{"doi":"10.1002/pbc.30956","title":"Palliative care and suicidality: Complicated conversations at two ends of the spectrum","abstract":"Lucas and colleagues1 highlight an important and challenging clinical scenario when healthcare providers identify adolescents and young adults (AYA) who find themselves confronting suicidal thoughts in the face of difficult-to-tolerate treatments for a life-limiting illness. As medical technology and therapeutics advance to prolong life, these thorny medically complex clinical situations intertwined with developmentally appropriate existential questions will continue to be more common. The authors correctly point out that, “Many patients at the end of life express the wish to stop pursuing curative therapy and allow a natural death; however, it is important to recognize when this becomes acute suicidality.”1 When does “natural death” cross the line into personal agency expressed through suicidal thoughts? This clinical challenge has been described previously in the landmark 2003 publication by the Institute of Medicine (IOM), “When Children Die: Improving Palliative and End-of-Life Care for Children and Their Families.”2 At that time, illustrative stories of children and families included the story of—“Melissa Devane,” a 13-year-old with osteogenic sarcoma who responded to ongoing treatment but had progressive recurrence four years later. “Melissa reacted by saying, ‘I'd rather die than have more chemotherapy’ and ‘you're unreal—I'm going to die anyway.’” IOM authors noted, “As children mature, their intellectual and emotional understanding of serious illness and the prospect of death evolves. This story describes the complex relationships between a severely ill adolescent and her parents and physician and the different concerns she has as she moves from diagnosis and treatment to recurrences and further treatment, to death. The adolescent is in conflict with her parents and physician about undergoing burdensome experimental treatment but eventually persuades them to respect her wishes.”2 She did not verbalize explicit suicide plans. Notably, at that time, there were no advance care planning guides for AYAs with terminal illnesses and few validated tools to assess suicidality in youth, particularly medically ill youth. Today, through the needed expansion of palliative care as a field with multidisciplinary research inclusive of AYA mental health, clinicians, patients, and their families have many more tools available with which to frame psychological and psychiatric assessments.3 Importantly, we in Western countries have come a long way from when healthcare providers refrained from asking medically ill patients regarding their thoughts about death and dying and especially about suicidal thoughts and behaviors. There is now research to show that AYA with cancer have suicidal thoughts4 and make suicide attempts during the course of treatment and into survivorship.5, 6 Tools that allow advance care planning for adolescents and young adults have been available since 2012.7, 8 But we can still do better given the low implementation rates of palliative care in youth.9 In a systematic review and meta-analysis including 52 studies, children, adolescents, and young adults with cancer were found to experience an increased risk of depression, anxiety, and psychotic disorders after cancer remission compared with siblings and noncancer-matched controls.10 Leaders in the field of pediatric palliative care and child and adolescent psychiatry call for more interventions and research to address the gap.11 What are normal emotional responses to one's own death for AYA and when does it cross a line into suicidal ideation that requires safety management? With the advent of social media and the 24-h continuous global information delivery cycle, researchers need to continue to study what is the “new normal” for the developmental understanding of death in healthy and medically ill AYA today. We understand that for each individual AYA, their understanding of their own personal mortality will vary given their experiences, family beliefs, and culture. ","journal":"Pediatric Blood & Cancer","year":2024,"id":495533,"datarank":0.0,"base_score":0.0,"endowment":0.0,"self_citation_contribution":0.0,"citation_network_contribution":0.0,"self_endowment_contribution":0.0,"citer_contribution":0.0,"corpus_percentile":null,"corpus_rank":null,"citation_count":0,"citer_count":0,"citers_with_citation_signal":0,"citers_with_endowment":0,"datacite_reuse_total":0,"is_dataset":false,"is_dataset_confidence":0.958,"is_data_producer":false,"deposit_databanks":null,"is_oa":true,"file_count":0,"downloads":0,"has_version_chain":false,"published_date":"2024-01-01","fair_score":null,"fair_percentile":null,"algorithm_id":"datarank_citation_only_1hop_v6","ranking_scope":"data_only","authors":[{"id":266909,"name":"Lisa M. Horowitz","orcid":"0000-0002-4827-1390","position":1,"is_corresponding":false},{"id":275343,"name":"Maryland Pao","orcid":"0000-0002-6987-2611","position":0,"is_corresponding":true}],"reference_count":16,"raw_metadata":null,"created_at":"2026-07-19T02:09:19.627139Z","pmid":"38511908","pmcid":null,"fwci":null,"citation_percentile":null,"influential_citations":0,"oa_status":null,"license":null,"views":0,"total_file_size_bytes":0,"version_count":0,"fair_f":null,"fair_a":null,"fair_i":null,"fair_r":null,"fair_zscore":null,"fair_rationale":null,"fair_model":null,"fair_agent_version":null,"fair_fulltext_source":null,"fair_has_llm":null,"fair_computed_at":null,"clinical_trials":[],"software_tools":[],"db_accessions":[],"linked_datasets":[],"topics":[]}