When is hastened death considered suicide? A systematically conducted literature review about palliative care professionals' experiences where assisted dying is legal.

BACKGROUND: Laws allowing assisted suicide and euthanasia have been implemented in many locations around the world but some individuals suffering with terminal illness receiving palliative care services are hastening death or die by suicide without assistance. This systematic review aims to summarise evidence of palliative care professionals' experiences of patients who died by suicide or hastened death in areas where assisted dying is legal and to understand when hastened death is considered to be a suicide. METHODS: AMED, CINAHL Complete, PsycINFO, PubMED, and Academic Search Ultimate were searched for articles from inception through June 2018. Quality assessment used the Hawker framework. RESULTS: A total of 1518 titles were screened resulting in thirty studies meeting eligibility criteria for this review. Published studies about professionals' experiences from areas with legalised assisted dying includes limited information about patients who hasten death outside legal guidelines, die by suicide without assistance, or if the law impacts suicide among palliative care patients. CONCLUSION: There are a range of experiences and emotions professionals' experience with patients who die by euthanasia, assisted suicide, or hasten death without assistance. The included literature suggests improved communication among professionals is needed but does not explicitly identify when a hastened death is deemed a suicide in areas where assisted dying is practiced. More research is needed to help clarify what hastened death means in a palliative care context and identify how and if assisted dying impacts issues of suicide in palliative care settings.

The Role of Stigma and Denormalization in Suicide-Prevention Laws in East Asia: A Sociocultural, Historical, and Ethical Perspective.

In many Western countries, the criminalization and stigmatization of suicide has given way to a biomedical approach aimed at destigmatizing suicide and treating underlying mental illness. By contrast, in many East Asian countries, suicide has never historically been criminalized or stigmatized. High rates of suicide in Japan, South Korea, and Taiwan have recently led policy makers in those countries to pursue innovative suicide-prevention strategies. The intentional denormalization of harmful behaviors has been discussed in the public health and ethics literatures, particularly with regard to smoking cessation, and could represent a novel mechanism for preventing suicides in East Asia. Using examples from the sociocultural, historical, and legal discourses surrounding suicide in Western and East Asian contexts, we suggest that denormalization can be a justified, culturally relevant suicide-prevention strategy, but that care must be taken to avoid shaming or stigmatizing suicidal individuals. Specifically, we propose the term weak denormalization to refer to an ethically permissible strategy at the mildest end of a spectrum of denormalizing approaches-milder than the reintegrative shaming described in the criminal justice literature, and diametrically opposed to outright stigmatization, which is generally considered ethically impermissible. Given the severe stigma of mental illness in East Asia, adopting the dominant Western view of suicide as solely a psychiatric concern would not be justified. Weak denormalization strategies in East Asia should be culturally tailored and rigorously tested on a small scale. They should include social supports, praise for the bravery of those of who seek help, and strategies to reduce shame regarding perceived social failure.

Suicide, guns, and buyback programs: An epidemiologic analysis of firearm-related deaths in Connecticut.

BACKGROUND: Gun buyback programs aim to remove unwanted firearms from the community with the goal of preventing firearm injury and death. Buyback programs are held in many communities, but evidence demonstrating their effectiveness is lacking. The purpose of this study is to compare firearms collected at buyback events to crime guns and firearms used in homicides and suicides. METHODS: Detailed firearm and case data were obtained from the Hartford Police Department and the Office of the Chief Medical Examiner from January through December of 2015. Information was reviewed for guns collected at buyback events, crime guns confiscated by police, and for weapons associated with firearm fatalities. Detailed firearm data included type, manufacturer, model, and caliber (small, ≤ 0.32 caliber; medium, 0.357 caliber to 9 mm; large, ≥ 0.40 caliber). χ analyses were used for comparisons between groups. RESULTS: In 2015, 224 crime guns were seized by the Hartford Police, 169 guns were collected at four community buyback events, and there were 187 firearm-related deaths statewide (105 suicides, 81 homicides, 1 legal intervention). Comparisons between buyback, crime, and fatality-related firearms are shown in the table below. Medium caliber handguns account for the majority of crime guns and fatalities, and buyback programs collected smaller caliber handguns. The demographics of individuals who turn in guns at buyback events and commit suicide are similar: age (buyback, 63 ± 11; suicide, 52 ± 18; homicide, 34 ± 12 years), sex (buyback, 81%; suicide, 91%; homicide, 84% men), and race (buyback, 80%; suicide, 97%; homicide, 47% white). CONCLUSION: Handguns account for the majority of crime guns and firearm-related fatalities in Connecticut. Buyback programs are both an opportunity to remove unwanted handguns from the community and to remove firearms from the homes of individuals at increased risk of suicide. LEVEL OF EVIDENCE: Epidemiologic/therapeutic study, level IV.

