD:
“Instead of asking patients if they have
any thought of suicide, the practitioner
might ask what solutions the patient
has for dealing with depression or
discomfort. They could mention suicide.
Have a conversation with family members
as well. Every time there is a treatment,
ask not only how the patient is doing
physically, but also what is it like at
home, what kind of support they have,
and are they experiencing pain.”
LWW-OTUS_SEP25-10-0903-BM.indd 16
Resources
• Joyce Hendershott, LISW-S, ACSW,
Clinical Program Manager of
Nursing Staff Development & Patient
Education at Ohio State University
James Cancer Hospital and the
Solove Research Institute, recom-
mends as especially helpful for health
care professionals an article on the
NCI site, “Evaluation and Treatment of
Suicidal Patients with Cancer—Effects
of Suicide on Family and Health Care
Providers,” which addresses many
common questions and provides sta-
tistics on the incidence of the problem:
http://www.cancer.gov/cancertopics/
pdq/supportivecare/depression/
Patient/page5
• And the National Association of Social
Workers Code of Ethics includes ethi-
cal standards, including those specific
to self harm or harm to others. These
are listed under Section 1, Social
Worker’s Ethical Responsibilities to
Clients: http://www.socialworkers.
org/pubs/code/code.asp
• Ms. Hendershott also pointed to
the National Suicide Prevention
actual act of suicide, a patient with a his-
tory of depression, he said.
“The concerns with cancer patients are
how well their treatment is going, is the
patient feeling desperate, and with that
desperateness is there a history we have
to pay attention to. Those would be key
indicators. And some kind of depression
assessment or substance abuse assessment
would be critical.”
Dr. Schumacher advises asking about
the patient’s social support at home:
“Many people are alone, and this might
be a candidate who needs a little more
attention.”
He said he doesn’t like to characterize,
but a diagnosis of throat cancer or oral
cancer is often associated with alcohol and
smoking, which might be associated with
depression.
And cancer patients often times have
more access to narcotics, so if the tendency
for suicide is there, the opportunity may
be greater.
Dr. Schumacher encourages any physi-
cian or nurse practitioner in the field to
do a psychological assessment on anyone
newly diagnosed, to look for potential key
indicators.
In an oral interview, the practitioner
can ask the patient how they have dealt
with loss, whether they have had trau-
matic health issues in the past, and ask
for the patient’s own perspective on their
situation.
And instead of asking if they have any
thought of suicide, the practitioner might
ask what solutions the patient has for deal-
ing with depression or discomfort. They
could mention suicide.
Have a conversation with family mem-
bers as well, Dr. Schumacher advised.
Lifeline at 1-800-273-TALK (8255),
a free, 24-hour suicide prevention
hotline available to anyone in sui-
cidal crisis or emotional distress.
The national prevention center
routes the call to the crisis center
nearest to the caller.
• Matthew J. Loscalzo, LCSW,
Professor and Executive Director
of the Department of Supportive
Care Medicine at City of Hope,
also recommends the American
Psychosocial Oncology Society
(www.apos-society.org), which
connects cancer patients and their
families with mental health profes-
sionals in their area.
• Also very helpful is CancerCare
(www.cancercare.org), which offers
free telephone counseling.
• Both Ms. Hendershott and Mr.
Loscalzo and other experts, though,
strongly urge that any suicidal indi-
vidual should be taken to an emer-
gency room or to an emergency
community mental health center
for evaluation and treatment.
“Every time there is a treatment, ask
not only how the patient is doing physi-
cally, but also what is it like at home, what
kind of support they have, and are they
experiencing pain—pain is a very major
issue, poorly controlled pain or nausea or
vomiting. Make sure that hasn’t gotten the
better of the patient.”
Tell the Truth
But will the patient tell the truth?
“The relationship with the physi-
cian is very important in getting an hon-
RICHARD M. GOLDBERG, MD: “When
a patient takes their own life, it means
to me that I didn’t do an adequate job
dealing with the consequences of their
disease. While that kind of decision may
take great courage, it also can be a
sign of isolation for the individual facing
this ordeal that is exactly what those of
us who devote our lives to caring for
patients with cancer are striving to avert.”
continued on page 18
9/21/10 4:42:23 PM
 18
➞SUICIDE
september 25
continued from page 16
est answer from a suicidal patient,”
Dr. Schumacher said. “The best
oncologists I’ve worked with are very
attentive and emotionally supportive,
•
and have developed a very high level
oncology times
of sensitivity.”
The suicide Dr. Schumacher re-
called was a very difficult case, in
that the patient was expecting a visit
from the hospice physician, who
when she got to the house found the
patient had shot himself. The patient
LWW-OTUS_SEP25-10-0903-BM.indd 18
probably wanted her, and no one else, to
find him first, Dr. Schumacher said.
“That was really difficult for the doctor,
and very, very difficult for the nursing staff,
because one might think ‘if only I’d gotten
there an hour earlier…,” he said. “All the
what-ifs.”
Dr. Schumacher said he gave himself a
reality break there, realizing that if some-
one is very determined to commit suicide,
they eventually will.
“We try and find ways to intervene
as best as we possibly can, but generally,
even if you stop them once, somebody
who is determined will make another
attempt.”
Oncologist Felt He ‘Dropped the Ball’
A Nebraska farmer in his late 70s with
end-stage lung cancer took his
own life shortly after that diagnosis was
made.
Peter M. Townley, MD, a partner at
Nebraska Cancer Specialists in Omaha,
was the oncologist who made the
diagnosis.
It was Stage 4 disease, but with no
bone or brain metastases,only some liver
metastasis, Dr. Townley recalled in relat-
ing the sad situation to OT. The patient
presented with no symptoms other
than cough, and his only complaint
was feeling more tired than usual.
Dr. Townley said the man never
returned to discuss treatment before
he shot himself.
“I had no warning at all that he
was depressed,” Dr. Townley said. “I
felt like I had somehow dropped the
ball, that I should have seen some
clue that something was going to
happen.”
He said patients at the Omaha
clinic fill out questionnaires before
visits and are asked how they are
handling the diagnosis. Counselors
are available, and they make it a
point to engage family members
and ask how the patient is doing
emotionally.
“We try to give patients several
chances [to talk about emotional is-
sues], we get to know them fairly
quickly and get a sense” of the pa-
tients’ state of mind. But in this case,
I was caught off guard.”
Dr. Townley said the experience
has made him much more sensitive
about the risk of suicide.
He said he has a patient, a man in
his late 40s, very recently diagnosed
with metastatic lung cancer. The man
appeared very despondent when
told the cancer was incurable.
“He had his girlfriend with him,
and I asked him several times how
worried he was about this, what did
he think he was going to do, but he
didn’t want to talk,” Dr Townley said.
“I reassured him that if pain becomes
a problem we could control that, tried
to reassure him on many levels, but he
just wanted to leave.”
This could have been a warning
sign, Dr. Townley said, but he
continued to talk to the patient’s
girlfriend, and the man stayed.
Dr. Townley then asked the man
directly if he was thinking about
hurting himself.
“He told me he was terribly de-
pressed by the news, but no, he had
just had enough information for the
day.”
The patient lived quite a distance
from Omaha and Dr. Townley re-
ferred him to oncologists in his area.
He followed up on the patient and
found that the man did start treat-
ment there.
Dr. Townley compared this pa-
tient with the farmer who did commit
suicide. The farmer “was just very
matter of fact, didn’t come across
at all as being depressed.” He said
he learned from the patient’s long-
time family physician that the man
had committed suicide.
“The family doctor was not as sur-
prised about the suicide as I was,”
Dr. Townley said. “He said the man
had always worked on the farm and
was familiar with the cycle of life,
and perhaps just thought his time
had come.”
9/21/10 4:42:26 PM
 19
Action Plan
References

