Abstract

Introduction

This work deals with the family relationship of elderly people who have persistent ideation of death, or have attempted suicide. It is considered that these relationships involve a conjunction of meanings built over the course of a lifetime, and which tend to accumulate and remain. The family links that maintain these relationships can manifest as networks of affection, security, differences, continuity of values, and the belief in belonging – or they can be externalized through conflicts, hurts, rejections and abandonment¹1. Mafra SCT. A tarefa do cuidar e as expectativas sociais diante de um envelhecimento demográfico: a importância de ressignificar o papel da família. Rev. Bras. Geriatr. Gerontol. 2011; 14(2):353-364.^,22. Marques FD, Sousa L. Integridade familiar: especificidades em idosos pobres. Paidéia 2012; 22(52):207-216..

Ageing is a process that is inherent to the cycle of life, with changes, that can be concentrated, or extended, in the physical, financial, psychological, emotional and structural aspects. When there is not a multidimensional support in this phase of life, the elderly person will usually see him or herself as useless, without future outlook and, thus, become more vulnerable to suicide²2. Marques FD, Sousa L. Integridade familiar: especificidades em idosos pobres. Paidéia 2012; 22(52):207-216.^,33. Kim YR, Kyoung HC, Youngmin O, Hae KL, Yong S, Chung TL, Kyoung UL. Elderly suicide attempters by self-poisoning in Korea. Int Psychogeriatr 2011; 23(6):979-985..

The way in which elderly people live their family relationships, and the way in which families accept them in their old age, are associated with the structure and the organization of the family. The cultural and social context, which each family builds in its day-to-day existence, can determine the transformations and the affective intensity shared by all of its members during the course of a life²2. Marques FD, Sousa L. Integridade familiar: especificidades em idosos pobres. Paidéia 2012; 22(52):207-216.^,44. Conwell Y, Duberstein PR, Caine ED. Riskfactors for suicide in later life. Biological Psychiatry 2002; 52(3):193-204..

In 2009, suicide was one of the ten leading causes of death in the United States – that is to say, every 15 minutes one person committed suicide. Looking at the figures for suicide attempts, one encounters the worrying data that for each person who dies of suicide, 20 to 30 have tried. The risk for actual suicide is greater in older people than in other subgroups of the population⁵5. American Association of Suicidology. Elder suicide facts heet. [acessado 2014 maio 10]. Disponível em: http://www.sciencedaily.com
http://www.sciencedaily.com... . Estimates suggest that by the year 2020, the number of deaths by suicide in the world will increase by 50%. In the last 45 years the growth of this phenomenon has been 60%⁶6. Vidal CEL, Gontijo ECDM, Lima LA. Tentativas de suicídio: fatores prognósticos e estimativa do excesso de mortalidade. Cad Saude Publica 2013; 29(1):175-187..

A study in the Languedoc Roussillon region of France, with 1,873 elderly people, identified that 9.8% of them had manifested suicidal ideation. Among those over 80 the ideation rate increased to 11.3% in men and 21.4% in women. Among those who thought of killing themselves, 3.7% have made at least one attempt over their lifetime. In women, the rates were 2.8% more frequent, and the attempts made by men, historically, tended to be more lethal⁷7. Ritchie K, Artero S, Beluche I. Prevalence of DSM-IV psychiatric disorder in the French elderly population. Br J Psychiatry 2004; 184:147-152.. A survey carried out with 530 old people surveyed by the Family Health Strategy in the south of Brazil concluded that 15.7% of them had a risk of suicide⁸8. Ciulla L, Nogueira EL, Silva Filho IG, Tres GL, Engroff P, Ciulla V, Cataldo Neto A. Suicide risk in the elderly: data from Brazilian public health care program. J Affect Disord 2014; 152-154:513-516..

