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Finding Hope
31 October 2019

Mental health is a key aspect of palliative care. How does one find hope and answers at life’s end? Venus Ther, HCA Deputy Head of PSS, sheds light on the risk factors for suicidal ideation and the importance of community and familial support.

By Venus Ther, HCA Deputy Head of PSS

1. Hopelessness is highly correlated with suicidal ideation. How do you help your patients find hope even when death is near?

I believe that every person carries hope – in various forms, in all situations.

Hope can change and develop as situations evolve. Hope often seems absent when death approaches, as we tend to perceive death as the end – the end of hope. Although our patients’ physical bodies are failing, I believe there is always potential for growth, for hope, in other aspects of their being. 

This can be in the form of their awareness and acceptance of emotions towards oneself, relationships with loved ones and their sense of spirituality (in other words, their pursuit of meaning and purpose in this concluding phase of their life journey).

Hope is both an individual and communal resource. As a medical social worker, I see myself as working alongside patients and families, in recognising their existing hopes and expanding and deepening them for their journeys ahead.

2. What are some risk factors for suicidal ideation?

Apart from the sense of hopelessness, some other risk factors are:

  • History of suicide ideation/attempts in the family or among other loved ones
  • Pre-existing mental health conditions (e.g. schizophrenia, depression)
  • Poorly managed pain and/or symptoms (e.g. breathlessness, nausea)
  • Experience of isolation or lack of meaningful relationships with family and other significant others
  • A strong sense of being a burden to one’s family or caregiver

3. What are some tell-tale signs you commonly look out for during home visits that might suggest a patient is contemplating suicide?

Apart from more obvious signs such as explicitly talking about wanting to end their life soon or requesting for the medical team to help end their life, these are other less overt signs:

  • Depressed, low moods
  • Sense of anhedonia (patient is no longer experiencing pleasure in the relationships or activities he/she previously enjoyed)
  • Turning away visits by family members and other loved ones
  • Giving away of valued possessions
  • Neglect of self (patient might stop taking medications, eating; personal hygiene needs are not sufficiently met)

4. There is no doubt social support plays a big role in bringing comfort to patients’ last days. How does HCA support patients who live in social isolation?

Patients may experience social isolation when they do not feel understood and heard by their families and loved ones.

We attend to them through individual as well as family counselling sessions, with the intent of co-building more connectedness within the patients’ sense of self, as well as among the family members. 

We collaborate with community agencies in coordinating and providing social support for this group of patients. These agencies provide befriending and practical care services (such as meal deliveries and housekeeping) for patients who may not have others to rely on.

5. Could you share a case in which a patient, who had previously expressed suicidal ideation, subsequently found hope in his/her own situation? What was the turning point/breakthrough?

Mr Chia, in his 70s, was my first patient. He was married with children. His children were married and lived apart from him.

His relationship with his children were distant as he had extramarital affairs in his younger years and had also spent the recent years overseas with his girlfriend and their two teenage children. 

Mr Chia returned to Singapore when he was diagnosed with terminal cancer and he was very grateful towards his wife for letting him stay with her and persuading their children to help in his care by providing for him financially.

His wife was subsequently diagnosed with an illness that affected her mobility. He was deeply grieved and took up a caregiving role briefly for his wife. As his wife’s condition deteriorated further, their children decided to move her to stay in one of their homes for more care. In addition, Mr Chia was also getting frailer himself, and was unable to be her caregiver any longer. 

Mr Chia lived on his own thereafter and was trying to care for himself. He had also lost contact with his wife, as his children were not supportive of bringing him to visit their mother.

He started to express suicidal ideation then: he spoke of losing hope of being able to reciprocate his wife’s care for him. He spoke more intensely about his sense of guilt towards his wife and children, as well as his girlfriend (and teenage children). 

The home care team made more regular visits and worked with his children (who were uncontactable at times) to monitor him. I had the chance to connect with his neighbour, who agreed to visit him daily to check on him.

The turning point came when Mr Chia subsequently found more peace and respite in his religious faith – he would reminisce about his past experiences of religious retreats whenever I visited.

I remember him well; puffing away on his cigarette whenever I visited him. He placed his hope in his pursuit of spiritual growth and often showed me his prayer books and prayer beads.

His children, being more aware of his very poor prognosis, began to visit him more and also brought their mother to visit him. These gestures were very important for him, as his deepest hope of being forgiven and accepted by his children was fulfilled. 

He subsequently agreed to inpatient hospice admission and passed away a few weeks later.

Mr Chia and his family have taught me the power of forgiveness – of self and of others – as well as the value of spirituality as a resource in very difficult times.