Emergency admissions and bad news disclosure as precipitators of suicide: A territory-wide cohort analysis of 458 oncology patients who completed suicides

Abstract

Background: Cancer patients are known to have higher average risk of suicide compared with general population. Acute clinical stressors, caused by deteriorating physical condition, may precipitate suicidal attempts in cancer patients.

Methods: Coroner’s files of all 4613 suicidal deaths of Hong Kong in 2012-2016 were reviewed. The files contained detailed reports on demographics, autopsy, police investigations and medical summary. Cancer was recorded in coroner’s files in 458 subjects (9.9%). Medical records of these 458 subjects were reviewed manually in a territory-wide electronic patient record system which covered 80% of all cancer care.

Results: More than half (56%) were diagnosed to have metastatic or incurable cancer at the time of suicide (advanced cancer patients). Advanced cancer patients had significantly higher health resources utilization compared with early-staged patients in terms of emergency room visit, clinic attendance and hospitalization. Emergency admissions, which represented symptom crisis, was temporally related to suicide. Ninety percent of suicide episodes occurred within 100 days of emergency admissions (median 12 days). Disclosure of bad news may represent another emotional stressor. Among advanced cancer patients, suicide occurred at a median time of 6 months after disclosure of bad news of metastases (median 182 days, interquartile range (IQR) 46-534 days). Suicide occurred at 2 months after the bad news of cessation of active cancer treatments (median 60 days, IQR 24-196 days). For psychiatric risk factors, advanced cancer patients had lower rate of psychiatric diagnosis compared with early-staged cancer patients (12.5% vs 23.7% p = 0.003). Similar trend was observed in other factors including gambling, debt and history of self-harm (2.3% vs 0.0%, p = 0.03; 2.8% vs 0.3%, p = 0.02; 4.4% vs 1.3%, p = 0.08 respectively).

Conclusions: Emergency admissions and bad news disclosure represent acute stressors that may precipitate suicidal attempts in cancer patients. Such temporal relationship was particularly strong in advanced cancer patients, suggesting a critical window for suicidal prevention interventions.

Legal entity responsible for the study: The authors.

Funding: The Hong Kong Jockey Club, Li Ka Shing Foundation.

Disclosure: T.C. Lam: Research grant / Funding (self): Roche; Research grant / Funding (self): Mundipharma. All other authors have declared no conflicts of interest.