The literature points out that two-thirds or more of old people who are accompanied in the primary health services seek care at these locations in the 30 days prior to the suicide⁹9. Conwell Y, Thompson C. Suicidal behavior in elders. Psychiatr Clin North Am 2008; 31(2):333-356., and had indicated introspective ideation and gestures, of isolation, despair and profound emotional suffering, to their families¹⁰10. Figueiredo AEB, Silva RM, Mangas RMN, Vieira LJS, Furtado HMJ, Gutierrez DMD, Sousa GS. Suicídio de idosos: impactos na família brasileira. Cien Saude Colet 2012; 17(8):1993-2002.. Durkheim¹¹11. Durkheim E. O Suicídio – Um Estudo Sociológico. Rio de Janeiro: Zahar Editores, 2011. defined ‘suicidal behavior’ as the act by which an individual causes harm to himself, in any degree of lethal intention and knowledge of motive for the act. Shneidman¹²12. Shneidman ES. Autopsy of a Suicidal Mind. Oxford: Oxford University Press, 2004., completing this reflection, de-fines as suicidal tendencies any self-destructive acts that can cause serious wounds or death after a prolonged period. That is to say, to understand suicidal behavior it is important to include in the consideration the emergence of self-destructive thoughts and actions that are presented in a direct, or indirect, rapid or prolonged form.

In spite of the exponential increase in the number of old people in Brazil, there is a clear absence of public policies directed to the elderly population that establish a dialogue with the phenomenon of suicide, and this makes access to adequate care difficult for older people who have this demand. The absence of this policy intensifies the elderly people's problems, principally the problems of those that do not have a healthy family life and have few alternatives for facing and solving conflicts.

Although an increase in suicide rates, suicidal ideation and suicide attempts associated with advancing age has recently been observed all over the world, there are still few studies going into this subject in depth, particularly in Brazil and Latin America. The literature notes the connection between cases of suicide and the subject's social and family context, and with the impact of these cases on families and on the social circle¹⁰10. Figueiredo AEB, Silva RM, Mangas RMN, Vieira LJS, Furtado HMJ, Gutierrez DMD, Sousa GS. Suicídio de idosos: impactos na família brasileira. Cien Saude Colet 2012; 17(8):1993-2002.^,1313. Martinez VTP, Parra ZL. Repercusión familiar del comportamiento suicida. Rev Cubana Med Gen Integr 2004; 20(5-6):[cerca de 6 p.].^,1414. Krüger LL, Werlang BG. A dinâmica familiar no contexto da crise suicida. Psico-USF 2010; 15(1):59-70..

A non-systematized search, in September 2014, using the search terms ‘suicide attempt’, ‘suicidal ideation’, ‘elderly people’, and ‘family’ on the Medline database returned 113 studies. Analysis of the abstracts showed ten related to the joint theme ‘family and suicide attempt’. Of these, two dealt with the family's perception of the suicide, and none mentioned the old person who tried to commit suicide in a context considering his/her family relationships.

With a view to contributing to expansion of knowledge on this subject, and based on what the empirical data in Brazil show, this study investigates how family relationships, such as they are perceived by the elderly people themselves, contribute to suicidal ideation and suicide attempts, in a universe that includes localities in five of the Regions of Brazil.

Method

This article presents a view on results of the study entitled Study on suicide attempts in elderly people from the point of view of public health, with a qualitative approach, which makes it possible to comprehend experiences and relationships, and also to recover the facts of a given historical period¹⁵15. Minayo MCS. Hermenêutica-dialética como caminho do pensamento social próprio. In: Minayo MCS, Deslandes SF, organizadores. Caminhos do pensamento: epistemologia e método. Rio de Janeiro: Ed. Fiocruz; 2002. p. 83-107.. In the case of this study, it was of great importance to hear the subjects so as to understand the contextualization of the underlying meanings attributed by them to the family events that contributed to their thinking of ending their own life, or trying to, articulating their present situation in relation to the history of the past, and their projection of the future.

The people interviewed were men and women living in 14 different locations of the country where there are high coefficients of death by suicide¹⁶16. Pinto LW, Assis SG, Pires TO. Mortalidade por suicídio em pessoas com 60 anos ou mais nos municípios brasileiros no período de 1996 a 2007. Cien Saude Colet 2012; 17(8):1963-1972.: in the Northern region of the country, in Manaus; in the Northeast, in Fortaleza, Piripiri, Teresina and Recife; in the Center-West, in Campo Grande and Dourados; in the Southeast, in São Paulo, Rio de Janeiro and Campos dos Goytacazes; and in the South, in Porto Alegre, Venâncio Aires, Candelária and Santa Cruz do Sul.

