Is There an “Epidemic” of Suicide Among the Elderly?

(The author is a former professor of sociology at the University of California, Davis. Her book Passing On: What’s Fair in Family Inheritance? explores the ethical and practical challenges of deciding how to distribute our worldly goods when we die – Jay Niver, editor)

Word has it that elders’ suicides are out of control. Google “suicide in the elderly,” and you’ll find it described as a “quiet epidemic,” a “needless tragedy,” a “pressing public health concern.” You’ll learn that “older Americans are quietly killing themselves” in nursing homes and assisted-living centers. That, compared with the suicide rate in the U.S. at all ages, the rate for those aged 85 and older is “alarmingly high.”

But is it? No. According to the National Vital Statistics Reports, Deaths in 2018 (the most recent available data), only 1,248 of the 880,280 women and men ages 85 and over who died that year were suicides. About twice that number were reported for 75-to-84 year-olds.

True, the suicide rate at age 85 and over, 19.1 per 100,000 population, is higher than average, especially for men. But that’s only because the denominator – the size of the population that age – is small.

Suicides are undercounted, of course – perhaps more so among the elderly, where many are likely attributed to pre-existing medical conditions. Death-with-dignity laws that permit some terminally ill persons to receive medical aid in dying declare the cause of death to be the fatal illness. The same is true for someone who foregoes life-prolonging medical treatments or self-administers a lethal dose of morphine in hospice care. Some alcohol- and drug-related deaths and accidents may mask intent.

But even if we multiply reported suicides by, say, 10, that’s still only 12,480 in the population aged 85 and over in 2018. Compared with the almost 900,000 this age who died that year, this is a mere blip.

Given – as Atul Gawande writes in Being Mortal: Medicine and What Matters in the End –that most elders will spend significant periods “too reduced and debilitated to live independently,” why don’t many more end their own lives? We can postulate many reasons, but one is surely the outright denial of our rights as seniors to end our lives on our own terms. The media, healthcare institutions and legislators, buttressed by social attitudes, are all complicit.

In April 2019, PBS NewsHour ran a story called Lethal Plans: When Seniors Turn to Suicide in Long-Term Care. “Hundreds of suicides by older adults each year – nearly one per day – are related to long-term care,” we’re told. “Thousands more people may be at risk in those settings, where up to a third of residents report suicidal thoughts.”

An industry spokesperson responds that suicides are rare. He’s right about that. But, he adds, such deaths are “horrifically tragic” when they do occur. Most facilities offer “a very supervised environment,” and those who receive Medicare or Medicaid funding are required to monitor patients for suicidal behavior.

Let’s consider what we’re being told here: “Nearly one” suicide per day? Surely that’s very low, even if we multiply by 10. “Thousands more may be at risk.” A systematic review of studies of long-term care facilities did find that active or passive suicidal thoughts are common among residents – from 5 to 33 percent in the past month across the facilities with comparable data. But suicidal thoughts can mean many things: a definite plan, a wish, a threat, a fantasy? How do we interpret such findings?

The psychiatric literature tends to view “suicidal ideation” almost by definition as a sign of mental illness associated with clinical conditions such as depression, schizophrenia, impulsivity, cognitive impairment, and even “maladaptive emotion regulation.” Less-clinical approaches identify factors such as social isolation, loneliness, and functional decline.

Largely missing from this discourse, however – except when adorned with quotation marks – is the concept of rational suicide as a thoughtful decision made in the context (or anticipation) of a set of circumstances that a person is not willing to tolerate. Not a mental illness or an idle impulse – in other words, a considered choice. Yet, the overriding institutional response to the “risk” of suicide is clear: All seniors who express or even harbor such thoughts must be rescued, treated, protected, stopped.

Lethal Plans assures us that most facilities offer a “very supervised environment,” but this can easily morph into policing in the name of protection. State inspectors blame nursing homes for failing to heed suicidal warning signs or for evicting patients who tried to kill themselves, we’re told, and assisted-living centers that promote independence and autonomy can miss warning signs of suicide risk.

We’re warned that most seniors who choose to end their lives don’t talk about it in advance. Of course they don’t. Spill the beans, and psychiatrists, social workers, family members, legal proxies, and other gatekeepers may be summoned; security staff alerted; rooms searched; rights trampled. “If suicide is a concern,” an addendum to the PBS program advises, “restrict access to lethal means, including weapons, medications, chemicals, cords and plastic bags. Ensure that windows, stairwells and exits are secure.” This sounds like policing to me.

Full disclosure: I live happily in a light-filled studio apartment on the 15th floor of a nonprofit senior residential community. Most of us are in “independent living,” but many will move to assisted living, memory care, or skilled nursing over time. Our management supports voluntarily stopping of eating and drinking (VSED) as well as medical aid in dying (MAiD) for those who are eligible under California’s End of Life Option Act. However, residents exercising these options must bring in medical providers, caregivers, and companions from outside.

Other than these two options, residents are told that taking matters into our own hands is unacceptable.

“If staff were to become aware of a resident contemplating this scenario and trying to harm themselves,” a memo explains, “they should … refer the resident to appropriate interventions, such as spiritual care and psychological care. Residents trying to follow the Final Exit Network’s guidance on methods of self-deliverance or do-it-yourself ways to end your life pose a risk to themselves, other residents and our staff.”

It’s difficult to understand how preventing people of advanced age from ending their lives safely when they are “ready to go” poses risks to others. Who defines “a good life” or “a good death” or even “good care,” if not ourselves? We need to normalize the discussion about end-of-life options to encompass informed and self-managed exits as legitimate personal choices.

Health systems and lifetime care communities that support VSED and MAiD could adopt comparable guidelines and facilities for safe and comfortable self-deliverance. Just knowing that this option is possible, whether or not one actually exercises it, can be a comfort. It certainly is for me.

I hope that I can make my final exit here in my studio. I will be diligent about protecting the staff and other residents from exposure to lethal substances or the aftermath of a peaceful death. I will try to make clear that my departure in no way reflects on the quality of care or the warmth and congeniality of the community.

What it will reflect is the determination to end my life on good terms, while I’m still mentally and physically capable of doing so. Because I’m approaching age 85, I’ll be adding to the “epidemic” of elder suicides. It won’t be self-harm, however.  And it won’t be anyone’s fault. Quite the contrary: It will be a simple, self-affirming declaration that I don’t want to ruin a good life by waiting too long.