Chapter 1 - The Epidemiology of Suicide

			     CHAPTER 1			       Page 9


	      "The psychoanalytic theories of suicide prove,

	      perhaps, only what was already obvious:  that

	      the processes which lead a man to take his own

	      life are at least as complex and difficult as

	      those by which he continues to live.  The

	      theories help untangle the intricacy of motive

	      and define the deep ambiguity of the wish to

	      die but say little about what it means to be

	      suicidal, and how it feels.  "

	      - A. Alvarez, The Savage God

	  Suicide is the eighth leading cause of death in the United

    States.(1) Based on the assumption that suicide is not a rational

    choice, society has long sought to prevent or discourage the

    practice.  In fact, society has generally regarded a suicide attempt

    as a plea for help or an indication of a need for psychiatric

    treatment.  The debate about legalizing assisted suicide and

    euthanasia has challenged these assumptions, suggesting that for at

    least some individuals, society should shift from prevention to

    toleration or assistance.

	  Central to the current discussion of assisted suicide and

    euthanasia is a need to understand the nature of suicide, the

    motivation of individuals who commit suicide, and the specific risk

    factors.  Suicide outside the context of terminal or chronic illness

    has been the subject of extensive study by sociologists,

    psychiatrists, and epidemiologists.  Their findings shed light on

    the phenomenon of suicide overall, and on the motivations of those

    who request suicide when facing a terminal or severe illness.

    According to available data, only a small percentage of terminally

    ill or severely ill patients attempt or commit suicide.  What

    distinguishes their life circumstances, medical conditions, or

    outlook from those who are also severely ill and do not attempt

    suicide?  What do they have in common with individuals who do not

    face physical illness and attempt or commit suicide?


      (1)   G. Winokur and D. W. Black, "Suicide - What Can Be Done,"

	    New England Journal of Medicine 327 (1992):  490-91.

     page 10		   WHEN DEATH IS SOUGHT

	  Data about the desire for and incidence of suicide are not

    available for all patient populations.  However, important studies

    have been conducted of acquired immunodeficiency syndrome (AIDS) and

    cancer patients as well as the elderly.(2) In many respects, these

    conditions epitomize for the public the circumstances under which

    suicide might be considered a rational choice.

Suicide in the General Population

	  Overall, 2.9 percent of the adult population attempts

    suicide,(3) and the suicide rate in the general population over a

    lifetime of 70 years is approximately one percent.(4) Studies of

    suicide attempters suggest that one percent to two percent complete

    suicide within a year after the initial attempt, with another one

    percent committing suicide in each following year.(5) Suicide is

    especially prevalent among the young and the elderly.  It is the

    third leading cause of death for individuals 15 to 24 years of age.

    Over the last 30 years, the suicide rate in this age group has

    increased dramatically.(6) Among younger people who attempt suicide,

    between 0.1 percent and 10 percent will eventually commit suicide.

    Yet it is the elderly who have the highest rates of suicide --

    overall suicide rates for individuals over 65 were approximately 22

    per 100,000 in 1986.(7)


    (2)	   See chapter 2 for a discussion of suicide and special patient


    (3)	   D. C. Clark, "Rational Suicide and People with Terminal

	   Conditions or Disabilities," Issues in Law and Medicinc 8


    (4)	   Depression Guideline Panel, Depression in Primary Care, vol.

	   1, Detection and Diagnosis, Clinical Practice Guideline, no. 5,

	   AHCPR pub. no. 93-0550 (Rockville, Md.:  U. S. Department of Health

	   and Human Services, Public Health Sec, Agency for Health Care Policy

	   and Research, April 1993), 36.

    (5)	   G. M. Asnis et al., "Suicidal Behaviors in Adult Psychiatric

	   Outpatients, I:Description and Prevalence," American Journal of

	   Psychiatry 150 (1993): 108-12.

    (6)	   In 1950 the rate for adolescent suicides was 2.7 per 100,000;

	   in 1980 the rate increased to 8.5 per 100,000.  C. Runyan and E. A.