The fieldwork included 63 elderly people who have had suicidal ideation or have attempted suicide in the last 5 years. The subjects were identified through the public services in the following institutions: in Family Health Strategy (ESF); in Psychosocial Care Centers (CAPS); in emergency departments of general hospitals; and in philanthropic services – long-term care institutions, and religious centers – which provided us with names and addresses. Inclusion of the subject was by the following criteria: age 60 or older; history of suicidal ideation or suicide attempt; ability to express him- or herself; and with or without financial independence. Those who presented mental difficulty (alterations in the memory or in consciousness) and those who are not able to verbalize their life history were excluded. The subjects were contacted by telephone or through Community Health Agents (ACSs) and professionals of the institutions referred to, who were especially helpful in locating the subjects and scheduling visits. One limitation was the difficulty of access to private hospitals for identification of elderly people who had attempted suicide.

The main instrument of research was the semi-structured interview, carried out using a script with questions relating to: (1) personal and socioeconomic profile, providing a brief social characterization and characterization of lifestyle; and (2) atmosphere and impact of the suicide attempt, including assessment of that environment, the prior mental state, and the consequences of the act on the health of the subject and on his or her family¹⁷17. Cavalcante FG, Minayo MCS, Meneghel SN, Silva RM, Gutierrez DMD, Conte M, Figueiredo AEB, Grubits S, Cavalcante ACS, Mangas RMN, Vieira LJES, Moreira GAR. Autópsia psicológica e psicossocial sobre suicídio de idosos: abordagem metodológica. Cien Saude Colet 2012; 17(8):2039-2052.. The interviews were always carried out with the elderly person located in a welcoming and private environment chosen by him- or herself (veranda, living rooms, covered area, or kitchen), aiming to avoid any embarrassment during the conversation. One of these conversations, only, was mediated by a community health agent, acting as translator, because the subject communicated in German.

The fieldwork was carried out between November 2013 and July 2014. The interviews were all recorded with the consent of the subject. Initially, the investigator provided information about the importance of this survey, and the aims and objectives were read, as was the Informed Consent Form, providing an environment of empathy that could facilitate the narrative of memories, thoughts and sentiments. An effort was made to respect strong moments of emotion or crying. In general, the subjects were thankful for the fact of being able to talk about what had happened without being judged and, on the contrary, praised the comprehensive and welcoming moment.

After the interviews had been held they were transcribed in full, followed by an organization of the data into a corpus. A comprehensive reading of the material was then carried out immediately, in which it was sought to achieve a view of the matter as a whole and an understanding of the particularities of the material generated by the interviews, identifying the ideas about suicidal ideation and suicide attempts.

The hermeneutic-dialectic approach was used in the analysis¹⁵15. Minayo MCS. Hermenêutica-dialética como caminho do pensamento social próprio. In: Minayo MCS, Deslandes SF, organizadores. Caminhos do pensamento: epistemologia e método. Rio de Janeiro: Ed. Fiocruz; 2002. p. 83-107., aiming to articulate the objective of the study, the report of the interviewees, the inferences of the investigators in terms of comprehension and interpretation, and discussion of the findings vis-à-vis the relevant literature. The following important structures stood out in this work: significant family losses; family and inter-generational conflicts; and actual or veiled violence; and this made it possible to carry out a comprehensive summary of the situation.

The research project that gave rise to this text was approved by the Research Ethics Committee of the Oswaldo Cruz Foundation (CEP/Fiocruz). All the participants of the studies signed a Free Consent Form, and all recommendations and ethical constraints were obeyed. At the moment of the interview, any of the subjects who were identified as being in crisis and without therapeutic support were sent to the referral services and are being followed up.

Results and discussion

Significant family losses

The contents manifested in the speeches of the elderly subjects about the dimension and impact of losses that they suffered during their existence are very strongly present: the death of a loved one, absence of manifestations of affection between members of families, restriction on their autonomy, slow encirclement of their liberty, and financial usurpation.

