When working with people with terminal illness, you’ve no doubt heard: 

• “I don’t want to live like this anymore”
• “If Medical Aid in Dying isn’t available, I’ll find another way.”
• “I want help dying, but I don’t want people to think I killed myself.”
• “I want to go quickly before the dementia gets worse”
• “Some days I’m ready to die, but when the pain eases, I’m not so sure.”

 

As therapists and helpers, we sit with competing truths every day. 

 

Our clients have their competing truths: “If I wasn’t suffering, I’d want to go on living… but I am suffering, and this is not the kind of life I want”. 

 

And we have our own:  “I want to support autonomy and dignity—and I also have an ethical mandate to intervene if this is suicide”

 

But, what happens when we’re not convinced it’s suicide? What if the wish to die makes sense in the context of our client’s life and illness?

 

This is the gray zone: distinguishing a desire to hasten death (DHD)—an autonomy-driven wish to shape the how and when of an already-approaching death—from suicidality, a potentially treatable crisis rooted in psychological pain and not contingent on a terminal prognosis. There are many difficult questions with no easy answers.

 

As therapists, social workers, psychologists, care managers, and palliative team members, we are the bridge—translating nuance, honoring autonomy and dignity, and navigating ethics codes (even when they compete with our values).

 

This article aims to offer you a framework for differentiating desire to hasten death (DHD) from suicidality —so you have the tools to stay present with your client, even when the path feels scary and unclear.

What is “desire to hasten death” (DHD)?

Desire to hasten death is a spectrum of thoughts, feelings, and intentions in people living with life-limiting illness. At one end are fleeting wishes (“I sometimes wish this would be over”); at the other are sustained, autonomy-driven requests to control the circumstances of dying—sometimes expressed as interest in Medical Aid in Dying (MAiD) or Death with Dignity (DWD). 

Key points:

• DHD is usually linked to terminal illness, perceived loss of dignity or autonomy, unrelieved symptoms, existential/spiritual distress, and concerns about being a burden.
• It can fluctuate with pain control, mood, meaning-making, and relationship support.
• DHD is not the same as suicidality, though they can co-occur, especially when depression or traumatic stress are present.

How common is “desire to hasten death” (DHD)?

In a study of people with terminal cancer: 

• 44.5%  report at least fleeting desire for death during illness.
• 17% reported a more persistent wish to die.
• 12% openly discussed Medical Aid in Dying with their physician

Of course, these numbers vary by study, diagnosis, symptom burden, depression, culture, and access to palliative care. The takeaway for practice is simple: expect to hear DHD in your work with people with terminal illness. Normalize the conversation. Treat it as an invitation to relieve suffering, not a reason to withdraw.

What Desire to Hasten Death is Not

Words matter—especially at the end of life.

• DHD is not “suicide.” The goal in DHD is to shape an already-approaching death to reduce suffering and preserve dignity. The goal in suicide is to end an otherwise open-ended life.
• DHD may lead to discussions about Medical Aid in Dying (MAiD)/Death with Dignity(DWD), legal in some states in which the patient must self-administer a prescribed medication and must have decision-making capacity and a terminal diagnosis under specific legal criteria.
• Requesting and taking medication under a Death with Dignity law results in the end of a life already ending. A patient’s primary objective is not to end an otherwise open-ended span of life, but to find personal meaning and dignity in their approaching death. By taking medication, they are acting to shorten their final hours or days.

• Many professional and public-health organizations discourage the phrase “physician-assisted suicide” because it conflates distinct phenomena and increases stigma for patients and clinicians.

Hold this frame gently when you document, educate, and consult—it reduces shame, improves communication, and aligns care with law and ethics.

How do we differentiate DHD from suicidality?

1) Context & trajectory

• DHD: Anchored in a terminal prognosis with a relatively predictable decline; often emerges alongside conversations about hospice, symptom control, and legacy work.
• Suicide: Not contingent on a terminal timeline; often tied to psychiatric syndromes (e.g., major depression, PTSD, substance use), acute losses, trauma, or social isolation.

2) Primary intention

• DHD: To reduce suffering and maintain dignity and control over a death that is already imminent.
• Suicide: To escape intolerable psychological pain in a life that could otherwise continue.

3) Affect and stability

• DHD: Can be reasoned, calm, and consistent with values; may wax and wane with pain control and support.
• Suicide: Often accompanied by hopelessness, anhedonia, agitation, or constricted thinking; frequently time-limited and treatable with mental-health care and safety planning.

4) Means & planning

• DHD: May include ethical and legal consultation about Medical Aid in Dying (MAiD)/Death with Dignity(DWD); emphasizes capacity, safeguards, and multidisciplinary review.
• Suicide: May involve impulsive or secretive planning, access to lethal means, or preparatory behaviors (giving away possessions, farewell notes).

5) Treatability

• DHD: Support often focuses on palliative symptom management, meaning-centered therapies, spiritual care, family meetings, and team communication.
• Suicide: Requires immediate safety assessment, removal of means, intensive mental-health treatment, and collaborative safety planning.

The hard truth: There are lots of difficult questions—and no easy answers

End-of-life work asks us to hold both/and truths:

• Both autonomy and protection.
• Both suffering that is biopsychosocial-spiritual and suffering that is treatable.
• Both a patient’s right to determine what a “death with dignity” means and our duty to ensure that treatable depression, delirium, trauma, or coercion are not driving decisions.