	   Gerken, "Epidemiology and Prevention of Adolescent Injury:

	   A Review  and Research Agenda," Journal of the American Medical

	   Association 262 (1989):  2273-79.

    (7)	   P.J.  Meehan, L.E.  Saltzman, and R.W.  Sattin, "Suicide

	   Among Older United States Residents:  Epidemiologic

	   Characteristics and Trends," American Journal of Public

	   Health 81 (1991): 1198-1200.


	  Suicide is generally described as the intentional taking of

    one's own life.  For the individual who commits suicide, the act

    usually represents a solution to a problem or life circumstance that

    the individual fears will only become worse.(8) Believing that their

    suffering will continue or intensify, suicidal individuals can

    envision no option but death.  As articulated by a prominent

    suicidologist, the common stimulus to suicide is intolerable

    psychological pain.  Suicide represents an escape or release from

    that pain.(9)

	  Contrary to popular opinion, suicide is not usually a reaction

    to an acute problem or crisis in one's life or even to a terminal

    illness.  Single events do not cause someone to commit suicide.

    Instead, certain personal characteristics are associated with a

    higher risk of attempting or committing suicide.  The way in which

    an individual copes with problems over the course of his or her life

    usually indicates whether the person is emotionally predisposed to

    suicide.  Studies that examine the psychological background of

    individuals who kill themselves show that 95 percent have a

    diagnosable mental disorder at the time of death.  Depression,

    accompanied by symptoms of hopelessness and helplessness, is the

    most prevalent condition among individuals who commit suicide.  This

    is especially true of the elderly, who are more likely than the

    young to commit suicide during an acute depressive episode.

	  In general, individuals who attempt suicide differ from those

    who complete suicide.  Suicide attempters are likely to be female

    and generally attempt suicide by taking an overdose of medication.

    Suicide completers, by contrast, are more often male and tend to use

    more lethal means.(10) Approximately 40 percent of patients who

    commit suicide have made previous suicide attempts.  (11) Thoughts

    about suicide, referred to as "suicidal ideation," are an important

    risk factor for suicide.  However, many individuals experience

    suicidal ideation but never commit or attempt suicide.  This is

    especially true for patients with advanced terminal illness or

    debilitating chronic illness.


    (8)	    A. Alvarcz describes how it feels to be suicidal as

	    follows:  The logic of suicide is different.  It is like the

	    unanswerable logic of a nightmare, or like the science-fiction

	    fantasy of being projected suddenly into another dimension:

	    everything makes sense and follows its own strict rules; yet at

	    the same time, evething is also different, perverted, upside

	    down.  Once a man decides to take his own life he enters a

	    shut-off, impregnable but wholly convincing world where every

	    detail fits and each incident reinforces his decision."  A.

	    Alvarez, The Savage God: A Study of Suicide (New York:  Random

	    House, 1970),121.

    (9)	    E. S. Shneidman, "Some Essentials for Suicide and Some

	    Implications for Response," in Suicide, ed.  A. Roy (Baltimore:

	    Williams and Wilkins, 1986), 1-16.

    (10)    S. B. Sorenson, "Suicide Among the Elderly:  Issues

	    Facing Public Health," American Journal of Public Health 81

	    (1991):  1109-10.

    (11)    Asnis et al.

    page 12		   WHEN DEATH IS SOUGHT

	  The highest rates of suicide occur among patients with major

    affect or mood disorders (including depression), alcoholics, and

    schizophrenics.  Individuals with clinical, or major, depression

    have a 15 percent rate of suicide.  Ten percent of schizophrenics

    commit suicide, while alcoholism carries a four percent to six

    percent risk.(12) The elderly are also at increased risk for suicide

    and depression,(13)especially elderly white males, who have a

    suicide rate five times that of the general population.(14)

	  Individuals who commit suicide generally have no history of

    mental health treatment, although they often evidence a major

    psychiatric illness at the time of death.  The primary risk factors

    for completed suicides are major depression, substance abuse, severe

    personality disorders, male gender, older age, living alone,

    physical illness, and previous suicide attempts.  For terminally ill

    patients with cancer and AIDS, several additional risk factors are

    also present.(15)

	  Another significant predictor of suicide is a feeling of

    hopelessness or helplessness, a principal symptom of depression.