The laments and the sadness are profound in relation to deaths of important members of the family and of the social circle. While the death of a work or community colleague is suffered as a lack that is a normal part of life, the loss of a son or daughter is profoundly felt for the fact of being premature. But all produce a sensation of accumulation of losses of points of reference in which the circle of primary relationships is harmed.

The death of others reminds us of our own vulnerability and finitude¹⁸18. Sun FK, Long A, Huang XY, Huang HM. Family care of Taiwanese patients who had attempted suicide: a grounded theory study. J Adv Nurs 2008; 62(1):53-61. and, for an elderly person, there is a growing understanding that he/she does not have control over her own life and that of her loved ones⁴4. Conwell Y, Duberstein PR, Caine ED. Riskfactors for suicide in later life. Biological Psychiatry 2002; 52(3):193-204.^,1919. Szanto K, Prigerson HG, Reynolds CF. Suicide in elderly life. Clinical Neuroscience Research 2001; (1):366-376.^,2020. Mitty E, Flores S. Suicide in late life. Geriatric Nursing 2008; 29(3):160-165.. Durkheim¹¹11. Durkheim E. O Suicídio – Um Estudo Sociológico. Rio de Janeiro: Zahar Editores, 2011. remembers (p.163) that “the individual no longer has a taste for existence when there is no longer a single intermediary who connects him or her to reality and society”. For this reason, that person submerges into discouragement and tedium.

Suicide of a family member produces a range of sentiments in anyone, but above all for the elderly person – from sadness, to despair at not having been able to do anything about it¹⁰10. Figueiredo AEB, Silva RM, Mangas RMN, Vieira LJS, Furtado HMJ, Gutierrez DMD, Sousa GS. Suicídio de idosos: impactos na família brasileira. Cien Saude Colet 2012; 17(8):1993-2002.. The loss of a child, by itself, causes a void, but this feeling is stronger when the death is programmed, desired and carried out by the act of suicide, because it sets off a deconstruction in the family, weakening the internal resources of the parents. For this reason, significant life changes, and histories of suicide in the family, are strongly associated with the risk of self-inflicted deaths of elderly people⁴4. Conwell Y, Duberstein PR, Caine ED. Riskfactors for suicide in later life. Biological Psychiatry 2002; 52(3):193-204.^,2121. Beeston D. Older people and suicide. Stoke-on-Trent: Centre for Ageing and Mental Health. Stanfordshire: Stanfordshire University; 2006.^,2222. Conwell, Y. Suicide in later life: Challenges and priorities for prevention. Am J Prev Med 2014; 47(3S2):244-250..

Processes of migration are also mentioned as losses, since usually, at the moment of old age, when memories of the past are re-lived, more lack is felt of those who have distanced themselves in time and from their native soil, particularly if, when the loneliness occurs, social support is scarce.

Living in long-term institutions can result in distancing from relatives, at just the moment of life when the person is more fragile. A Brazilian survey indicated that visits by members of the family diminished as the time during which the person has been institutionalized increases. In these cases, the bonds of affection begin to become undone, increasing the isolation, the abandonment, the void and the loss of meaning in life²2. Marques FD, Sousa L. Integridade familiar: especificidades em idosos pobres. Paidéia 2012; 22(52):207-216.–⁴4. Conwell Y, Duberstein PR, Caine ED. Riskfactors for suicide in later life. Biological Psychiatry 2002; 52(3):193-204.,¹⁶16. Pinto LW, Assis SG, Pires TO. Mortalidade por suicídio em pessoas com 60 anos ou mais nos municípios brasileiros no período de 1996 a 2007. Cien Saude Colet 2012; 17(8):1963-1972.,¹⁹19. Szanto K, Prigerson HG, Reynolds CF. Suicide in elderly life. Clinical Neuroscience Research 2001; (1):366-376.,²³23. Demirçin S, Akkoyun M, Yilmaz R, Gökdogan MR. Suicide of elderly persons: Towards a framework for prevention. Geriatr Gerontol Int 2011; 11(1):107-113.,²⁴24. Oliveira SC, Santos AA, Pavarini SCI. Relação entre sintomas depressivos e a funcionalidade familiar de idosos institucionalizados. Rev Esc Enferm USP 2014; 48(1):66-72..

