Lethal Plans: When Seniors Turn To Suicide In Long-Term Care
Intelligencer JournalApr 22, 2019
When
His son and daughter expected him to stay two weeks, tops, before going home to begin chemotherapy. From the start, they were alarmed by the lack of care at the center, where, they said, staff seemed indifferent, if not incompetent — failing to check on him promptly, handing pills to a man who couldn’t swallow.
Anders never mentioned suicide to his children, who camped out day and night by his bedside to monitor his care.
But two days after Christmas, alone in his nursing home room, Anders killed himself. He didn’t leave a note.
The act stunned his family. His daughter,
“It’s sad he was feeling in such a desperate place in the end,” Juno said.
In a nation where suicide continues to climb, claiming more than 47,000 lives in 2017, such deaths among older adults — including the 2.2 million who live in long-term care settings — are often overlooked. A six-month investigation by
If You Need Help
If you or someone you know has talked about contemplating suicide, call the National Suicide Prevention Lifeline at 1-800-273-8255, or use the online Lifeline Crisis Chat, both available 24 hours a day, seven days a week.
People 60 and older can call the Institute on Aging’s 24-hour, toll-free Friendship Line at 800-971-0016. IOA also makes ongoing outreach calls to lonely older adults.
Poor documentation makes it difficult to tell exactly how often such deaths occur. But a KHN analysis of new data from the
Each suicide results from a unique blend of factors, of course. But the fact that frail older Americans are managing to kill themselves in what are supposed to be safe, supervised havens raises questions about whether these facilities pay enough attention to risk factors like mental health, physical decline and disconnectedness — and events such as losing a spouse or leaving one’s home. More controversial is whether older adults in those settings should be able to take their lives through what some fiercely defend as “rational suicide.”
Tracking suicides in long-term care is difficult. No federal regulations require reporting of such deaths and most states either don’t count — or won’t divulge — how many people end their own lives in those settings.
In research they presented at the 2018
KHN extrapolated the finding to the entire
But representatives of the long-term care industry point out that by any measure, such suicides are rare.
The deaths are “horrifically tragic” when they occur, said Dr.
“I think the industry is pretty attuned to it and paying attention to it,” Gifford said, noting that mental health issues among older adults in general must be addressed. “I don’t see this data as pointing to a problem in the facilities.”
KHN examined over 500 attempted and completed suicides in long-term care settings from 2012 to 2017 by analyzing thousands of death records, medical examiner reports, state inspections, court cases and incident reports.
Even in supervised settings, records show, older people find ways to end their own lives. Many used guns, sometimes in places where firearms weren’t allowed or should have been securely stored. Others hanged themselves, jumped from windows, overdosed on pills or suffocated themselves with plastic bags. (The analysis did not examine medical aid-in-dying, a rare and restricted method by which people who are terminally ill and mentally competent can get a doctor’s prescription for lethal drugs. That is legal only in seven states and the
Descriptions KHN unearthed in public records shed light on residents’ despair: Some told nursing home staff they were depressed or lonely; some felt that their families had abandoned them or that they had nothing to live for. Others said they had just lived long enough: “I am too old to still be living,” one patient told staff. In some cases, state inspectors found nursing homes to blame for failing to heed suicidal warning signs or evicting patients who tried to kill themselves.
A better understanding is crucial: Experts agree that late-life suicide is an under-recognized problem that is poised to grow.
By 2030, all baby boomers will be older than 65 and 1 in 5 U.S. residents will be of retirement age, according to census data. Of those who reach 65, two-thirds can expect to need some type of long-term care. And, for poorly understood reasons, that generation has had higher rates of suicide at every stage, said Dr.
“The rise in rates in people in middle age is going to be carried with them into older adulthood,” he said.
Long-term care settings could be a critical place to intervene to avert suicide — and to help people find meaning, purpose and quality of life, Mezuk argued: “There’s so much more that can be done. It would be hard for us to be doing less.”
‘In A Desperate Place’
In
Anders, a taciturn Army veteran, lived a low-key retirement in
Following the
Anders landed at the Bay at
In his week in the
His children scrambled to transfer him elsewhere, but they ran out of time. On
“I firmly believe that had he had better care, it would’ve been a different ending,”
Research shows events like losing a spouse and a new cancer diagnosis put people at higher risk of suicide, but close monitoring requires resources that many facilities don’t have.
Nursing homes already struggle to provide enough staffing for basic care. Assisted living centers that promote independence and autonomy can miss warning signs of suicide risk, experts warn.
In the weeks before and after Anders’ death, state inspectors found a litany of problems at the facility, including staffing shortages. When inspectors found a patient lying on the floor, they couldn’t locate any staff in the unit to help.
Merely having a suicide on-site does not mean a nursing home broke federal rules. But in some suicides KHN reviewed, nursing homes were penalized for failing to meet requirements for federally funded facilities, such as maintaining residents’ well-being, preventing avoidable accidents and telling a patient’s doctor and family if they are at risk of harm.
For example:
An 81-year-old architect fatally shot himself while his roommate was nearby in their shared room in a
Prevention needs to start long before these deaths occur, with thorough screenings upon entry to the facilities and ongoing monitoring, Conwell said. The main risk factors for senior suicide are what he calls “the four D’s”: depression, debility, access to deadly means and disconnectedness.
“Pretty much all of the factors that we associate with completed suicide risk are going to be concentrated in long-term care,” Conwell said.