    Hopelessness is the common factor that links depression and suicide

    in the general population.  In fact, hopelessness is a better

    predictor of completed suicide than depression alone.(16) Feelings

    of hopelessness and helplessness interact with the perception of

    psychological pain and the individual's sense that his or her

    current suffering is inescapable.

	  Individuals who are terminally ill constitute only a small

    portion of the total number of suicides.  In fact, most people who

    kill themselves are in good physical health.  Among all suicides,

    only two percent to four percent are terminally ill.(17) One study

    of adults over 50 years of age showed that more individuals

    committed suicide in the mistaken belief that they were dying of

    cancer than those who actually had a terminal illness and committed


     (12)     Clark.

     (13)     H. Hendin and G. Klerman, "Commentary: Physician-Assisted

	      Suicide:  The Dangers of Legalization,"  American Journal

	      of Psychiatry 150 (1993): 143-45.

     (14)     Y. Conwell and E. D. Caine, "Rational Suicide and the

	      Right to Die:  Reality and Myth," New England Journal of

	      Medicine 325 (1991):  1100-1103.

     (15)     See chapter 2 for discussion.

     (16)     W. Breitbart, "Suicide Risk and Pain in Cancer and

	      AIDS Patients," in Current and Emerging Issues in Cancer Pain:

	      Research and Practice, ed.  C. R. Chapman and K. M. Foley

	      (New York: Raven Press, 1993), 49-65.

     (17)     Clark.


    suicide.  The study supports the estimate that two thirds of older

    persons who die by suicide are in relatively good physical


	  Individuals with serious chronic and terminal illness face an

    increased risk of suicide -- some studies suggest that the risk for

    cancer patients is about twice that of the general population.  Some

    experts, however, have observed that many terminally ill patients

    experience a phenomenon called "cancer cures psychoneuroses."  This

    phenomenon occurs when patients become aware that they have cancer

    or another progressive terminal illness, and the process of facing

    and mastering their fear of death dissolves many other anxieties or

    neuroses.  As explained by one psychiatrist, "As one's focus turns

    from the trivial diversions of life, a fuller appreciation of the

    elemental factors in existence may emerge."(19)

	  Thus, some terminally ill patients may exhibit lower

    psychological stress than might be expected.  Apart from

    circumstances where patients are depressed, terminally ill

    individuals are often resilient, and fight for life throughout their

    illness.  Studies indicate that for many patients with severe pain,

    disfigurement, or disability, the vast majority do not desire

    suicide.  In one study of terminally ill patients, of those who

    expressed a wish to die, all met diagnostic criteria for major

    depression.(20) Like other suicidal individuals, patients who desire

    suicide or an early death during a terminal illness are usually

    suffering from a treatable mental illness, most commonly


 Risk Factors for Suicide


	  Depression, including major depression and depressive

    symptoms, is a critical risk factor for completed suicides.(22)


  (18)	  Ibid.

  (19)	  F. P. McKegney and M. A. O'Dowd, "Clinical and

	  Research Reports:  Suicidality and HIV Status,"American

	  Journal of Psychiatty 149 (1992):  396-98.

  (20)	  J. H. Brown et al., "Is It Normal for Terminally Ill

	  Patients to Desire Death?"  American Journal of Psychiatry 143


   (21)	  Ibid.

