Table 2. Strategies and techniques in dealing with a (potential) desire to die.

Strategy	Technique
1. Ask how the patient feels psychologically and spiritually	Feelings of helplessness, hopelessness, meaninglessness, futility, loss of morale and loss of faith, need to be brought to light, as does the nature of the desire to die: how stable is it? Is there a sense that there is no alternative? This will make it possible to consider whether there might be any options for solutions.
2. Investigate for depression or any other psychiatric disorder that can seriously impair judgment	If the patient is suffering from depression or any other severe psychiatric disorder, this should be investigated and its severity assessed.
3. Notice your own feelings when talking with the patient	It is important to notice, define, and in the first instance merely “sit with” any feelings you may have of fear, distress, annoyance, tiredness, irritation, distraction, or suddenly wishing the patient were dead. Later, take time to assess whether they contain important clues to the patient‘s situation.
4. If there are any hints that the patient harbors a desire to die, this should be proactively asked about.	A cautious approach to the subject can pay off: “Are you thinking about just giving up on yourself … chucking it all in?” “Would you rather be dead?” “Are you thinking of putting an end to your own life?”
5. Involve relatives	If the patient agrees, it can be a good idea to talk with the relatives about the patient’s desire to die, and to get their view of the matter.
6. Work out coping strategies that will help the patient to deal with the situation he or she is in	Evidence-based interventions are available: for example, existential techniques such as meaning- or value-centered therapy
7. Explore and support the patient’s desire for increased personal influence and control	Support the patient in reflecting about the possibilities for being in control of the situation. If needed, concrete steps to improve the patient’s control should be initiated.
8. Stay with suffering that cannot be prevented	If it is not possible to adequately relieve pain or suffering, it is important to continue to make oneself available to the patient, to continue to stay with the situation, talk about it, and look for solutions. Doing this is in itself the solution on offer.
9. Change goals of care and decisions about life-prolonging interventions	Talking about these matters can in itself be a way for the patient to deal with the desire to die.
10. Symptom control	Inadequately controlled symptoms such as pain, breathlessness, nausea, vomiting, anxiety, and depression play an important part in a patient‘s developing a desire to die. The best possible symptom control is part of caring for the patient.
11. Consult colleagues and hold case conferences	In situations of tension and dilemma, consulting with colleagues or (ethical) case conferences are a proven means of finding new thoughts and options by bringing in a third party.
12. Involve other professionals	When particular topics are at issue (more precise psychiatric diagnosis, religious confliction, etc.), psychiatric/psychotherapeutic expertise, social workers, religious pastoral workers, or other experts should be called upon.

Source: Extracts from „S3-Leitlinie Palliativmedizin für Patienten mit einer nicht-heilbaren Krebserkrankung“ (2)