Introduction
When elderly people choose to die by their own hand it is necessary to understand how they experienced their existence in order to comprehend the act of suicide. The human dimensions of elderly people's encounters with aging and death constitute key factors, but this is not reflected in research into suicide among the elderly. This issue requires a qualitative research approach since such methods are suited to exploring the meanings of phenomena as experienced by the individuals themselves (Malterud, Reference Malterud2001). There are few qualitative studies of the life experiences of suicidal elderly people. In a systematic review, Lakeman and FitzGerald (Reference Lakeman and FitzGerald2008) found only three studies that concerned the elderly. Crocker and colleagues (Reference Crocker, Clare and Evans2006) interviewed elderly people who had attempted suicide and found that they struggled to accept age-related loss of control. Moore (Reference Moore1997), in interviews with a group of elderly people who had been admitted to a psychiatric department because they were depressed and had suicidal thoughts, found that mental suffering, loneliness and powerlessness were central themes of the experience of these elderly people.
In a Norwegian qualitative research project on suicide among the elderly (of which this study forms a part), the informants described the personal traits of the elderly people (Kjølseth et al., Reference Kjølseth, Ekeberg and Sissel Steihaug2009). Many of them emerged as people with particular characteristics. They had been markedly action-oriented throughout their lives, and their self-esteem was linked to activity and achievement. They were dependent on being in control. Emotionally they were predominantly closed and kept a distance between themselves and their surroundings – a pattern that often had a negative effect on their relationships. We concluded that, on the basis of the described personality traits, these elderly people would find difficulty in accepting and adapting to age-related loss of function.
We no longer have access to the thoughts, feelings and considerations of the elderly people who committed suicide. But through their narratives, those who knew them can provide us with knowledge about what the elderly had told them of their life experience as well as about their own interpretation and understanding of this. As far as we know, there are no studies on elderly suicide cases with an equivalent subject and methodological approach. The objective of this study is to acquire an understanding of the suicides among a group of elderly people by studying how they experienced their existence towards the end of life.
Methods
Design
This is a psychological autopsy study based on qualitative interviews. A psychological autopsy reconstructs the suicide through interviews with informants who knew the deceased well (Beskow et al., Reference Beskow, Runeson and Asgard1990). We chose to apply a qualitative method in the study since the nature and complexity of the problem and the lack of knowledge in the field of study indicate the appropriateness of a qualitative research approach. We wanted to explore each individual's experience, and we do this methodically through interpreting and reflecting on the informants’ narratives. The form of the interview allowed the informants to provide information about the elderly people in a more nuanced manner than through a questionnaire.
Sampling
A total of 172 municipal medical officers in ten counties in southern Norway were asked to report regularly to the project manager all definite suicides among those aged over 65 years in their region. The details of this procedure are described in an earlier work (Kjølseth et al., Reference Kjølseth, Ekeberg and Sissel Steihaug2009). Altogether 29 suicides were reported to the project over a period of approximately 18 months (2006–7). In two cases the relatives did not want to take part in the interview, in three cases it was impossible to obtain information on the relatives, and in one case the cause of death was uncertain. The study therefore comprises 23 suicides: four women and 19 men aged between 65 and 90 years. Four of them were under 70, seven were between 70 and 80, and 12 were over 80. The average age was 78.
Informants
The objective was to have two or three informants for each suicide: close relatives, their family doctor, and the home-based nurse/home help (if relevant). Eleven had no home-based care nurse, and six had no contact with their family doctor. The relatives interviewed were four spouses, 19 children, three siblings, and eight daughters-in-law or sons-in-law/close friends. The prerequisite for participating in the interview was that the informants had had close contact with the elderly person – as relatives or as his/her family doctor for a long period (years) – or had had regular contact during the last year of life as a home-based care nurse or home help. In this context, the term “close contact” implies that such persons knew the deceased well. A total of 63 interviews were conducted for the 23 suicides with 34 relatives, 17 family doctors and 12 home-based care nurses.