   (22)	  As early as the 17th century, writers identified a

	  link between depression or melancholy and suicide.  The Anatomy

	  of Melancholy, written in 1621 by Richard Burton, identified

	  melancholy as a medical and psychological phenomenon.  The

	  author argued that suicide "is the result of melancholy that

	  desires self-destruction:  'In other diseases there is some hope

	  likely, but these unhappy men are born to misery, past all hope

	  of recovery, invariably sick, the longer they live the worse

	  they are, and death alone must ease them."' T. L. Beauchamp,

	  "Suicide in the Age of Reason," in Suicide and Euthanasia:

	  Historical and Contemporary Themes, ed.  B. A. Brody (Dordrecht:

	  Kulwer Academic Publishers, 1999),172.

    page 14		       WHEN DEATH IS SOUGHT

	  Depression is present in 50 percent of all suicides, and those

    suffering from depression are at 25 times greater risk for suicide

    than the general population.(23) In addition, older persons with

    depression are more likely to commit suicide than younger persons

    who are depressed.(24)

	  The prevalence of major depressive disorder in western

    industrialized nations is 2.3 percent to 3.2 percent for men and 4.5

    percent to 9.3 percent for women.  An individual's lifetime risk of

    depression ranges from seven percent to 12 percent for men and 20

    percent to 25 percent for women.  Studies indicate that the risk of

    depression is not related to race, education, or income.(25)

	  The general population.  Depressive disorders should clearly

    be distinguished from realistically depressed or sad moods that may

    accompany specific losses or disappointments in life.  Clinical

    depression is a syndrome described as an abnormal reaction to life's

    difficulties.  In addition to sadness, clinical depression

    encompasses a variety of symptoms:  pervasive despair or

    irritability, hopelessness, loss of interest in activities that are

    usually considered enjoyable, trouble sleeping or excessive

    sleeping, appetite loss or weight change, fatigue, and preoccupation

    with death or suicide.

	  The Diagnostic and Statistical Manual of Mental Disorders,

    third edition, revised (DSM-III-R), published in 1987 by the

    American Psychiatric Association, lists criteria for major

    depression.(26) At least five of the following symptoms must be

    present during the same period, one of which must be depressed mood

    or loss of interest or pleasure, to satisfy these criteria for

    depression.  Symptoms must be evident most of the day, on a daily

    basis for at least two weeks:

		    1. depressed mood

		    2. markedly diminished interest or pleasure in

		       almost all activities

		    3. significant weight loss/gain

		    4. insomnia/hypersomnia

		    5. psychomotor agitation/retardation

		    6. fatigue

		    7. feelings of worthlessness (guilt)

		    8. impaired concentration (indecisiveness)

		    9. recurrent thoughts of death or suicide.


    (23)   W. Breitbart, "Cancer Pain and Suicide," in Advances

	   in Pain Research and Therapy, ed.  K. M. Foley et al., vol

	   (New York:  Raven Press, 1990), 399-412.

    (24)   Clark.

    (25)   Depression Guideline Panel, 23.

    (26)   Ibid., 18.


	  Unfortunately, because a common symptom of depression is a

    loss of insight and a feeling of hopelessness, depressed people

    usually have little understanding of the severity of their illness.

    They are often the last to recognize their problem and seek help.

    It is therefore critical that primary care physicians develop the

    skills to recognize depression in patients, particularly the

    terminally ill and elderly, whose depressive symptoms may be masked

    by coexisting medical conditions such as dementia or coronary artery


	  Risk factors for major depressive disorder.  Overall, women

    have higher rates of depression than men.  Individuals with a

    history of depressive illness in first-degree relatives are also

    more prone to depression.  Prior suicide attempts and prior episodes

    of major depression also place individuals at risk.  Other important

    risk factors for major depression include onset of depression under

    age 40, postpartum period, lack of social support, stressful life

    events, and current alcohol or substance abuse.  In addition, other

    general medical conditions are risk factors for major depression.

    Depressive symptoms are detectable in approximately 12 percent to 16

    percent of patients with another nonpsychiatric medical

    condition.(27) When major depression is present, it should be

    treated as an independent condition.

	  Depression may coincide with other medical conditions for

    several reasons.  First, the medical condition may biologically

    cause depression.  Second, the condition may trigger depression in

    patients who are genetically predisposed to depression.  Third, the

    presence of illness or disease can psychologically cause depression,

    as is often observed in patients with cancer.  Finally, especially

    for cancer patients, some treatments or medications have side

    effects that cause depressive moods or symptoms.

