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Differentiating Suicide From Life-Ending Acts and End-of-Life Decisions: A Model Based on Chronic Kidney Disease and Dialysis

Received February 23, 2007; revised June 1, 2007; accepted June 5, 2007. From the Mayo Clinic, Dept. of Psychiatry and Psychology, and the Dept. of Psychiatry, Tufts University School of Medicine, Baystate Medical Center, Springfield, MA. Send correspondence and reprint requests to John Michael Bostwick, M.D., Associate Professor of Psychiatry Mayo Clinic, Dept. of Psychiatry and Psychology, Mayo Building., W11A, 200 First Street SW, Rochester, MN 55905. e-mail: bostwick.john{at}mayo.edu
© 2009 The Academy of Psychosomatic Medicine

BACKGROUND: Technological advances continue to yield life-prolonging treatments that complicate the occurrence of death. Until recently, refusal to submit to recommended care was considered suicide. OBJECTIVE: Physicians must now decide how to respond to requests for hastened dying. METHOD: The authors propose a four-square grid distinguishing true suicide from behaviors such as treatment termination and lethal noncompliance. RESULTS: One axis characterizes whether actions hasten death. The other identifies how the patient’s social and medical network collaborate in the decision-making process. CONCLUSION: Using chronic kidney disease to model intent and collaboration, treatment is framed within a paradigm that reflects both end-of-life decision-making complexities and contemporary conceptualizations of suicide.

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