Interviews
The main objective of the interviews conducted for each suicide was to understand the suicide. The informants were asked to relate what the elderly person had communicated to them about his/her experience of life during the final phase, and how the informants themselves had seen and understood the circumstances of the elderly person. The interviewer structured the conversation to ensure that the external conditions of the life of the elderly person were described – such as lifetime events, health, aging, personality traits, the social context and relationships. The open structure of the interviews also encouraged the informants to take up topics they viewed as important in their account of the deceased. The interviews usually lasted approximately two hours and were tape-recorded in their entirety. They took place two to six months after the suicide, as recommended by Beskow et al. (Reference Beskow, Runeson and Asgard1990). All the interviews were conducted by the first author, who is a specialist in internal medicine/geriatrics and has long clinical experience. She also has a particular interest in the problem of suicide among elderly people, as well as experience of conducting qualitative interviews.
Data analysis
All the interviews were transcribed almost verbatim by the first author. The analysis follows the “systematic text condensation method”, a method based on elements from both phenomenological analysis and grounded theory (Smith, Reference Smith2003), and which has been modified by Malterud (Reference Malterud2001; Reference Malterud2002). The analysis has four stages: first the interviewer/first author read through all the interviews several times to acquire an overall picture and to capture the essence of what is recounted in each suicide case. The first author had already gained a good insight into the material during the interviewing and transcribing process. In the next stage of the analysis, the meaning units of the text were identified – extracts that give information about the topic defined in the problem. These text elements were then systemized and coded so that they could then be read in connection with other related text elements across informants.
The objective of this study was to understand the suicide, and to do so required the use of different perspectives in the analysis. The issue in question had three components: (i) What characterized each elderly person as a person? (ii) What were the external conditions that impacted on the elderly person in the final stage of life (addressing, in particular, illness, functional decline and relationships)? (iii) What had the elderly person told others about their life experience during this final stage, and how had the informants interpreted and understood this? The entire analysis process was conducted separately for the three respective components, even though in practice the analyses partially overlapped. Finally, information from the different approaches to the perspectives were viewed in an overall context – first for the individual elderly person and then across the material. This took place in the third phase of the analysis in which the content was abstracted and summarized into main topics and sub-topics. In the last phase the results were re-contextualized, i.e. the content descriptions were validated against the original material. During the entire course of the analysis there was a constant shift between the abstracted results, categories/topics and the original text. Many of the interviews were also read by the co-authors and then discussed with the author. Co-author SS also participated in the analysis.
Ethics
The study was approved by the regional ethical research committee. The informants were guaranteed anonymity in the published results. The informants had a positive attitude to being interviewed (only two suicides had to be excluded because the relatives did not want to take part). Many said that participating had been a positive experience since the interview helped them to express thoughts and feelings about the suicide. The interviews brought up sensitive subjects and could be a strain for the informants. The interviewer's clinical background was important for enabling an assessment/follow-up of any reactions among the informants.
Results
We found the path that leads to an understanding of the suicides through the three main topics of the interviews: the elderly people's experience of their life, their perception of themselves, and their conceptions of death. For a few of the deceased, among whom two who did not have any close relationships, the interviews gave little information on some topics but provided significant descriptions of the external conditions. However, for the majority of those interviewed the three topics were unambiguous, and there were similarities in the content through the entire body of material.
Experience of their life
This is described through two sub-topics: This life has been lived and Life as a burden.
This life has been lived
Many of the elderly people had emphasized that they had nothing left to live for: everything that had given value to life had been lost. The informants describe how over time the elderly seemed to lose the will to live, and a recurring statement was that they were “tired of living”. Several of the informants also said that they could understand the life experience of the elderly person. One family doctor said about his patient: “In a way he had no life left.” The various losses they sustained often concerned several – and always important – areas of their lives. Three of them had lost their partner a relatively short time before the suicide, while also contracting a serous illness themselves. Illness and functional decline meant that many of them lost their previous roles in both the family and social settings.
Important “life objects” had disappeared. One elderly person who had been an unusually skilful woodcarver lost this ability after injuring his hand. His doctor told us: “He talked about it a lot, and showed us the things he had made. And he always said there'd be no more now. It was an important part of life!” The quality of life had different prerequisites: for one 79-year-old man it was an allotment garden with a small house. His illness meant that he could no longer manage to look after the garden and he was preparing to sell it. “In the past few years his life had centred on that small house,” his daughter told us. Another was approaching 87 when he said that “the time had come.” He had been a reader and a writer all his life, but now he was going blind and deaf. The doctor could understand the suicide: “He was old enough to die.”