	  A wide range of chronic illnesses are associated with an

    increased risk of depression.  Studies indicate that patients with

    dementia illnesses such as Parkinson's, Huntington's, and

    Alzheimer's diseases have higher rates of major depression.

    Diabetes patients are three times as likely as the general

    population to develop major depression.(28)


     (27)   Ibid., 5.

     (28)   Ibid., 55-65.  This source discusses the incidence of

	    depression in several other chronic conditions - coronary artery

	    disease, chronic fatigue syndrome, fibromyalgia, and stroke.


    Treatment for depression in patients with chronic illness may

    offer patients the ability to adjust to the complex circumstances

    they face in coping with illnesses that are frequently debilitating

    and progressive.

	  Patients with advanced disease or terminal illness frequently

    experience many psychological symptoms, including anxiety, fatigue,

    and lack of concentration.  Terminally ill patients may also develop

    major depression or severe depressive symptoms.  Although it is

    normal and expected that terminally ill patients "feel sadness for

    the anticipated loss of health, life and all it means, and loss of a

    future with all that it might hold," most patients call upon their

    coping mechanisms to manage these feelings.(29) It is a myth,

    however, that severe clinical depression is a normal and expected

    component of terminal illness.

	  Healthy individuals, including health care professionals,

    often believe that it is normal for terminally ill patients to

    experience major depression.  They understand feelings of

    hopelessness as expected and rational given the patient's condition

    and prognosis.  As one psychiatrist explains:

	      Expressions like "I'd want to die if I

	      were in that situation" or "I'd be depressed

	      too" are common, even among health care

	      professionals.  This misunderstanding may

	      contribute to the poor diagnosis and treatment

	      of depression in patients with chronic or

	      terminal illness.  The presence of physical

	      symptoms that are associated with both the

	      illness and depression make the diagnosis even

	      more difficult.  Terminal illness as well as

	      depression may cause a patient to experience

	      physical symptoms of fatigue, apathy,

	      insomnia, weakness and loss of libido.(30)

	  For this reason, psychological symptoms of depression, such as

    hopelessness and helplessness, are often more reliable markers than

    physical symptoms in the assessment and treatment of major

    depression among individuals with chronic and terminal illness.

    Pain and Suffering

	  For some patients, uncontrolled pain is an important

    contributing factor for suicide and suicidal ideation.


    (29)   Jimmie C. Holland, Chief, Psychiatry Services, Memorial

	   Sloan-Kettering Cancer Center, "Letter to the Task Force on

	   Life and the Law," August 16, 1993.

    (30)   Ibid.


    Patients with uncontrolled pain may see death as the only

    escape from the pain they are experiencing.  However, pain is

    usually not an independent risk factor.  The significant variable in

    the relationship between pain and suicide is the interaction between

    pain and feelings of hopelessness and depression.  As stated by one

    psychiatrist:  "Pain plays an important role in vulnerability to

    suicide; however, associated psychological distress and mood

    disturbance seem to be essential co-factors in raising the risk of

    cancer suicide."(31)

	  Suffering represents a more global phenomenon of psychic

    distress.  While suffering is often associated with pain, it also

    occurs independently.  Different kinds of physical symptoms, such as

    difficulty breathing, can lead to suffering.  Suffering may also

    arise from diverse social factors such as isolation, loss, and


	  Pain.  The International Association for the Study of Pain

    defines pain as follows:

		    "An unpleasant sensory and emotional

	      experience associated with actual or potential

	      tissue damage, or described in terms of such

	      damage...  Pain is always subjective...  It is

	      unquestionably a sensation in a part or parts

	      of the body but it is also always unpleasant

	      and therefore an emotional experience.(32)

	  This definition reflects a distinction between pain and

    nociception.(33) Nociception refers to activity produced in the

    nervous system in response to potentially damaging ("noxious")

    stimuli.  Pain is the patient's perception of nociception.  A

    patient's pain reflects both the activity of his or her nervous

    system, and psychological, personal, and physiological factors.(34)

	  Different types of pain vary both in the way they affect

    patients and in their responsiveness to treatment.  Acute pain,

    which is of limited duration, may arise from injury or as a result

    of a surgical procedure.  Chronic pain is pain that persists well

    beyond the normal course of healing of a disease or injury or, most

    typically, is associated with chronic or progressive


    (3l)   Breitbart, "Suicide Risk and Pain," 54.

