The aim of this study was to provide insight into grief experiences following the loss of a partner, suffering from mental disorder, to PAD or suicide. Our results show that people bereaved by suicide and PAD of their partners not only lose their loved one, but also experience a lack of understanding and support from others. Although both PAD and suicide are considered unnatural causes of death, their implications for bereaved partners vary considerably. Following PAD, all persons involved are supported by the physician, who initiates and handles all contacts with officials. In contrast, following suicide, the bereaved partner has to find out what to do if he or she was present during the time of death or has found the partner’s body. Furthermore, many people bereaved by suicide at some point had to make difficult on-the-spot decisions, regarding their partner, to which they felt ill-prepared.
A good death?
A good death may be seen from the perspective of its impact on grief, mental health, and wellbeing of the bereaved. People bereaved by suicide are at higher risk of developing mental health issues and suicidal behavior compared to those bereaved by other modes of death [25]. Notably, it has been shown that loss to violent death is strongly associated with difficulty in accepting the loss, and consequently, with other prolonged grief symptoms (e.g., a continued sense of shock, bitterness, emptiness, and yearning), symptoms of posttraumatic stress disorder, and depression [26]. Given the predictive effects of prolonged grief on reduced mental health over time [27], it is likely that mental health issues in people bereaved through suicide are in part grief related. The analysis of GEQ showed that PAD had a protective effect on the severity of the grief experiences of bereaved partners compared to suicide. It is possible that the protective effect of PAD may be relevant to mental health issues and suicidal behavior of people bereaved by PAD. Future research is needed to further investigate this association.
Addition of other independent variables showed that it might be worthwhile to look beyond the PAD-suicide dichotomy. A partner’s violent death impacted the grief experiences of the bereaved in addition to the suicide. The interviews offered an even more nuanced view into grief than did the GEQ results. In addition to the cause of death (PAD or suicide), bereaved partners’ grief experiences were influenced by the death being violent or non-violent, irrespective of whether they were present during the death, and anticipated it. A previous study into grief experiences of people bereaved by suicide showed that the more the loved one’s suicide was expected, the less the bereaved seek explanations and meaning after the death [12]. Further similar studies might reveal a pattern in which grief experiences in the context of suicide and PAD might be placed on a scale from the experience of a good death without severe grief, to one of a horrible death followed by severe grief. PAD would be on the one end of this scale, and an unexpected and violent suicide on the other. In between we will find a planned non-violent suicide with the partner present, a planned non-violent suicide without the partner present, and an unexpected non-violent suicide without the partner present. Figure 1 illustrates this hypothesis. Overlapping this spectrum are reactions from outsiders who show little understanding of the severity of the mental disorder. Unlike suicide, following PAD, the bereaved partner can counter these reactions by the fact that a physician came to the conclusion that the suffering of the patient was unbearable and without a prospect of improvement. This can not only convince outsiders, but also reinforce the bereaved partner’s own interpretation of the past situation. Feeling isolated and experiencing a lack of understanding is also reflected in the ‘loss of support’ and ‘stigmatization’ subscales of the GEQ. A previous interview study on stigma suggested that death taboo still exists in Western society, more specifically concerning sudden deaths [28]. The authors reasoned that this might be related to the “shocking or unusual nature; causing others significant unease” [28]. Our study findings suggest that stigmatization may be less prevalent after PAD, despite the unnatural cause of the death. Thus, death taboo might be less related to the unnatural cause of death, but more to the violent and unexpected manner of it.
We have seen that bereaved persons sometimes struggle with questions and doubts following the loss of their significant others. Although the subscale ‘search for explanation’ did not show significant outcomes, the interviews showed that some people were confronted with questions – most often when the suicide was unexpected. The subscales ‘guilt’ and ‘responsibility’ also seem to be associated with these inner questions and doubts. Being confronted with blame and having the feeling of not being understood by the social environment seemed to stir up inner doubts even more.
Our findings show that feelings of self-doubt following the partner’s death seem to be related to the death being unanticipated. When the death was expected, some of the questions (e.g., about why and how) had been resolved by talking to the partner – questions that bereaved partners following an unexpected death were still struggling with. Anticipating the death of the partner and having conversations about it are parts of a process known as anticipatory grief [29]. Conversations about the death seem to strengthen the bond between partners. However, they also confront the healthy partner with the past, present, and future losses [29], as losses are not limited to the death of the partner but may include altered relationships or other social and economic changes. In this context it is interesting to note that a program focused on family connections in people with suicidal behavior disorder [30] may contribute to reducing grief associated with the mental illness of a loved one, and it would be worthwhile to investigate the effects of the family connection program on grief if the loved one eventually dies by suicide.