Experience of life had a time perspective. Bodily functions had been in decline for some time, and many experienced considerable deterioration in the period before the suicide. One of the men had expressed it as follows: “It'll only get worse. There's nothing left now.” Some of them had undergone treatment that had not improved their condition, while others refused to seek medical help. They experienced the losses as “absolute”, and they had a realistic view of the future. Life would not improve. “Slowly but surely he saw no meaning in the life he was living,” one daughter recounted.
Life as a burden
Life was perceived as a burden for many of the elderly people. One of them had characterized it as “a life you couldn't live with”. It revolved around illness and loss, and some of them also lived in deep conflict with their close relatives. They suffered illnesses that had a substantial effect on their lives, even though not all of them were life-threatening. Six suffered from cancer illnesses that caused pain and that would limit their life perspective. Six were seriously affected by cardiac, lung and neurological illness, while others had chronic illnesses that impaired their functions (skeletal/muscular, urogenital disorders). One of those in the latter group had been clear in his assessment of life in a wheelchair: “I couldn't stand it. I've lived long enough. There's no point in living like this.”
Only three had been in touch with the specialist psychiatric health service for depression. One of these had experienced recurring deep depression and had expressed the wish to die for some time. Two had developed symptoms of dementia, one of whom could recognize the symptoms from several family members who had suffered from the same illness. A son related the following about the other: “He told us quite plainly that he had a miserable life. In his clearest moments he saw how tragic it really was, how little he managed to do. What a life! To get old and to realize that you can't fix things any more, can't remember. I saw what it was like for him. He escaped!”
The illnesses caused a diversity of problems such as pain, breathlessness, difficulties in talking and eating, and immobility. Two of the elderly developed serious vision impairment. “Living is really exhausting for me now,” was a statement from a man who had lived with a serious lung illness for many years. Many others had said the same: “I'm tired. I can't stand any more,” was a recurrent statement. Having to accept help for intimate hygiene was experienced as degrading. Some (five of them) had recently been suffering from severe anxiety. They viewed this in the context of loneliness – even though they had close relatives – or of a fear of helplessness. The sum total of all the strains of old age meant that they perceived life as a burden, a burden that also became greater for many of them because they did not want, or were unable, to communicate it to others. It was said of one of them that: “He chose to bear the burden of his life completely alone.”
Their perception of themselves
“Losing oneself”
The informants told us that many of the elderly people had been very physically aware throughout their lives. The following statement about one of them illustrates this point: “He was focused on his physical problems. He wanted to be well, he wanted to be strong.” During the final stage of life, illness and aging had taken their strength away from them. Their bodies no longer obeyed them, and they had increasingly less energy. For some of them illness led to a lack of control over their natural functions and to the loss of sensory abilities. They struggled to accept the changes, and they expressed their regret about them. One daughter said: “He said it himself. ‘Now I just don't exist anymore’. Something he stood for had disappeared. I feel there was nothing left of my father.” Another put it this way: “We felt as if he was just disappearing.” The elderly people had been predominantly “action-oriented persons” all their lives, and functional decline took away their freedom of action.
They could no longer cope with life. Throughout their long lives they had had a high degree of control over their actions, and now they needed help. Even though this need was not pressing, they felt that others were making decisions for them. The inability to cope led to a loss of self-determination that was crucial for them. It was a matter of their dignity, and one of the men had experienced it as being “robbed of his identity”. The informants had seen and understood the experience of the elderly people, and one daughter told us: “The most difficult thing for him was losing control. He wanted to manage alone, and when he couldn't do it any longer then life was over.”
Self-determination and the potential to achieve were crucial for their perception of themselves, and without this they became worthless. Many of them had expressed their great fear of being institutionalized in the future – precisely because, in their view, they would then lose control over their own lives. One son said of his father: “Being in a nursing home wouldn't have been any life for him. I think he would've tried everything to avoid being put into a home.”
Conceptions of death
This topic has two sub-topics: Acknowledgment/acceptance and Death is better than life.
Acknowledgment/acceptance
Almost half the elderly people had a serious illness that would probably limit their life perspective. A number of these were said to have acknowledged that life was approaching its end and they were prepared to die. However, many of the others had appeared realistic about the fact that life was definitively in its final phase. A few had expressed their fear of pain, but it was said of several of them that they did not seem to be afraid of death. It was something they now realized was inevitable. The few who had expressed their personal beliefs had made these very clear. One son said of his father: “He had his feet on the ground. He didn't want any life-prolonging treatment. His attitude to death was that it was part of life – just like any of the flowers he had in the garden. When the season is over, they die and a new flower appears.” A daughter told us: “He went as far as to say that he was curious about dying!”