    (32)   International Association for the Study of Pain,

	   "Pain Terms:  A Current List with Definitions and Notes on

	   Usage," Pain (1986), suppl. 3, S217.

    (33)   Activity induced in the nociceptor and nociceptive

	   pathways by a noxious stimulus is not pain, which is always a

	   psychological state, even though we may well appreciate that

	   pain most often has a proximate physical cause."  Ibid.

    (34)   Portenoy, 3; International Association for the Study of

	   Pain; World Health Organization, Cancer Pain Relief

	   (Geneva:  World Health Organization, 1986), 9-10.

    page 18		 WHEN DEATH IS SOUGHT

    diseases.  Some types of pain are responsive to treatment

    while others, such as neuropathic pain or pain arising from chronic

    illness, are harder to treat.  Pain may be constant, or it may occur

    as a result of activity.  The characteristics of pain such as

    severity, quality (e.g., burning or stabbing), time course

    (continuous or intermittent), and location are important in

    assessing the nature of the pain.(35) Severity of pain may be less

    important than the patient's perception of pain and the fear of

    anticipated pain.

	  Pain may be characterized in terms of its mechanism or cause.

    Somatic pain, which may be caused by injury to a bone or damage to

    tissue, is generally localized and may be described as aching,

    stabbing, or pressure-like.  Visceral pain, such as that arising

    from obstruction of the intestine or ureter, is more poorly

    localized, and may be felt as aching or cramping.  Neuropathic pain

    results from damage to the nervous system.(36)

	  Pain is terribly real and immediately present for the person

    in pain, but can be less apparent to observers.  This divergence can

    lead to a sense of isolation on the part of the patient, and to

    inadequate responses by others in alleviating pain.

		    For the person in pain, so incontestably

	      and unnegotiably present is it that "having

	      pain" may come to be thought of as the most

	      vibrant example of what it is to "have

	      certainty," while for the other person it is

	      so elusive that "hearing about pain" may exist

	      as the primary model of what it is "to have

	      doubt."  Thus pain comes unsharably into our

	      midst as at once that which cannot be denied

	      and that which cannot be confirmed.(37)


    (35)    R. K. Portenoy, "Pain Assessment in Adults and

	    Children," in Why Do We Care?, Syllabus of the Postgraduate

	    Course, Memorial Sloan-Kettering Cancer Center, New York City,

	    April 2-4, 1992, 4-5; Acute Pain Management Guideline Panel,

	    Acute Pain Management:  Operative or Medical Procedures and

	    Trauma, Clinical Practice Guideline, AHCPR pub. no. 92-0032

	    (Rockville, Md.:  U. S. Department of Health and Human Services,

	    Public Health Service, Agency for Health Care Policy and

	    Research, February 1992), 7-14; E. Scarry, The Body in Pain:

	    The Making and Unmaking of the World (New York:  Oxford

	    University Press, 1985), 7-8.

    (36)    Portenoy, 4-5; Acute Pain Management Guideline Panel,

	    7-14; N. Coyle et al., "Character of Terminal Illness in the

	    Advanced Cancer Patient:  Pain and Other Symptoms During the

	    Last Four Weeks of Life," Journal of Pain and Symptom Management

	    5 (1990):  84.  While pain may arise primarily from

	    psychological causes, this is understood to occur only in rare


    (37)    Scarry, 4.