Unusual planned complex suicide committed with a muzzle-loading pistol in combination with subsequent hanging.

In Germany, suicides by firearms are not very common in contrast to deaths by hanging and intoxications. The use of historical muzzle-loading firearms in the context of suicides is a rarity. Contact shots from muzzle loaders cause an unusual wound morphology with extensive soot soiling. We report the case of a 59-year-old man, who committed a planned complex suicide by shooting into his mouth with a replica percussion gun in combination with hanging. The gunshot injury showed strong explosive effects in the oral cavity with fractures of the facial bones and the skull associated with cerebral evisceration (so-called Krönlein shot). Due to the special constellation of the case with hanging immediately after the shot, external bleeding from the head injuries was only moderate. Therefore, the head injuries could be assessed and partially reconstructed already at the scene.

Riesgo y suicidio en sistemas de puertas abiertas. Responsabilidad civil y aspectos médico legales / [Risk and suicide in open door institutions. Liability and phorensic issues].

Suicide is a complex issue and a source of discussion between different disciplines. Suicide assessment and management research had received a huge attention in the field. Argentina has a legal framework focused on protecting human rights. Malpractice and liability discussion is offered in cases of suicide in psychiatric patients recently admitted to an inpatient setting. Imminent and certain risk of damage is the legal requirement for involuntary psychiatric admission in terms of Mental Health Law in Argentina.

[Efficiency of inspections of the corpse before cremation performed in the area of the Halle University Medical Centre]. / Effizienz der Krematoriumsleichenschau im Bereich des Universitätsklinikums Halle.

From 1993 to 2007, the Institute of Forensic Medicine in Halle conducted 882 post-mortems before cremation. These records were now used for a systematic analysis of these cases to assess the efficiency of so-called second inspections of the corpse carried out in the area covered by the Halle University Hospital. In the period under review, considerable fluctuations were found from year to year, but these are mainly attributable to changes in the Saxony-Anhalt burial law introduced in 2002. Our 882 post-mortems were based on 84,677 corpse inspections before cremation; thus, an autopsy was performed in about 1% of all cases. Males were significantly overrepresented, younger age groups were dominant and there was a relatively high percentage where the first inspection of the corpse could not determine the manner of death or had to declare death by an unnatural cause. With regard to the manner and cause of death, the results of the first inspection and the post-mortem differed significantly. In 17.6% of our 882 cases, only the post-mortem revealed that death had been due to an unnatural cause. Despite the presence of sometimes strong clues to an unnatural cause, 156 of these cases were classified as natural deaths (56.4%) or the manner of death was stated as undetermined (43.6%). For more than two thirds of these 156 cases we were able to inspect the records kept by the Departments of Public Prosecution. 105 of these at first overlooked cases of unnatural deaths turned out to be deaths by accident. The other cases included 11 suicides, and 36 deaths related to medical treatment. In the remaining four cases, the autopsy results strongly suggested homicide, but only in one of these four cases subsequent police investigations were able to identify the perpetrator. This outcome demonstrates that the rule of inspecting the corpse a second time before cremation is clearly indispensable, even in its currently rather limited form.