There will be days when every box is checked and the path is still not obvious. That’s normal. Lean on consultation, ethics committees, palliative colleagues, spiritual care, and the person’s support system. 

What should mental health providers ask?

Openers

• “Many people with serious illness have thoughts about death—sometimes fleeting, sometimes persistent. What thoughts have been showing up for you lately?”
• “When those thoughts arrive, what are they trying to help you with? What problem are they solving?”

Clarifying DHD vs. suicidality

• “Do these thoughts feel connected to your illness and how it’s changing your life, or do they feel more like the depression you’ve battled before?”
• “Are you wishing this would be over, or are you wanting to die right now?”
• “Have you thought about acting on these thoughts? Do you have a plan? What has kept you safe so far?”

Assessing frequency, intent, and drivers

• “How often do these thoughts come—rarely, sometimes, daily?”
• “What makes them louder—pain, loss of independence, feeling like a burden, financial concerns?”
• “What quiets them—medication relief, meaningful time with family, prayer, nature, music?”

Capacity and coherence

• “If we pressed pause on your physical suffering—say your pain were well controlled—how might your wish change?”
• “What would feel like a ‘good enough’ last chapter for you? What matters most now?”

Relational and team alignment

• “Who knows about these thoughts? How have your loved ones responded?”
• “Would you like me to help you talk with your medical team about options—including hospice, palliative care, or MAiD/DWD?”

How much should past depression or suicide attempts matter?

Short answer: It depends. Past depression and suicide attempts are vital clinical data. They increase risk that current DHD statements may actually reflect treatable suicidality or a depression-amplified despair. At the same time, many people with well-treated depression retain decision-making capacity and can articulate a values-consistent DHD within a terminal context.

Use a structured, trauma-informed review:

 

1.History with nuance

• Diagnoses, number and severity of attempts, triggers, lethality, rescue factors, and recovery trajectory.
• What treatments helped (meds, psychotherapy, ECT/TMS, spirituality, community)? What’s helped this person—specifically?

2. What’s the same / what’s different now

• Are current thoughts phenomenologically similar to past suicidal crises (impulsive, shame-laden, isolating)?
• Or are they values-consistent, discussed openly, and bound to the terminal trajectory?

3. Capacity & cognition

 

• Screen for delirium, neurocognitive disorder, medication effects, hypoxia, and other reversible causes of decision-making impairment.
• If in doubt, request a formal capacity evaluation.

4. Treat before you decide

 

• Treat clinical depression, anxiety, pain, insomnia, delirium, PTSD, substance use, and demoralization. Reassess the wish after symptoms improve.
• Dignity Therapy and Meaning-Centered Psychotherapy can reduce distress for patients and families.

5. Document 

 

• Your documentation should make clear what changed after symptom treatment and how the person’s values show up in their goals-of-care decisions.

When depression remains moderate–severe or thoughts feel impulsive/ambivalent, prioritize suicide prevention and post-vention planning—even in hospice. 

When depression is well-treated, capacity is intact, and the person’s wish remains clear, consistent, and values-congruent, center autonomy and palliative options (within your state’s laws and your professional ethics).

 

Red flags that require urgent action

• High, persistent hopelessness; severe anxiety or agitation
• Major depression not yet treated (or worsening despite treatment)
• Concrete plans to die by suicide or to hasten death in secret, outside legal/medical pathways
• Recent attempt, escalating substance use, access to lethal means
• Cognitive impairment, delirium, or possible coercion
• Sudden “calm” after intense distress; goodbye behaviors; giving away belongings

When red flags are present, activate your suicide-prevention protocol, involve the care team and family (with consent), remove/lethal-means access, and increase contact until stabilized. You can center dignity and safety.

Ethics in the gray zone

• Autonomy & authenticity: Does the expressed wish align with the person’s lifelong values, culture, and identity? Is the expression consistent over time?
• Beneficence & non-maleficence: Have we adequately treated pain, dyspnea, nausea, constipation, anxiety, insomnia, depression, and addressed spiritual distress?
• Justice & access: Does the person have access to hospice, palliative care, social support, and culturally responsive services?
• Fidelity: Are we transparent about our own scope of competence, values, the law in our state, and our limits? If we cannot participate, how do we avoid abandonment and offer appropriate referrals?

Talking points for families and teams

• “Our first priority is to relieve suffering—physical, emotional, spiritual.”
• “It’s common for thoughts about death to rise and fall. We’ll keep checking in.”
• “Are you open to starting by addressing depression and anxiety and then re-evaluating this wish after symptoms ease?”
• “If a person continues to express a clear, consistent wish within the law and with capacity, our role is to ensure the process is ethical, safe, and compassionate.”
• “Language matters. We avoid terms that increase stigma and confusion.”

A brief word about public opinions and history

Over the last several decades, public support for allowing people with incurable disease to choose a medically supported death has widened and the language we use has become more precise. 

The clinical bottom line: Know your state. Know your institution’s policy. And always consult with legal counsel, ethics committees, and trusted colleagues with an expertise in this area. 

Keep learning with us

If you’re a therapist, social worker, psychologist, or aging-services professional, consider our 6-hour Ethics & Psychotherapy at End of Life CE course. You’ll leave with frameworks, scripts, and tools to navigate the hardest conversations with clarity and compassion.