	   CHAPTER 1 - The EPIDEMIOLOGY OF SUICIDE	       page 19

	  In recent decades, new approaches have been developed to

    assess and report pain.  Self-reporting of pain by patients is

    central to pain assessment.  While self-reporting can be

    supplemented by physiological and behavioral observation, it is

    widely recognized that patients' behavior and physiological

    characteristics do not always correlate with the level of pain

    experienced by the patient.(38) Assessing and reporting pain is

    critical to effective pain relief.(39) It can also lead to important

    information about other aspects of the patient's medical condition,

    alerting the patient to disease and preventing further injury.(40)

	  Different types of pain impose different burdens for patients

    and present distinct challenges to health care professionals.  Acute

    pain and chronic pain differ both physiologically and in the

    difficulties they entail.  Acute pain has a well-defined temporal

    pattern of onset, and generally results from potentially damaging

    stimuli associated with injury or disease.  It usually is associated

    with observable physical signs and responses of the autonomic

    nervous system.  Acute pain usually does not persist beyond days or


	  Chronic pain has been defined as "pain that persists a month

    beyond the usual course of an acute disease or a reasonable time for

    an injury to heal or that is associated with a chronic pathological

    process that causes continuous pain or pain [that] recurs at

    intervals for months or years."(42) Chronic pain may be caused by a

    patient's chronic or progressive disease, or by prolonged

    dysfunction of the nervous system.  Although chronic pain may be

    severe and debilitating, a patient in chronic pain may not display

    the objective signs associated with acute pain.  Chronic pain may


     (38)    Acute Pain Management Guideline Panel, 7-14;

	     International Association for the Study of Pain, Task Force on

	     Professional Education, Core Curriculum for Professional

	     Education in Pain (Seattle:  IASP Publications, 1991), 4-7,


     39)     The American Pain Society reports that "the most

	     common reason for unrelieved pain in U.S. hospitals is the

	     failure of staff to routinely assess pain and pain relief."

	     Principles of Analgesic Use in the Treatment of Acute Pain and

	     Cancer Pain, 3d ed. (Skokie, Ill.:  American Pain Society,

	     1992), 2. A similar view was shared by 76% of respondents in a

	     survey of cancer specialists.  J. H. Von Roenn et al.,

	     "Physician Attitudes and Practice in Cancer Pain Management:  A

	     Survey from the Eastern Cooperative Oncology Group,"Annals of

	     Internal Medicine 119 (1993):121-26.

     (4O)    Portenoy, 5; Acute Pain Management Guideline Panel.

     (41)    K. M. Foley, "The Treatment of Cancer Pain," New

	     England Journal of Medicine 3 (1985):  85; J. J. Bonica,

	     "Definitions and Taxonomy of Pain," in The Management of Pain,

	     ed.  J. J. Bonica, 2d ed.  (Philadelphia:  Lea and Febiger,


     (42)    Bonica, 19.

     page 20		     WHEN DEATH IS SOUGHT

    therefore be less visible, adding to the burden individuals

    face in coping with the pain in their daily activities and

    relationships with others.

	  Millions of patients in the United States experience

    significant or severe chronic pain.  Among the most common

    conditions are recurrent severe headaches, back disorders, and

    arthritis.  Pain may also arise from other chronic illnesses such as

    sickle cell disease, nerve injury, and sinusitis.

	  Chronic pain often entails serious physical, emotional, and

    financial burdens for the patient and those closest to him or her.

    The physical symptoms arising from chronic pain are distressing:

    loss of sleep, a decline in physical activity, fatigue, and

    progressive physical deterioration.  It can lead to changes in the

    patient's personality and life-style, affecting the ability to carry

    out even the simplest daily tasks.(43 As described by one physician,

    chronic illness also entails mourning over the loss of good health

    and a constant struggle to avoid the next episode of illness:

		    "Each time the cycle of symptoms begins,

	      the sufferer loses faith in the dependability

	      and adaptability of basic bodily processes

	      that the rest of us rely on as part of our

	      general sense of well-being.  This loss of

	      confidence becomes grim expectation of the

	      worst, and, in some, demoralization and

	      hopelessness.  ...The fidelity of our bodies

	      is so basic that we never think of it --- it

	      is the certain grounds of our daily

	      experience.  Chronic illness is a betrayal of

	      that fundamental trust.(44)

	  Physical symptoms.  Many patients who are terminally or

    chronically ill undergo distressing physical symptoms in addition to

    pain.  These symptoms may include dyspnea (difficulty in breathing),

    nausea, diarrhea, constipation, and fatigue.  Multiple symptoms may

    be present simultaneously.  In advanced cancer patients, for

    instance, "pain, dyspnea and other symptoms do not occur in

    isolation:  they interact so as to produce a `crescendo' effect.

