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Ciênc. saúde coletiva vol.17 n.8 Rio de Janeiro Aug. 2012
The authors reply
Preventing suicide by caring for and sustaining life in old age
In our study about elderly individuals our attention was strongly drawn to the fact that the time of life, represented by an hourglass with sand pouring from one bulb to the other, is a highly complex marker. The possibility of either turning the hourglass upside down or not, filling it up or emptying it out, renovating life or accelerating death, points to what gerontologist Ligia Py and philosopher José Francisco Oliveira refer to in their text as pain, suffering, loneliness, despair and a state of abandonment. The two above mentioned debaters took a phenomenological and existentialist approach to highlight the experience of loss that weakens internal resources, with tensions that make elderly individuals more vulnerable to the point that they see themselves as having hit rock bottom, with no way back. In that respect, we should emphasize that the existential problem is caused by progressive or incisive accumulation of stressful factors which throughout time seriously threatened the internal and social balance of some individuals. This required them to make huge efforts to overcome and win the obstacles imposed by life. In that sense, they operated as high risk factors.
Throughout their existence, however, some of those people continued to realize that life started challenging them (physically, psychologically, socially and economically) even more cruelly or devastatingly and, paradoxically, they felt more fragile and vulnerable to recollect themselves or find once again within them the vitality and strength they once had to face difficulties. Therefore, throughout life's storms, some of them very intense and uninterrupted, there are those that see themselves as very fragile as they become older, with little tolerance to pain or suffering, tired and exhausted, whether they have the support of friends and family or not, and they end up choosing to end their own lives. We observed that the cumulative impact of stressful factors (such as illnesses, disabilities, personal, social or economic crises) in many cases of suicide, causes the inner defense system to fail and leads us to conclude that efficient suicide prevention must identify the suffering endured by the elderly individual before it takes huge proportions.
The elderly individual needs to be seen, understood and cared for globally, their countless needs must be acknowledged and there must be an understanding that they may undergo progressive decline of their bodily, cognitive and socioeconomic functions. This decline may be associated with one or more illnesses, physical, sensory and mental limitations or to loss of power and influence within the family and socio-cultural spheres. Such changes that usually end up increasing elderly people's dependence and decreasing their autonomy may cause successful adaptation.
A person who has cultivated his inner being, enriched by reflections about life, tends to successfully experience the last stage of the existential cycle, especially if they have a close family and social group that provides them with continence and support. In that sense, we agree with Marília Berzins and Helena Watanabe when they say that suicide is part of life, to the extent that it calls into question the relationship of the person who kills themselves with society. As a deliberate gesture that is regarded as "not natural" and "not expected", the abovementioned debaters argue that suicide operates as a form of communication to the extent that it makes desperation, once anonymous and invisible, become public. The authors add emphatically: "the elderly individual who commits suicide breaks the pattern of silence about their suffering and invades the public space".
As seen in the article being debated, the final gesture is eloquent; it is shocking and makes family and society reflect. However, many times suicidal ideation is usually communicated and anticipated, commented or announced in loose, isolated or compelling sentences. However, despite the warnings of their intention to die, such sentences are often not interpreted as a cry for help by family members, friends or professionals and tend to be discredited or ignored. When choosing death, elderly individuals, especially men, can execute their plan quickly and choose a lethal method. Therefore, suicide signs and risks must be urgently identified and preventive measures be taken to care for and preserve life.
Finally, we agree with some of the thoughts of Blanca Werlang, who has also been contributing to qualify and spread the strategy of psychological autopsy to study suicide in our country. That author points out difficulties found in predicting whether individuals are potentially suicidal and anticipating the gesture of those who will commit the self-destructive act. This difficulty lies in the unquestionable fact that ultimately self-inflicted death consists of a human act resulting from one's deliberation.
Although it acknowledges predictive difficulties, the analysis of 51 cases presented here points to the fact that there are unequivocal signs that elderly individuals were planning to take their own lives. Therefore, most authors who study the phenomenon agree that it is possible to prevent the final act, because the main risk factors are already sufficiently known. Thus, it is up to family members, health and social assistance professionals and managers to develop means and resources to minimize the suffering of elderly individuals, to disclose risk and protective factors and to develop strategies to address difficulties, pathologies and limits imposed by ageing. Strengthening psychological defenses, social bonds and having expanded and specific care programs are crucial actions that will enable elderly individuals to live a healthy and socially dignified end of life.