Study of the association between PAlliative care and Suicidal Risk: A mixed quantitative and qualitative approach

Context In France, life expectancy has risen considerably thanks to improved living conditions and medical advances leading to a reduction in the early lethality of certain severe pathologies, and consequently an increase in the number of people in chronic or terminal phases. As a result, the number of people in a chronic or terminal phase has risen. The time required to care for these illnesses has lengthened, as has the end-of-life period, which requires specific, tailored support. Palliative care (PC) units, which have been widely deployed since the 1990s, provide comprehensive, multidisciplinary care for patients suffering from serious, progressive and/or terminal pathologies. While the aim of Hospice Palliative Care is not to cure a patient's illness, professionals organize care that focuses on the physical and psychological comfort of patients. Numerous studies have shown that suffering from a chronic, disabling, painful somatic pathology or one with an unfavorable prognosis increases the risk of suicide. Mental illness is also a major risk factor for suicide, and psychological pain is a breeding ground for suicidal ideation. The palliative care population therefore includes patients at high risk of suicide. To our knowledge, very few studies have investigated the impact of PH on suicide reduction.

Objectives The study presented has a twofold aim. First, it will clarify the association between SP management and subsequent risk of self-inflicted acts (SIAs) and suicide mortality (SM) in France. To do this, we will take advantage of data from the French National Health Data System (SNDS), enabling us to examine this question on a national scale. We will complement this quantitative approach with a qualitative one based on a series of interviews with patients and caregivers to clarify the mechanisms involved.

Method This project will be based on a mixed approach combining a quantitative and a qualitative study. The quantitative study will be based on a longitudinal cohort study using SNDS data for the whole of metropolitan France, enabling us to study the impact of MS on the risk of GAI and MS in populations suffering from severe somatic pathologies. Initially, we will provide a socio-demographic and clinical description of the population treated in MS between 2010 and 2022. This will enable us to identify the most frequent disorders, which will be used to create one or more groups of cases by pathology, as well as control populations according to these pathologies, with sufficient statistical power for comparisons. In order to study the effect of SP on the risk of GAI/MS at one year after inclusion in each of the study populations, we will use a survival model (e.g. Fine & Gray model which takes into account competitive effects such as death), adjusting for patient demographic (age, sex) and medical characteristics (comorbidities, treatment delivered, consultations carried out).

The qualitative study will be conducted on the basis of individual interviews with 4 distinct populations: healthcare professionals in MS, hospital healthcare professionals in specialties identified by the quantitative investigation, patients managed in MS and patients with similar pathologies, not managed in MS. Each individual interview will be analyzed according to a thematic analysis guide. Following this first stage, a cross-sectional analysis of the verbatims will be carried out, by population group, looking for common and singular elements within the discourse, the dynamics explaining the experiences and points of view, and the individual and collective factors contributing to the events. Particular attention will therefore be paid to care pathways, pathologies, socio-demographic and epidemiological data (age, gender, CSP, family and social network, pathology(ies), territories, care and support offer and actors, etc.). The qualitative analysis will be put into perspective with the results of the quantitative analysis and will enable a more detailed interpretation of the quantitative results, taking into account referral practices towards PH, according to the representations, experiences, practices, constraints, location, profiles of professionals and according to the experiences, representations, expectations, constraints and needs of users.

Perspective This study will enable us to confirm or not the hypothesis that PH represents a means of reducing the suicidal risk of people suffering from severe terminal somatic pathologies. Our qualitative study will also suggest mechanisms at work to explain a possible association. On the other hand, as part of national debates on end-of-life issues, the question has arisen as to whether legalizing euthanasia and assisted suicide might clash with suicide prevention: some requests for active end-of-life could mask a suicidal crisis. As emphasized by the French National Consultative Ethics Committee (2022) and the Citizens' Convention on the End of Life (2023), the development of PS must be a prerequisite for the legalization of euthanasia and assisted suicide. The results of our study could provide new arguments for this essential point of care organization.

Our results may also inform debates on the management of patients with severe and resistant psychiatric pathologies. The study of the characteristics of patients admitted to SP will enable us to describe the place of these patients in palliative care, and to open up reflection on their possible needs.

Our results may also shed light on debates on the management of patients with severe and resistant psychiatric pathologies