    The dyspneic patient will experience increasing anxiety and rapid

    breathing, which may then exacerbate pain arising from metastases in

    the ribs and spine."(45)


	 (43)	 Foley, 85; Bonica, "Definitions and Taxonomy of Pain,"19;

		 Bonica, Management Of Pain, 189-95.

	 (44)	 A. Kleinnian, The Illness Narratives:  Suffering

		 Healing, and the Human Condition (New York:  Basic Books,

		 1988), 45.

	 (45)	 World Health Organization, Cancer Pain Relief and

		 Palliative Care:  Report of a WHO, Expert Committee, WHO

		 Technical Report Series 804 (Geneva:  World Health

		 Organization, 1990),41.


    Both pain and other physical symptoms directly diminish a

    patient's quality of life.  Apart from the experience of pain or

    discomfort itself, pain and other symptoms of serious illness may

    severely limit a patient's activities, denying some patients the

    capacity to engage in the activities of daily living most important

    to their sense of well-being and self.(46)

	  Severe or chronic pain can be associated with mild or severe

    disability as well as psychological conditions, such as major

    depression.(47) Patients with terminal illness and those with a

    nonterminal condition may suffer from chronic pain.  To date,

    medicine has less experience treating chronic pain for nonterminal

    patients.  While most pain arising from terminal illness responds to

    treatment, the alleviation of pain caused by nonterminal, chronic

    illness is less certain.(48)

	  Suffering.  Suffering is a more global experience of impaired

    quality of life.(49) As defined by one physician, suffering is "the

    state of severe distress associated with events that threaten the

    intactness of the person."(50) The threat might be to the person's

    existence or integrity, to maintaining his or her role in the family

    or in society, or to his or her sense of self and identity.  While

    pain and suffering are often associated, minor pain can occur

    without causing suffering, and suffering can occur in the absence of

    physical pain.  Distressing physical symptoms and disabilities can

    lead to intense suffering for patients with degenerative disorders

    such as amyotrophic lateral sclerosis (ALS), or those who are

    quadriplegic as the result of a spinal cord injury.  Moreover,

    suffering is not limited to medical patients.  Suffering may arise

    from many causes, including physical incapacity, social isolation,

    fear, the death of a loved one, or frustration of a cherished



    (46)    Coyle et al.

    (47)    M.  J. Massie and J. C. Holland, "The Cancer Patient

	    with Pain:  Psychiatric Complications and Their Management,"

	    Journal of Pain and Symptom Management 7 (1992):  100-101;

	    Breitbart, "Cancer Pain and Suicide," 404; R. K. Portenoy,

	    "Overview of Symptom Prevalence and Assessment," in Why Do We

	    Care?, Syllabus of the Postgraduate Course, Memorial

	    Sloan-Kettering Cancer Center, New York City, April 2-4,

	    1992, 183-89.

    (48)     World Health Organization, Cancer Pain Relief, 10.

	     On the treatment of chronic pain see Chapter 3.

    (49)     Portenoy, 3.

    (50)     E. J. Cassell, "The Nature of Suffering and the

	     Goals of Medicine," New England Journal of Medicine 306

	     (1982):  640.

    (51)     Ibid., 64l-44.

    page 22		     WHEN DEATH IS SOUGHT

	  Even more so than with pain, an individual's experience of

    suffering reflects his or her unique psychological and personal

    characteristics.  Suffering is in effect the experience of severe

    psychological pain, arising from medical or personal causes.

    Because the experience of suffering is subjective, people are often

    unaware of the causes or extent of another person's suffering.

    Ultimately, suffering is a distinctly human, not a medical,