Some of the informants told us about depressive symptoms among a few of the elderly people (six of them) during the final phase, and three of these had been in touch with the specialist psychiatric health service. The majority had not been perceived as depressed by those around them or by the healthcare staff, but some informants described a form of sadness or grief that they expressed as follows: “Now and then he was a bit down, but not depressed. He acknowledged that life was approaching its end, and that was a burden.” Several of the informants viewed the situation as the elderly person being sad about approaching death and realizing that they could not live longer. A nurse said of her patient, who was suffering from cancer and who had prepared the suicide over a considerable time: “She fully understood her situation. She was often sad, but not what I'd call depressed.” A son also had a clear opinion about his father's suicide: “It wasn't the sort of depressive suicide of a person who could have lived on for many years. He had little time left.”
Death is better than life
Over time many of the elderly people had expressed the wish to die and had said that they hoped to die. Life had become too much of a burden. They could not bear to live, and therefore they wanted to die. Many had said that “they couldn't live like this”. They put it in different ways: some said that they had no “interest” in living or no “desire” and “will” to live, or, as one of them said: “Death is better than this life.” Several of them had mentioned that it was nevertheless only a question of time before death came, and they were ready to give up life. To some extent the conditions of life at that moment were too difficult to tolerate, and several envisaged a continued life that they did not want. A 90-year-old woman had said: “I hope I die before I lose my sight. I don't want to sit here in the dark.” When against all odds she survived an emergency operation she was so frail that she was unable to walk. When she got home she gathered all her strength to regain her mobility, and when she had recovered the ability to walk sufficiently well she managed to go down to the river where she drowned herself. The nurse who knew her had the following comment: “She spent a lot of time trying to recover her mobility. And we think it was so she could manage to walk down there. She got what she wanted!” The strength of will of the elderly people was a key factor of the informants’ understanding of the suicide, and several of them told us that “He/she wanted to do it!” One daughter talked about her father's motive: “He must have thought ‘I must do it while I still can’.” And another daughter said: “He wanted to die with his shoes on.”
The timing of the suicide was not chosen randomly. One woman had lived with a cancer illness for many years. During the last few months the condition had deteriorated and she gradually became more immobile. The home-based care nurse told us: “She had a rose bush just at the bottom of the stairs and she was waiting for it to start to flower. But when it flowered she couldn't manage to go downstairs to see it. That day she told me she had lain awake all night and watched a spider slowly spinning its web down towards her face without being able to brush it away.” She committed suicide shortly afterwards.
Discussion
The results reveal clear common features, both in what the elderly people had communicated about their experience of life in the period just before their death and in the informants’ understanding of the elderly person's situation. In many ways the elderly people perceived their lives as being over. They had lost many of the elements that had made life worth living for them. The burden of illness, functional decline and, in some cases, family conflicts made life unbearable. The loss of self-determination and freedom of action had a particularly strong negative impact on their self-esteem, and they felt that they were losing “themselves”. They had a realistic perspective on the future: they expected further functional decline. At the same time, their attitude to approaching death was one of acceptance, and many of them had expressed the wish to die for some time.
How can our results be viewed alongside established knowledge about suicides among elderly people? Depression, somatic illness and isolation (i.e. an inadequate social network) are associated with the increased risk of suicide among the elderly (Harwood et al., Reference Harwood, Hawton, Hope and Jacoby2001; Beautrais, Reference Beautrais2002; Waern et al., Reference Waern, Rubenowitz, Runeson, Skoog, Wilhelmson and Allebeck2002a). Few studies have been conducted on the importance of functional decline, but some have shown a connection (Conwell et al., Reference Conwell2000). In our study, illness and the resulting functional decline were of crucial significance for the way the elderly experienced their lives. They perceived life as a burden, and they saw that life had nothing more to give them. The informants described fewer depressive conditions than expected in the light of quantitative studies (Harwood et al., Reference Harwood, Hawton, Hope and Jacoby2001;Waern et al., Reference Waern2002b). However, several of them described the elderly people as acknowledging that life was approaching its end and as expressing sadness over this. Perhaps it is important, although difficult, to distinguish between a clinically defined state of “illness” and a form of existential “grief” at the end of life?