In daily life, to be poor means to have great difficulties in survival. For elderly people, the restrictions imposed by the financial situation are much more cruel, because usually they are superimposed on other types of losses, such as loss of space to live in; abandonment – which may be conscious, or may be the result of relatives’ inability to take care of them; dependencies and difficulties due to illnesses or problems of age; and usurpation of their assets.

If initially there was a concern, on the part of the families, to prevent the suicide of this elderly person, they lacked comprehension of the multi-dimensional factors that had led her to it. The change of home was dealt with as if she was an object, making her totally lacking in any family dynamic, and she was quite unable to express her will.

The other reports show various risk factors that are already known by people who study the relationship between family problems and the phenomenon of suicide of elderly people: withdrawal of their autonomy to deal with their own money; subjugation to the adults of the family; obligation to support the children at this time of life when deserved rest would be more appropriate; isolation in relation to community and social life; encirclement of liberty even if in the name of care and protection; psychological violence, negligence, and ill-treatment²⁵25. Minayo MCS, Cavalcante FG. Tentativas de suicídio entre pessoas idosas: revisão de literatura (2002/2013). Rev Saude Publica 2010; 44(4):750-757..

Family and inter-generational conflicts

The subjects highlighted conflicts that they had lived through due to differences in view of the world, in multi-generational families, giving rise to incomprehension of the needs of the older people and disagreement with certain types of behavior on their part. Among the reasons for divergences were: abuse of drugs by some member of the family; difficulties of generations living together and understanding each other; fights between brothers, daughters-in-law and sons-in-law.

Abusive use of drugs is almost always accompanied by violence and even by small misdemeanors such as theft of goods belonging to the elderly person:

Additionally, there is a lot of difficulty in communication in daily routine, whether because sometimes the family members demand a certain type of performance from the elderly person, or because he or she, accustomed to giving orders and being obeyed, starts to be commanded by another nuclear family to which she is now attached. Frequently the elderly person does not know how to deal with these new situations, feels confused in her desires and way of thinking, which causes him or her an indescribable anguish:

When a family is disunited and there is little expression of affection, understanding or complicity, with a lot of impatience, anger and aggression, it is the elderly, particularly women, who suffer most.

Lack of family support can be a predictive factor for suicidal behavior in elderly people⁵5. American Association of Suicidology. Elder suicide facts heet. [acessado 2014 maio 10]. Disponível em: http://www.sciencedaily.com
http://www.sciencedaily.com... . Impoverishment of the primary relationships is reflected in the dynamic of daily life, which makes the environment of living together unbearable. The old person is hurt when sons, grandsons, daughters-in-law and sons-in-law do not get on with each other, because this deprives him/her of meetings with loved family members and isolates her even more. Because of feeling a lack of emotional support or because of not having adequate support from the people that she loves, the elderly person begins to disconnect from the link with life and begins to look forward, to her end⁴4. Conwell Y, Duberstein PR, Caine ED. Riskfactors for suicide in later life. Biological Psychiatry 2002; 52(3):193-204.^,1414. Krüger LL, Werlang BG. A dinâmica familiar no contexto da crise suicida. Psico-USF 2010; 15(1):59-70.^,2020. Mitty E, Flores S. Suicide in late life. Geriatric Nursing 2008; 29(3):160-165.^,2222. Conwell, Y. Suicide in later life: Challenges and priorities for prevention. Am J Prev Med 2014; 47(3S2):244-250.^,2525. Minayo MCS, Cavalcante FG. Tentativas de suicídio entre pessoas idosas: revisão de literatura (2002/2013). Rev Saude Publica 2010; 44(4):750-757..