Elementos para una política pública desde la percepción del suicidio en nariño / Elements for a public policy based on the perception of suicide in Nariño

Esta investigación pretende plantear los elementos para una política pública basada en la percepción de las comunidades acerca del suicidio en jóvenes del departamento de Nariño (Colombia). Se realizó un estudio cualitativo a partir de grupos focales y entrevistas individuales con diversos sectores poblacionales en los municipios de Pasto, la Unión, Tumaco e Ipiales. Se analizaron los factores percibidos de protección y de riesgo en los niveles individual, familiar, sociocultural y político, y los resultados se validaron con la población participante. Desde la percepción de los actores sociales, el suicidio es una problemática multideterminada que involucra aspectos cognitivos, relacionales, educativos, económicos, políticos y culturales. Se destaca la necesidad de implementar políticas sociales integradas dirigidas a fomentar factores protectores como el soporte social, la educación integral y la oferta de actividades para el uso del tiempo, e implementar programas que promuevan habilidades y competencias personales, junto con el diseño de estrategias conjuntas para reducir los factores de riesgo.

The objective of this study of community perceptions regarding the suicide of young people in the Department of Nariño (Colombia) was to provide elements for the formulation of a public policy. A qualitative study was carried out on the basis of focal groups and individual interviews with different population sectors in the municipalities of Pasto, la Unión, Tumaco, and Ipiales. Perceived protective and risk factors at the individual, family, socio-cultural, and political levels were analyzed, and the results were validated with the participating population. The social actors perceive suicide as a multi-determined problem that involves cognitive, relational, educational, economic, political, and cultural aspects. The study highlighted the need to implement inclusive social policies aimed at fostering protective factors such as social support, integrated education, and the availability of leisure time activities, and programs that promote personal skills and competences, as well as the need to design joint strategies to reduce risk factors.

Suicide by head explosion: unusual blast wave injuries to the cardiovascular system.

A 57-year-old employee in a military scientific institute was found acephalous in a supine position in an anteroom to the bunker. On the walls was abundant spattering of blood and tissue, concentrated above shoulder height. A mobile ignition device stood on the control desk. The complete destruction of the head down to the cervical spine suggested that the explosive charge (RDX) detonated in his mouth. The hands were virtually uninjured. The pressure effect in vessels caused numerous tears to the wall of the carotid arteries and the left vertebral artery, a tear-off of the left carotid artery of the aortic arch, and a 2.5-cm long crack of the thoracic aorta with 540-ml blood in the pericardial sac and a shredded window-like disruption of the left aortic valve cusp. The autopsy also showed an infraction of the sternum from the inside, and a contusion of the superior lobes of both lungs. The trace pattern on the right arm suggested suicide. A bone fragment of the mandible penetrated the right biceps muscle as a secondary projectile.

[Clinical autopsies. Practical approach, legal foundations and ethical considerations]. / Klinische Obduktionen. Praktisches Vorgehen, rechtliche Grundlagen und ethische Uberlegungen.

Only an autopsy can demonstrate topographical and morphological circumstances in detail and correlate the clinical and autopsy findings based on the examination of all organs. The practical approach in a fatality is described based on the example of the Lüdenscheid Hospital. A uniform legal regulation for dealing with corpses does not exist in Germany. There are two approaches to the question under which circumstances a clinical autopsy is allowed: the extended permission solution and the objection solution. Whether a clinical autopsy can be carried out is decided by the medical specialist selected on application. Autopsies can be necessary from insurance or administrative legal grounds or in the case of an anatomical autopsy is decided by the persons themselves. In order to guarantee the quality of an autopsy it is necessary to use a standardized approach with evaluation and assessment of the results, for example using a quality assurance protocol and the production of an autopsy report. Using this approach important information can be gained not only on the accuracy of the main diagnosis and cause of death but also on additional diseases, response to therapy and the course of the disease and under circumstances can lead to modifications in the approach.

Mental health system transformation after the Virginia Tech tragedy.

