A patient I have been treating in psychotherapy receives a diagnosis of ovarian cancer. She requests that I agree to aid her with physician-assisted suicide. Is this unusual? How should I respond to her?

We do not have reliable data about how often psychotherapy patients raise the issue of assisted suicide. Oncologists and those working in critical care settings report that many patients or their families bring up the subject (1). Oregon is not the only state where the topic is discussed, nor is it the only state where patients are aided in ending their lives by health care professionals. This "request" should be viewed as would be any communication in psychotherapy, i.e., it has manifest meaning(s) and unconscious meaning(s). The exploration of this communication is an important endeavor (2). A "Yes" or a "No" closes off the opportunity to understand the patient's concerns. Engaging the patient in understanding what she is requesting and why she is requesting it creates the forum for the patient to achieve a deeper self-understanding. There are several areas to consider as you and patient discuss her request.

An emergency consultation was requested for an 85-year-old woman who told a nurse she did not think she wanted to "go on this way." The consultation request was to "assess suicide risk." The patient had metastatic cancer from an unknown primary tumor. The psychiatrist met with her and reported that she was not suicidal. The patient was a retired social worker and used connections to colleagues to request a consultation from a psychoanalyst. Numerous telephone calls from her colleagues resulted in a psychoanalytically trained consultation-liaison psychiatrist going to see the patient. Over the next several days, the patient spoke about her life in detail, much of which involved abandonment by important people. At the end of approximately 45 minutes she would suggest that they end for the day. She was in considerable pain much of the time and short of breath from metastases to her lungs. At the end of the week the consultant asked the patient why it was important for her to see a psychoanalyst at this time. She responded that she was terrified that she would suffer untreated pain, quoting statistics on the percentage of patients with cancer who do not receive adequate analgesia in the final weeks of life. Looking directly into the psychiatrist's eyes she said, "I knew an analyst would understand my fears and not allow me to suffer." The psychiatrist responded that her fears were realistic in a general way but that her physician, someone she had only met during this hospitalization, was someone who would not allow her to suffer. He paged the physician who agreed to come to talk with them. The patient voiced her concerns, resulting in an angry response from the physician, who felt he was being accused without her knowing him. He made it clear that he would guide his treatment of her pain by her level of comfort and that they would together decide how much pain, or sedation, she would tolerate. Without prompting he told her he would take care of her until she died. After he left the patient said to the psychiatrist, "See I told you, an analyst would understand this." Over the next 2 weeks the patient required increasing doses of narcotic analgesics to manage her pain, resulting in sedation for most of each day, until she passed away.