The majority of the elderly were not alone. However, a previous partial study has shown that their relationships were marked by distance and could involve conflicts, and therefore functioned to a lesser extent as supportive (Kjølseth et al., Reference Kjølseth, Ekeberg and Sissel Steihaug2009). Since the elderly managed to such a small degree to communicate their feelings to others, it was also difficult for those around them to help them.
The risk factors are recognized in our study as parts of a whole into which elements from different theoretical suicide models also fit. As in our previous study it is appropriate to refer to Baumeister's theory of “suicide as escape from self” (Baumeister, Reference Baumeister1990). Baumeister views suicide in correlation with a damaged self-image caused by the fact that personal expectations can no longer be fulfilled. Here we can see clear parallels with the elderly people's experience of “losing oneself”. Their circumstances can also be viewed in the light of Williams’ “entrapment model” of suicidal behavior – individuals who feel they are “trapped” by external uncontrollable circumstances with no chance of escaping (Williams, Reference Williams2001). Advanced age and the burden of illness in the interview material indicated that the situation would deteriorate, a fact of which the elderly were only too well aware. But they were not “defeated” or beaten in their entrapment. The informants describe people who despite illness and reduced functional capacity still emerged as unambiguous and conscious of what they wanted.
The attitude of the elderly people to death was a key topic of the study, a topic that has been addressed very little in quantitative research into suicide among the elderly. In our view age in itself provides a significant perspective on the suicides, as the following quotation from Simone de Beauvoir illustrates: “For the aging person death is no longer a general abstract fate, it is a personal event, an event near at hand” (de Beauvoir, Reference de Beauvoir1948). Our results seem to confirm this statement. The elderly people had communicated an acknowledgement that death was imminent, and they accepted it. Indeed, the narratives of the informants indicate that many of them looked forward to it. What distinguishes elderly suicide cases from those of younger people is that they have lived a life. They can see and assess their present situation against the backdrop of a retrospective setting and a short future perspective, which inevitably entails the end of life. In this phase of life, confrontation with what Yalom (Reference Yalom1980) characterizes as major existential concerns is unavoidable – death, freedom, existential isolation and meaninglessness. In our own encounter with age and death we reveal ourselves, and we have to deal with ourselves as we have lived and as we have evolved.
In the discussion below it is therefore important to remember the descriptions of the elderly people as strong-willed, obstinate persons with action-oriented strategies as personality traits and with their identity closely linked to self-determination. Because they had to deal with themselves as they were, the existential confrontation in this phase of life with declining functional capacity became crucial. Accordingly, and as we view the results, for the majority of them suicide was the consequence of an existential choice. The discussion that follows is divided into two parts: first we discuss the prerequisites for referring to suicide as a choice, after which we address the content of the choice.
The choice
Rationality is a controversial concept in connection with suicide (Werth, Reference Werth1996). The philosopher Margaret Battin claims that rational suicides may occur provided that certain criteria are met (Battin, Reference Battin and Werth1999). Our purpose in this study is not to discuss the concept of rationality but to apply some of Battin's key criteria to elucidate whether the elderly people in our material had the prerequisites to make a reasoned choice. Battin presents three main requirements: ability to reason, a realistic world view and adequacy of information.
The life experience of the elderly people seemed to be based on an understandable personal assessment of their situation. This perception can be countered with arguments that they were depressed and that depression colored and narrowed their judgment. In our material only a minority were diagnosed with depression. On the other hand, depression among elderly people can be atypical and may show few classic symptoms. But many of the informants (and also the healthcare staff) were fully aware that they had not perceived the elderly as depressed. They described a sadness among some of them that was contingent on the situation, and some saw suicide as the primary issue, i.e. they were sad because they wanted to live but they could no longer tolerate their lives.
In Battin's view, depression does not exclude the fact that suicide can be a rational choice: “A currently depressed person may ‘adjust’ to the situation in the future, but that still does not make her choices, based on current realistic reactions to bad circumstances, irrational. She recognizes that the future will be bad, and makes a choice, a value based choice, about whether she is willing to undergo the process of coming to adapt it.” The majority of the informants were aware that they saw suicide as the choice of the elderly people. Statements that the elderly “had wanted the suicide” recurred. Several had been in a decision-making process over a period of time, and they had used the informants as discussion partners on the way. Nonetheless, the suicide came as an unexpected event for most of the informants.