Another point of tension is the non-existence of manifestations of affection between members of families, the sensation of abandonment by family members and friends, and the lack of support for dealing with situations of depression:

Family and social support has a direct and indirect function of relieving the negative psychological effects created by losses and by the various types of adversities that accumulate in old age, including serious depression or depressive states¹⁴14. Krüger LL, Werlang BG. A dinâmica familiar no contexto da crise suicida. Psico-USF 2010; 15(1):59-70.^,2020. Mitty E, Flores S. Suicide in late life. Geriatric Nursing 2008; 29(3):160-165.^,2424. Oliveira SC, Santos AA, Pavarini SCI. Relação entre sintomas depressivos e a funcionalidade familiar de idosos institucionalizados. Rev Esc Enferm USP 2014; 48(1):66-72.. When distancing occurs in the communication between the family members and the elderly person, he or she begins to feel like a hindrance and her discontent leads her closer to a process of suicide¹⁸18. Sun FK, Long A, Huang XY, Huang HM. Family care of Taiwanese patients who had attempted suicide: a grounded theory study. J Adv Nurs 2008; 62(1):53-61.^,1919. Szanto K, Prigerson HG, Reynolds CF. Suicide in elderly life. Clinical Neuroscience Research 2001; (1):366-376.. It can be seen that this happens in all the Brazilian regions.

A recent study by Conwell²²22. Conwell, Y. Suicide in later life: Challenges and priorities for prevention. Am J Prev Med 2014; 47(3S2):244-250. has as its guiding concept the idea that prevention of suicide by old people is linked to: enrichment of social networks; increase of support; and intervention in family dysfunctionality, and intervention in terms of the way of dealing with the challenges imposed on their life in old age. Social disconnection has potentially negative effects on their mental health, causing in them the desire to disconnect from society and get closer to suicide¹¹11. Durkheim E. O Suicídio – Um Estudo Sociológico. Rio de Janeiro: Zahar Editores, 2011..

One of these challenges to be overcome in the Brazilian scenario is the preparation of public policies and specific training of health professionals in the approach to the elderly person at risk for suicide. This would be principally in the health services, such as in Emergency, and in the Psychosocial Care Center (CAPS), which function as the port of entry for elderly people who are vulnerable to self-inflicted violence.

For all the reasons referred to above, it is vital to call attention to the importance of the family in care for people who show suicide desires, ideation and attempts, and never to omit to give importance to their feelings and their vulnerability¹⁸18. Sun FK, Long A, Huang XY, Huang HM. Family care of Taiwanese patients who had attempted suicide: a grounded theory study. J Adv Nurs 2008; 62(1):53-61.^,2020. Mitty E, Flores S. Suicide in late life. Geriatric Nursing 2008; 29(3):160-165..

Explicit and veiled violence

Reports of occurrence, and recurrence, of violence were a feature of the spoken reports by the elderly people in all the locations studied. These cases sometimes included ill-treatment that began when the person was a child, and accompanied him or her for their whole life. The outstanding reports are of sexual violence, physical violence, psychological violence, negligence, abandonment and financial violence. In most of the situations, the various types of violence were superimposed.

When one looks at the relationship between violence and suicide²¹21. Beeston D. Older people and suicide. Stoke-on-Trent: Centre for Ageing and Mental Health. Stanfordshire: Stanfordshire University; 2006.^,2626. Minayo MCS, Cavalcante FG. Estudo compreensivo sobre suicídio de mulheres idosas de sete cidades brasileiras. Cad Saude Publica 2013; 29(12):2405-2415., the literature highlights the predominance of women. In the report above, the marks of trauma seem to be alive, creating a dark and conflict-ridden existence that led this elderly woman to entertain ideation and desire for death.

Another subject, who was orphaned of her parents at the age of six, has a life history punctuated by various types of negligence, psychological violence, physical aggression and sexual abuse. Her existential suffering was so intense in infancy that she rebelled, and fled her home, living in the street and several times tried to kill herself.

One of the women interviewed highlighted her experience of conjugal violence during her years of marriage. The constant threats and ill-treatment that she suffered made her extremely uneasy in the family environment, exhausting her psychic forces and bringing her close to suicidal behavior.