Most seniors who choose to end their lives don’t talk about it in advance, and they often die on the first attempt, he said.
‘I Choose This “Shortcut”’
That was the case for the Rev.
“My father was an infinitely deliberate person,” said
At 90, the Methodist minister and human rights activist had a long history of making what he saw as unpopular but morally necessary decisions. He drew controversy in the pulpit in the 1950s for inviting African Americans into his
In 2013, facing a possible second bout of congestive heart failure and the decline of his beloved wife, Ruth, who had dementia, Andrews made his final decision. On Valentine’s Day, he took a handful of sleeping pills, pulled a plastic bag over his head and died.
“Fare-well! I am ready to die! I choose this ‘shortcut,’” it read in part. “I love you all, and do not wish a long, protracted death — with my loved ones waiting for me to die.”
“Elder suicide is an issue that we take seriously and work to prevent through the formal and informal support systems that we have in place,” she said.
At first,
“I always feel like he was gone too soon, even though I don’t think he felt like that at all,” he said.
Andrews has come to believe that elderly people should be able to decide when they’re ready to die.
“I think it’s a human right,” he said. “If you go out when you’re still functioning and still have the ability to choose, that may be the best way to do it and not leave it to other people to decide.”
That’s a view shared by
“The older you get, the more of your life you’ve already lived — hopefully, enjoyed — the less of it there is to look forward to,” said Davis, who has publicly discussed her desire to end her own life rather than die of dementia, as her mother did.
But Conwell, a leading geriatric psychiatrist, finds the idea of rational suicide by older Americans “really troublesome.” “We have this ageist society, and it’s awfully easy to hand over the message that they’re all doing us a favor,” he said.
‘So Preventable’
When older adults struggle with mental illness, families often turn to long-term care to keep them safe.
A jovial social worker who loved to dance,
Karpas enjoyed watching the sunset from the large, fourth-story window of her room at Ebenezer Loren on Park. But she had trouble adjusting to the sterile environment, according to son
“I do not want to live here for the rest of my life,” she told him.
On
Karpas, 79, was declared dead at the scene.
Schultz said he thinks the death was premeditated, because his mother took off her eyeglasses and pulled a stool next to the window. Escaping was easy: She just had to retract a screen that rolled up like a roller blind and open the window with a hand crank.
Pahlen said she believes medication mismanagement — the staff’s failure to give Karpas her regular mood stabilizer pills — contributed to her suicide. But a state health department investigation found staffers were not at fault in the death.
“Where do I even begin to heal from something that is so painful, because it was so preventable?” said
Nationwide, about half of people who die by suicide had a known mental health condition, according to the
That often leads caregivers, families and patients themselves to believe that depression is inevitable, so they dismiss or ignore signs of suicide risk, said Conwell.
“Older adulthood is not a time when it’s normal to feel depressed. It’s not a time when it’s normal to feel as if your life has no meaning,” he said. “If those things are coming across, that should send up a red flag.”
Solutions
Still, not everyone with depression is suicidal, and some who are suicidal don’t appear depressed, said
In the past 18 months, three suicides occurred at assisted living centers in the rural central
“He was very methodical. He had it planned out,” Rickard said. “Had the staff been trained, they would have been able to prevent it. Because none of them had been trained, they missed all the signs.”
Tiedemann, known as “Dutch,” lived there with his wife, Mary, who has dementia. The couple had nearly exhausted resources to pay for their care and faced moving to a new center, said their daughter,
After Tiedemann’s death, Davis moved her mother to a different facility in a nearby city.
At the facility where Tiedemann died, Rickard met with the residents, including many who reported thoughts of suicide.
“The room was filled with people who wanted to die,” she said. “These people came to me to say: ‘Tell me why I should still live.’”
Most suicide prevention funding targets young or middle-aged people, in part because those groups have so many years ahead of them. But it’s also because of ageist attitudes that suggest such investments and interventions are not as necessary for older adults, said
“Life at 80 is just as possible as life at 18,” Reed said. “Our suicide prevention strategies need to evolve. If they don’t, we’re going to be losing people we don’t need to lose.”
Even when there are clear indications of risk, there’s no consensus on the most effective way to respond. The most common responses — checking patients every 15 minutes, close observation, referring patients to psychiatric hospitals — may not be effective and may even be harmful, research shows.
But intervening can make a difference, said
She recalled a 98-year-old woman who entered a local nursing home last year after suffering several falls. The transition from the home she shared with her elderly brother was difficult. When the woman developed a urinary tract infection, her condition worsened. Anxious and depressed, she told an aide she wanted to hurt herself with a knife. She was referred for psychological services and improved. Weeks later, after a transfer to a new unit, she was found in her room with the cord of a call bell around her neck.
After a brief hospitalization, she returned to the nursing home and was surrounded by increased care: a referral to a psychiatrist, extra oversight by aides and social workers, regular calls from her brother. During weekly counseling sessions, the woman now reports she feels better. Barbera considers it a victory.
“She enjoys the music. She hangs out with peers. She watches what’s going on,” Barbera said. “She’s 99 now — and she’s looking toward 100.”
If you or someone you know has talked about contemplating suicide, call the National Suicide Prevention Lifeline at 1-800-273-8255, or use the online Lifeline Crisis Chat, both available 24 hours a day, seven days a week.
People 60 and older can call the Institute on Aging’s 24-hour, toll-free Friendship Line at 800-971-0016. IOA also makes ongoing outreach calls to lonely older adults.
Crédito: