Case

Suicide or a Well-Reasoned End-of-Life Decision? Jason is a 38-year-old gay man with AIDS. In his counseling session, he presents with concerns about dealing with the progression of his illness and uncertainty about his future. He reports that he has struggled with depression and anxiety for much of his life and was suicidal during adolescence when he was coming to realize he was gay. He has been estranged from his family of origin (parents, older brother, and younger sister) since he came out to them when he was in his early 20s. He was also rejected by his church and believes that “God turned His back on me, so I turned my back on him.” He does have some friends in his local gay community and in the HIV support group he attends once a week, but he has not been able to maintain a significant relationship since learning of his HIV status. Jason learned he was HIV positive 8 years ago, but based on how sick he was when he was tested, he reports that his physicians think he has been infected for at least 15 years. He started on medications immediately, but he has developed resistance to most of them because of an admitted lack of adherence to the sometimes complicated regimen. During a recent medical exam, Jason was told that the combination of medications he is now taking seems to be holding the HIV in check. But he does not appear to be getting any better, and there are no other options for him at this point. His physician told him she could not predict how much longer these medications would continue working but that it could be years and that new types of drugs are coming out on a regular basis. Jason thinks his quality of life is poor right now because of the side effects of the medications and the advanced state of his HIV infection, with his daily symptoms including night sweats, nausea, diarrhea, fatigue, and numbness or pain in the extremities. He has been unable to work on a plant assembly line for the past 6 years because of the HIV and associated problems. Even if he could work, he doesn’t think he would be able to find a job given his condition and the job market in the area. Jason is not sure he wants to continue living this way, especially because he has seen several of his friends in the HIV support group and in the larger gay community die terrible deaths related to HIV disease. He adds that, because it looks like he is going to die anyways, he might as well have a good quality of life the last few months and has seriously considered stopping his medications so the side effects go away. When he mentioned to his physician the idea of a “drug holiday,” which has been discussed in the HIV magazines he reads, his doctor said that if he stopped the medication he could expect to die within a few months and, at least right now, there would be no medications to start again if he changed his mind. In addition to the HIV medication, Jason is now taking two types of antidepressants, which help some of his anxiety. He has a prescription for an additional anxiolytic, which he reports taking more frequently recently because of his increased anxiety when he goes out in public. Jason thinks his HIV positive status is more apparent no and that people are staring at him and judging him. Jason also has a prescription for sleeping pills, a narcotic pain medication, and a prescription for the nerve condition he has developed. In addition, he is taking medication to counter the side effects of the other medicines, so he also has pills for nausea and diarrhea. As a result, Jason may take 30 or more pills a day, depending on how bad his symptoms are, and he is getting tired of having to do this day in and day out. Another side effect of all his medication is that he has little appetite and nothing tastes good. He smokes marijuana on a regular basis, both to increase his appetite and help with the nausea. Although he admits that he used to drink every day, he stopped using alcohol and other recreational drugs (other than marijuana) when he began his HIV medications. At the end of the session, Jason says that he has appreciated talking and that it has helped him to look at everything that he is facing in his life and what his future holds. He says that after listening to himself, he has decided that it makes the most sense to stop taking his HIV medication and enjoy the little time he has life by traveling. He wants to see parts of the country he has never explored instead of being stuck at home or at least close to a bathroom because of the medication side effects. He indicates that he may as well cash in his life insurance policy and pay for everything with his few remaining credit cards: it will not matter if he ruins his credit rating, and there is no one to whom he wants to leave his insurance money. Finally, he says that he does not think he needs another session because he will either be really sick or will be on the road in the next few weeks. Suicidal Client with Life-Threatening Disease