On the basis of the knowledge we have about the elderly people, their assessment of themselves in a future perspective seemed to correspond with a “realistic world view”. Even though some of them were still relatively self-sufficient, their functional capacity was declining and their anxiety about future dependence and institutionalization was realistic. Some of them were also aware that they had a serious illness that limited their life. In addition, it appeared that they had been given adequate information about their state of health, although we cannot claim that this applied to all of them.
The existential perspective
The existential perspective of the issue became clear for the authors during the analysis work. We have argued for our view that the elderly people made reasoned choices. Choice, in addition to anxiety and freedom, are key concerns of the Danish philosopher Søren Kierkegaard (Marino, Reference Marino, Hannay and Marino1998). We are of the opinion that examining our findings in the light of some aspects of Kierkegaard's discussion of these concepts may well contribute to an understanding of the suicides. In general, our understanding of Kierkegaard is based on the interpretation provided by Arne Grøn, the Danish professor of philosophy, of one of Kierkegaard's main works The Concept of Anxiety (Grøn, Reference Grøn1993).
According to Kierkegaard, the importance of anxiety is what it shows about being a human being. Anxiety is directed towards the future. It has no specific content, but can nonetheless be dependent on the situation. Anxiety is an expression of what Kierkegaard calls “freedom's possibility”, which gives a person the opportunity to choose. In a state of anxiety we are forced to reflect upon our situation, and through choices we are given the possibility to become free: “to become oneself”. However, anxiety also implies a lack of freedom and the risk of “losing oneself”. The choice one makes is not immaterial. The fundamental choice is to choose oneself – which involves deciding what one actually is. In Grøn's interpretation of Kierkegaard he writes that choosing oneself means becoming the person one already is, thus implying that one was “lost” for oneself. He claims that choosing oneself is regaining oneself, thereby gaining coherence or identity with oneself. It concerns acknowledging oneself and returning to oneself, he maintains.
Anxiety was part of the elderly people's lives – anxiety about a future that would entail further loss of self-determination and self-sufficiency. Without specifying in more detail what they feared, the majority of them had said that an existence of dependence was no life for them. Then they had no hope, and life was over. At that moment they experienced life as full of anxiety: they felt they were in the process of losing themselves. It was impossible to preserve their self-esteem, which to a large extent was based on their ability to achieve and on their self-determination. The manner in which their experience of life was communicated can be understood in the light of Grøn's interpretation of Kierkegaard's concept of anxiety: he claims that in a state of anxiety we stand and look down into an abyss that threatens to swallow us up. He maintains that it is as if we lose our footing since the world as we know it becomes unfamiliar. A state of anxiety, he says, causes us to reflect upon ourselves since the question is how we are to cope with the situation. As the elderly people saw things, the future was inevitable: they realized that the situation would get worse before the end. However, anxiety encompassed freedom's possibility. Their choice of suicide when they perceived that they were in the process of losing themselves can be seen as a way of choosing themselves, of becoming themselves again. They regain themselves as they see themselves – as people who can achieve and cope. With this perspective of understanding it can be claimed that through suicide the elderly people acknowledge themselves and through choice they attain coherence in their lives.
The perspective of choice was not equally clear for all the elderly people, and the material also shows individual variations that demonstrate the complexity of the issue. However, the results described the majority of them, and in our view the study can promote a deeper understanding of their suicides. This understanding has clinical implications. By recognizing that existential challenges in old age affect the suicidal behavior of the elderly, communication on such issues becomes important in the contact that healthcare staff have with elderly patients. Old age and death belong together. Nonetheless, professional attention is most often directed towards the medical/technical aspects of death (Neimeyer, Reference Neimeyer and Tomer2000). In a study of elderly people's opinions on issues concerning death, Lloyd-Williams et al. (Reference Lloyd-Williams, Kennedy, Sixsmith and Sixsmith2007) conclude: “Issues relating to the end of life are of major concern for older people, but are seldom addressed by professionals”. Studies show that elderly people are open to talking about such issues (Hallberg, Reference Hallberg2004). There may be several reasons why healthcare staff frequently seem to be unable to meet this need: emphasis is placed on technical medicine (including in the geriatric context), healthcare staff who are younger than their patients may feel uncertain and lack competence, and demands for efficiency do not allow the time and space for such dialogues.