In our sample, participants bereaved by PAD were in the relationship with their partners longer than those bereaved by suicide. In addition to the process leading to PAD, that may support anticipatory grief, the longer duration of the relationship may have helped anticipate the death.
It was evident from the study that bereaved partners lost so much more than their partner. Timely conversations may help them prepare for these losses in advance. Concepts of preparedness and anticipatory grief might be helpful to open such conversation between care providers. In case of planned suicides, specifically, in jurisdictions that do not allow PAD related to a mental disorder, care providers need to be aware of the challenges of partners having discussions with each other, and try to prevent the other partner from being seen as aiding and abetting the suicide.
Study strengths and limitations
This is the first study on grief experiences of life partners of people who died by PAD or suicide in case of a mental disorder. By including partners of people who died by mutilating or non-mutilating suicide, we obtained a nuanced view on grief of losing a loved one who intentionally ended his or her life due to a mental disorder. By combining a survey and an interview, we were able to show the broad variety of experiences and provide an indication of the severity of the grief.
The study had the following limitations. First, for the quantitative analyses, our sample size was small. Although a small sample size is generally associated with a low power to detect statistically significant associations, we found several significant associations to confirm our hypotheses, suggesting that our sample size yielded enough statistical power. However, generalizability of our findings may be limited by the small sample size. In addition, generalizability may be limited due to self-selection of participants in the study. It could bias the results if people were motivated to participate because of negative experiences, thus overrepresenting the severity of mental health problems. Conversely, if people were motivated by a desire to advocate for a specific method to die (particularly expected in PAD), this could lead to underrepresentation of severe mental health problems. Since the actual experiences of the participants were not one-sided – they also mentioned difficulties experienced in the process of PAD and positive aspects of suicide – we expected that self-selection bias did not skew our results.
It is noteworthy that our study took place in the Netherlands, and the results may not be generalizable to other jurisdictions.
We found gender differences between participants bereaved by suicide and PAD. It is known that more women die by PAD and more men by suicide [31]. Given the predominance of heterosexual relationships, gender distribution in our sample reflects expected general population patterns, with participants bereaved by suicide and PAD being most often women and men, respectively. We also found mean age differences between the two groups. Studies of granted euthanasia requests due to mental disorders found that most patients were under treatment for over ten years [32]. Thus, it is possible that people who died by suicide in our sample had a shorter mean duration of treatment compared with people who died by PAD. In addition, the time required to grant a request for PAD may be a contributing factor. Patients are likely to direct their initial request for PAD to their treating physician. If the physician refuses, the patient may turn to the EE. For psychiatric patients, the mean waiting time at the EE has been 10 months during the past years [32]. In addition, to meet the due care criteria of irremediable suffering, remaining treatment options sometimes need to be tried before considering PAD as an option.
Due to the COVID-19 pandemic, three interviews were conducted through video calls. The impact of COVID-19 was addressed during the interviews. Social restrictions related to COVID-19 may have impacted the experience of grief of the participants, such as recent feelings of isolation, or a decline in social contacts. Some respondents thought the measures, mainly social distancing, indeed contributed to these feelings.
Implications
Pending future studies with larger samples, our study provides initial evidence that PAD due to mental disorder may be associated with an increased understanding of the extent of the suffering of the deceased person by the bereaved and their social environment. In addition, the findings provide a more nuanced view on suicide, which is often considered a traumatic, violent, and sudden death. Our results show that it might do more justice to the act and its experience to distinguish between ways of suicide, so that non-sudden and non-violent suicides are not overlooked. In practice, non-violent suicide death cases might be reported as a natural deaths, thus limiting the reliability of current registrations. Specifically, planned suicides may be underreported. However, further research is needed on this.
According to the guideline of the Dutch Association for Psychiatry (NVvP), the physician considering PAD in case of a mental disorder should involve significant others of the patients in the process towards PAD and provide care to them afterwards [33]. Our study results support this recommendation. In addition, the results suggest that involvement of significant others should include attention for their perspective on a good death and their grief in order to further reduce the risk of prolonged grief and other negative grief experiences.