When Wanting to Die Isn’t Suicidal: Ethics and Admission of Patients with a History of Suicide Attempt into Hospice Care

In the emotionally complex world of palliative and hospice care, clinicians regularly encounter patients who express a desire to die. For some, it’s a quiet longing for peace at the end of a long and burdensome illness. For others, particularly those with a history of mental illness or prior suicide attempt, such expressions may sound alarm bells.

But what happens when a patient with a past suicide attempt—and no current psychiatric crisis—becomes hospice-eligible and now passively wishes for death? Is it ethical to admit them to hospice? Does their past suicide attempt change how we evaluate their motivations or determine their eligibility?

This question sits at the intersection of autonomy, mental health, end-of-life ethics, and regulatory compliance. Let’s examine the clinical, ethical, and practical dimensions.

The Ethical Foundation of Hospice

Hospice exists to provide compassionate, person-centered care for patients with a life-limiting illness and a prognosis of six months or less if the illness follows its natural course. The model of care is rooted in comfort, dignity, and quality of life—not in hastening death.

Many hospice patients, especially those with serious illness or cognitive decline, will express some variation of the phrase “I just want to go,” or “I’m done.” This is often a normal, non-pathological part of the dying process—a sign of existential readiness, not necessarily a mental illness.

However, when that expression comes from a patient with a documented history of suicide attempt, clinicians may hesitate, wondering:

• Is this person eligible for hospice care?
• Are they suicidal again?
• Are we “aiding and abetting” a suicide by admitting them?

These questions require thoughtful unpacking.

Past Suicide vs. Present Intent

A past suicide attempt—even a serious one—does not automatically preclude hospice admission. Many people survive suicide attempts and later go on to live full lives or decline from unrelated physical illnesses. A prior attempt should prompt a comprehensive mental health evaluation, not an automatic exclusion.

More important than the history is the current mental status:

• Does the patient have decision-making capacity?
• Is there active suicidal ideation now?
• Is their desire to die linked to treatable psychiatric illness like major depression?

If the answer to these questions reveals a mentally capable patient with a terminal illness who is not actively suicidal, then hospice care is not only ethical—it’s appropriate and necessary.

Passive Desire for Death Is Not Suicide

Patients who say, “I just want to die,” often mean:

• “I’m ready to stop fighting.”
• “I don’t want any more interventions.”
• “I want comfort, not cure.”

This kind of language, especially in the context of terminal illness, reflects a passive desire for natural death, not an active plan to hasten it.

We must resist conflating end-of-life acceptance with suicidality.

In contrast, active suicidal ideation typically includes:

• Preoccupation with dying by one’s own hand
• Specific plans, means, or expressed intent
• High levels of hopelessness or psychiatric crisis

These distinctions are crucial. Ethical hospice care includes monitoring for emotional suffering, but it also recognizes that death is not the enemy in a person who is truly dying. Suffering without relief is.

Clinical Responsibilities

When a patient with a past suicide attempt expresses a wish to die and is being evaluated for hospice, the following best practices are essential:

1. Assess for Capacity

Evaluate whether the patient:

• Understands their condition and prognosis
• Can weigh the risks and benefits of care options
• Can communicate consistent values and choices

If capacity is intact, their choices should be honored.

2. Perform a Suicide Risk Evaluation

Use clinical tools (e.g., Columbia-Suicide Severity Rating Scale) or psychiatric consultation if needed to assess for:

• Passive vs. active suicidal thoughts
• Risk factors (e.g., recent losses, psychiatric relapse)
• Protective factors (family support, spirituality, therapeutic alliance)

3. Involve the Interdisciplinary Team

Social workers, chaplains, and mental health professionals can help clarify goals of care, explore existential distress, and provide meaningful support.

The Ethics of Hospice in Context of Mental Illness

The presence of mental illness does not negate autonomy. A patient with chronic depression, PTSD, or even a history of psychosis may still retain decision-making capacity. If the disease is well-managed and the patient is terminally ill, their wish to focus on comfort care should be respected.

On the other hand, if the desire to die is primarily driven by active, untreated psychiatric symptoms in an otherwise non-terminal patient, then that patient may benefit more from psychiatric care than hospice.

The ethical principle of non-maleficence (do no harm) must be balanced with respect for autonomy and the duty to alleviate suffering.

Documentation Tips for Clinicians

To ensure ethical clarity and regulatory compliance, clinicians should document:

• The patient’s terminal prognosis
• Evidence of functional and nutritional decline
• A thorough mental status and suicide risk assessment
• Confirmation of decision-making capacity
• The patient’s stated goals of care
• Interdisciplinary team involvement
• A clear rationale: Hospice admission is based on prognosis and comfort-focused goals, not a means to facilitate death

Final Thoughts: A Call for Compassionate Clarity

The boundary between existential suffering and psychiatric crisis is not always sharp. But as hospice and palliative care providers, we are uniquely trained to walk this tightrope—with compassion, clarity, and humility.

Patients facing the end of life deserve care that honors both their suffering and their agency. A past suicide attempt does not strip them of the right to comfort. Nor should their expressions of grief or readiness be automatically pathologized.

Hospice care is about helping patients live well until they die, even when death is no longer a distant concept but an approaching companion. For patients who once tried to end their lives and now are truly nearing the end—what they need most is not suspicion, but support.

"Letting people make choices—even at the end of life—is how we honor their humanity."
— Dr. Atul Gawande, Being Mortal

References:

Quill TE, Byock IR. Responding to intractable terminal suffering: the role of terminal sedation and voluntary refusal of food and fluids. ACP-ASIM End-of-Life Care Consensus Panel. American College of Physicians-American Society of Internal Medicine. Ann Intern Med. 2000 Mar 7;132(5):408-14. doi: 10.7326/0003-4819-132-5-200003070-00012. Erratum in: Ann Intern Med 2000 Jun 20;132(12):1011. PMID: 10691593.

Morrison RS, Meier DE. Palliative care. N Engl J Med. 2004 Jun 17;350(25):2582–2590.

Ganzini L, Goy ER, Dobscha SK. Prevalence of depression and anxiety in patients requesting physicians' aid in dying: cross sectional survey. BMJ. 2008 Oct 7;337:a1682. doi: 10.1136/bmj.a1682. PMID: 18842645; PMCID: PMC2562435.

Columbia Lighthouse Project. Columbia-Suicide Severity Rating Scale (C-SSRS). 2008. Available at: https://cssrs.columbia.edu.