Joyce Hendershott, LISW-S,
ACSW, Clinical Program Manager
of Nursing Staff Development
& Patient Education at Ohio
State University James Cancer
MATTHEW J. LOSCALZO, LCSW:
“Suicide is a very hidden problem.
You can’t look at a person and know
they are suicidal….Most patients cope
well with the risk factors of a sense
of hopelessness, depression, pain not
adequately managed, and confusion
oncology times
Mr. Loscalzo said oncologists must
have an action plan for dealing with
suicidal patients. It is crucial to have a
contact with a psychiatrist who can
see an actively suicidal patient quickly,
whether the oncologist is in private
practice or in a large cancer center.
“With an actively suicidal pa-

•
Hospital and the Solove Research as a side effect of the drug or the tient, only a psychiatrist will do. I

september 25
Institute, also recommended cancer, but there is a subset of patients cannot imagine any oncologist who
the following references for fur- who don’t, and they need special does not have a contact with a psy-
ther helpful information for can- attention—and you cannot do that by chiatrist, psychologist, or social
cer care and other health care guesswork.” worker to assess some of these pa-
professionals: tients, a backup team of mental
health professionals.” OT
General
1. American Psychiatric
Association: Assessing and
Treating Suicidal Behaviors, a Quick
Reference Guide, 2003.
2. Billings C: Close observa-
tion of suicidal inpatients. Journal
of the American Psychiatric
Association 2001;7(2):49-50.
3. Joint Commission on
Accreditation of Healthcare
Organizations. Sentinel Event
Alert—Inpatient Suicides:
Recommendations for Prevention,
Suicide Precautions Divisional
Standard of Practice Page 5 of
5 December 2008. Available at:
http://www.jointcom mission.
org/AccreditationPrograms/
BehavioralHealthCare/
Standards/09_FAQs/
NPSG/Focused_risk_
assessment/NPSG.15.01.01/
Suicide+risk+reduction.htm
Accessed May 2009.
4. Logue EM, Parrish RS: Suicide
precautions in a medical/surgical
unit.Nursing Management
1998;29(10):33-34.
Research References
5. Bostwick J, Rackley S:
Completed suicide in medical/
surgical patients: who is at
risk? Current Psychiatry Reports
2007;9:242-246.
6. Farrow TL, O’Brien AJ:
“No-suicide contracts” and in-
formed consent: An analysis of
ethical issues. Nursing Ethics
2003;10:199-207.
7. Farrow TL: “No Suicide
Contracts” in Community Crisis
Situations: A Conceptual Analysis.
Journal of Psychiatric and Mental
Health Nursing 2003;10:199-
202.
8. Tishler C, Reiss N: Inpatient
suicide: preventing a common
sentinel event. Department of
Psychology, The Ohio State
University. General Hospital
Psychiatry 2009;31:103-109.
9. Wint D, Akil M: Suicidality
in the General Hospitalized
Patient. Hospital Physician
2006;42:13-18.

LWW-OTUS_SEP25-10-0903-BM.indd 19 9/21/10 4:42:26 PM