The elderly people interviewed in this study, it needs to be pointed out, were born between 1930 and 1940, a period when feminist movements were insipient and no strategies in defense of women yet existed. Many women, up to the end of their cycle of life, kept the cruelties that they lived through to themselves, or projected them on their families. Their social role, also as it is seen in the profile of the group that was analyzed, was restricted to procreation and taking care of the home. Many of them got married in adolescence, sometimes through marriages arranged by relatives and for reasons that had nothing to do with desire and feelings²⁶26. Minayo MCS, Cavalcante FG. Estudo compreensivo sobre suicídio de mulheres idosas de sete cidades brasileiras. Cad Saude Publica 2013; 29(12):2405-2415.. Also, they lived in a time when there was almost no dialogue between mother and daughter, tending to leave young girls without orientation for dealing with their partners. This is the case of one elderly lady who crystalized in her memory – and referred to verbally almost throughout the whole of the interview – the feeling of fear of men and repulsion for the sexual act, for which she was never prepared: The first time, I thought I was dying.

Some women refer to this moment in their conjugal life as one of subjugation:

Durkheim¹¹11. Durkheim E. O Suicídio – Um Estudo Sociológico. Rio de Janeiro: Zahar Editores, 2011. states in his studies that “life is frequently difficult and often disappointing or empty”. Thus it is necessary that the collective sensitivity should be able to transmit optimism so that people face the world with confidence. However, the speech of the elderly people described here reveals us the opposite, because at the end of their existence they suffer the most painful losses and live through a worsening of the family and social problems and conflicts that have accumulated during the whole of their life: deaths of people who were their points of reference, deaths of affection and of their autonomy, loss of their goods, and of the sense of direction in their lives.

Final considerations

Firstly it is important to highlight the limits of this study: in Brazil, and in the world, there is not sufficient literature at present that gives a voice to the older person who has suicidal ideation or has made a suicide attempt, to enable one to understand their own reasons for wanting to kill themselves. Thus, the research that gave rise to this study is considered to be an exploratory activity. The vocalization of the reasons for the desires for death and for the acts carried out toward that purpose needs to be made through qualitative approaches – as well as epidemiological or clinical studies – which achieve deeper understanding of the reasons for these people's acts, as expressed by the elderly subjects themselves²⁶26. Minayo MCS, Cavalcante FG. Estudo compreensivo sobre suicídio de mulheres idosas de sete cidades brasileiras. Cad Saude Publica 2013; 29(12):2405-2415..

The choice of the subject ‘Family relationships of elderly people who have had suicidal ideation and/or made suicide attempts’ was an inference of the importance of this question in the speech of the elderly people interviewed in the research on which this article was based. Hence this exercise in going deeper. However, it can never be said that there is a single cause that is responsible for self-inflicted deaths or for desires to end one's own life. Family problems, thus, run side by side with other factors associated with suicidal behavior. This context needs to be taken into account by the relations, and by the institutions of social support. The lack of public services to serve the specific needs of the elderly increases the risk of suicide being committed, because it does not offer a network of social support in the various sectors and with inclusion of the family.

Although this article is a first study experience, it was possible, in the reconstruction of the life history of the elderly person, to identify the difficulties and the family problems that can be identified among the multiple factors that set off self-inflicted violence, in this age range: significant losses of relatives; processes of migration that have distanced the elderly people from their families; absence of expressions of affection; a feeling of abandonment and isolation; loss of autonomy to handle one's own money; family disharmonies; and various types of violence – sexual, physical, psychological; abandonment and neglect, often all suffered together, over the length of a life, and now having their repercussions in the experience of aging.

These people, when telling their stories, gave clues as to what they hoped for from their families: acceptance, welcome, comprehension and liberty to realize their small wishes without being crowded; to end their lives in a dignified way and without suffering; to find help and protection for the progressive reduction of their capacities; to continue to participate in the decisions of the family and to prolong to the maximum their social achievements and prerogatives such as property, authority and respect.

On the role of the families in care for the ageing relative, Brazilian studies show that the burden is arduous and puts a great responsibility on them. As well as the day-to-day difficulties of managing the needs of all, there are also conflicts of values, mentalities and behaviors that can put younger and older people on opposing sides. Due to all these factors, Brazilian families need to be supported by social and health policies and programs, to enable them to offer the due care to their elderly people.

Acknowledgments

This work included the participation of field researchers Jarlideire Soares Freitas and Livia Andrade Marques of the Universidade de Fortaleza (UNIFOR).

References

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