To enable the health service to become aware of and help elderly people in existential situations that may lead to the risk of suicide, elderly patients must trust their helpers. The understanding of the situation of these elderly people is dependent on them being seen as the individuals they actually are and have been. Helpers must have the time to listen to their stories, as well as the ability and courage to take up difficult subjects with them. In this context there is reason to note that the majority of the elderly in this study were not perceived as depressed by the informants, and even where such symptoms were described, they formed part of a complex whole. This underlines the importance of an overall approach to the issue of suicide among the elderly; it is not merely a question of indications that require anti-depressive treatment.
Validity
One methodological problem with psychological autopsy studies is that the information we receive on the elderly people has already been interpreted by the informants. The informants are “speaking for others”, and the data are what Morse (Reference Morse2001) calls “shadowed”. Their relationship to the deceased and their reactions to the suicide will influence the information given in the interviews. In qualitative interviews the researcher can acquire an impression of such correlations that can be taken up and elaborated on in the conversation, which in turn enriches the information. With two exceptions there were several informants for each suicide, and in general their descriptions tallied well. The informants’ different relationships with the deceased helped to amplify and give more substance to the descriptions. If divergent opinions emerged, the form of the interview allowed these to be explored further to ensure more detailed information. “Conflicting” information from different informants did not appear to be a problem in the study. The validity was also strengthened during the interviews through follow-up questions to clarify the informants’ accounts. The interviews took place a relatively short time after the suicide to ensure that the healthcare staff also remembered their patients well.
Through the informants’ narratives we tried “to hear the voices of the elderly people”. Although our informants were the best available sources of the information we were seeking, there are still reasons for humility and caution concerning the results and the interpretation of them. The results reveal the elderly people's reported experience of life as closely as we could reach this subjective phenomenon.
The researchers’ own prior understanding will affect both the asking of the questions and the interpretation, and it was important to ensure awareness of this beforehand. The interviewer's medical background implied a medical/biological understanding. The method entails a conversation between the researcher and the informants through which the researcher gradually acquires a deeper understanding of the topic. The result also entails the researchers’ own “horizon of understanding” (Wulff et al., Reference Wulff, Pedersen and Rosenberg1990) being changed/expanded, as we experienced during the study when the issue acquired an existential perspective without this reducing the importance of the various aspects of the circumstances of the elderly people. The collaboration between the researchers was significant at all stages of the analysis process since several perspectives extended the limit of comprehension without consensus being the goal.
Transferability
For a study using qualitative methodology, the material comprises a relatively high number of suicides from a large geographical region in Norway constituting both urban and rural areas. The suicides were reported regularly by the registration body in a large number of Norwegian municipalities with no selection other than that there should be no doubt that the cause of death was suicide. According to the suicide figures from the region in question in 2006, almost half the suicides were reported to the project (Statistics Norway, personal communication). Inadequate registration routines in some municipalities may be the cause of the shortfall, and/or the fact that deaths from uncertain causes that were classified as suicide at a later date were not reported.
The age range from 65 to 90 years is represented, and the average age is high. The material comprises few women, and a reservation must therefore be made concerning the importance of gender to transferability. It is possible that the results describe a “masculine” pattern. On the other hand, three out of four women in the material constituted obvious “type examples”. The material covers a group of elderly people who were born in Norway during the first half of the 1900s, i.e. at a time when social conditions were characterized by frugality, even poverty. Their need to be productive and to manage without help may be affected by the time in which they lived. This may limit the transferability to elderly people from other cultural/social communities. However, the results are clear and apply for the majority of the elderly people in the study. We are therefore of the opinion that it is probable that the results can be applied to other elderly people with suicidal behavior in Norway.
Conflict of interest
None.
Description of authors' roles
Ildri Kjølseth designed the study, conducted the interviews, analyzed the interviews and wrote the paper. Øivind Ekeberg was the main supervisor throughout the project; he took part in designing the study, the analysis and the writing process. Sissel Steihaug was second supervisor in the project; she participated in the analysis and in the writing process.