On 16 April 2007, a deeply disturbed Virginia Tech student murdered thirty-two fellow students and faculty and then shot himself. Less than one year later, the Virginia legislature improved the emergency evaluation process, modified the criteria for involuntary commitment, tightened procedures for mandatory outpatient treatment, and increased state funding for community mental health services. The unanswered question, however, is whether the necessary political momentum can be sustained for the long-term investment in community services and the fundamental legal changes needed to transform a system focused on managing access to scarce hospital beds to a community-based system of accessible voluntary services.

Sallekhana: the ethicality and legality of religious suicide by starvation in the Jain religious community.

This article examines Sallekhana, the Jain religious ritual of fasting to death, from the American and Indian legal and ethical perspectives. Two cases are presented. The first involves a woman in her twenties who starved herself to escape a voice in her head. The second case involves a woman with terminal cancer who chose to starve to death rather than accept palliative care. Both are analyzed with attention paid to the Jain theological rationale behind the practice and the social circumstances that predicate this vow. I argue that within Jain communities the moral presumption should be that Sallekhana is a valid religious ritual and should therefore be legally protected if it is freely chosen by an informed person free from coercion.

Aftermath of suicide in the hospital: institutional response.

BACKGROUND: A suicide can be a devastating event in the hospital, and few guidelines exist to aid an institution's response. METHOD: The authors describe a framework of immediate, short-term and long-term responses in the event of an in-hospital suicide. CONCLUSION: Implications for administration, communication, assessment, physical environment, and standards of care throughout the hospital are discussed that are relevant to both general-medical and psychiatric settings. Suggestions for the successful management of the aftermath of a suicide, such as the formation of a multidisciplinary leadership team, are included.

MMPI inmate profiles: suicide completers, suicide attempters, and non-suicidal controls.

Results from the Minnesota Multiphasic Personality Inventory (MMPI) were compared for three groups of male inmates in federal penitentiaries: 47 suicide completers, 43 suicide attempters and, 123 non-suicidal controls. Analyses show that the groups differed on all 10 clinical scales and on at least 8 after Bonferroni correction. Attempters obtained the highest scores on 4 of 8 scales; they also posted the highest scores on 3 others, but differences were significant only against non-suicidal controls. Completers posted the highest score on only one scale (Mf), but the difference was significant only against non-suicidal controls. All told, completers proved more similar to non-suicidal controls than to attempters. Regarding profiles, completers are more strongly correlated with non-suicidal controls (r=0.95) than with attempters (r=0.86); non-suicidal controls are less strongly correlated with attempters (r=0.88). The fact that attempters seem more pathological than the others can mislead clinicians screening for suicide risk.

[Suicidal monointoxication with flunitrazepam. Further comment on coloration phenomena of the upper gastrointestinal tract]. / Suizidale Monointoxikation mit Flunitrazepam--ein Beitrag zu Färbungsphänomenen der Schleimhaut des oberen Gastrointestinaltrakts.

Fatal monointoxications with benzodiazepines, for instance with a suicidal intention, are exceptional findings. We report the autopsy case of an 82-year-old woman who died due to a suicidal monointoxication with Rohypnol 1 mg film tablets (therapeutical agent: flunitrazepam). 0.065 mg/L flunitrazepam and 0.34 mg/L 7-aminoflunitrazepam were detected in a postmortem heart blood sample and toxicological analysis revealed the metabolite 7-aminoflunitrazepam in gastric contents, too. At external examination, a bluish-turquoise coloration was seen around the woman's right nostril and within the oral cavity. At autopsy, similar coloration phenomena were seen on the mucosa of the distal esophagus and the stomach. Formerly, bluish stains on mouth and nostrils were considered indicative of intoxications with organophosphates such as parathion (E 605). More recently, case reports accumulate where an intoxication with Rohypnol 1 film tablets (containing the coloring agent indigocarmine in its core) have to be considered as a potential differential diagnosis of such coloration phenomena.