SUICIDALLITY IN THE HOSPITALIZED PATIENT
WHAT IS KNOWN ABOUT SUICIDE
Suicide has been described throughout recorded history. In early times, it was considered an appropriate alternative to certain types of victimization such as rape or defeat in battle. Certain cultures prescribed suicide in specific circumstances or even forced embers to commit suicide as a part of ritualistic ceremonies. Today, many religions specifically prohibit or denounce suicide. Some states consider suicide a felony and individuals who attempt suicide can be prosecuted. In our society, many people have strong feelings and judgmental opinions regarding the act of suicide.
In spite of a strong cultural bias against suicide today, it is the 8th leading cause of death nationwide. This statistic takes into account only obvious and identifiable suicides. Many coroners, for example, refuse to classify a death as suicide unless a note is found. Among young people aged 15 to 24, suicide is the 3rd leading cause of death. The rate of adolescent/young adult suicide doubles in the 20 year period from 1965 to `985.
Perhaps because suicide is such a puzzling and distressing behavior, many myths have developed about it. Belief in suicide myths could actually deter a caregiver from assessing a patient for suicidal thoughts. Here are some typical examples.
Myth #1 Suicidal people are always depressed. Although this is often the case, some people who attempt suicide do not appear depressed at all but appear agitated, may be psychotic or organically impaired.
Myth #2 If you ask questions about suicide, you will give a patient the idea. Belief in this myth could prevent a caregiver from asking some difficult but essential questions. Accurate assessment requires investigation regarding the existence of a suicide plan and its’ potential lethality.
Myth #3 People with families who come from “good homes” do not commit suicide. Suicide attempts occur across the social and economic spectrum. Mot suicides are committed by non-psychotic individuals who have recently experienced a life disruption such as a significant loss.
Myth #4 Suicide is unrelated to alcohol or other drug abuse. In fact, suicidal thoughts and suicide attempts often are closely related to use of alcohol or other drugs. Patients may feel depressed and hopeless about their addiction and the negative consequences addiction has engendered in their life or may become impulsive while under the influence of alcohol or other drugs.
Myth #5 People who verbalize suicidal thoughts are manipulative and don’t need to be taken seriously. All suicidal threats are serious and must be responded to in a timely and appropriate manner. Most people who commit suicide have directly or indirectly verbalized intent prior to their action.
Such myths reflect our societies’ discomfort with and negative feelings about suicidal thoughts, impulses and plans. Obviously, if caregivers were to hold any of these myths as accurate information about suicide, their ability to evaluate a patient for suicidal risk could be impaired.
THE SUICIDAL RISK ASSESSMENT
How does a concerned health care provider make a suicide evaluation? As with any type of evaluation, the basic task is to gather, and then logically order, factual data. First, what behaviors and/or verbalizations alert the caregiver to the possibility that suicidal thoughts are present? Are there recent life events that challenge the patients; self-identity or cause a real or anticipated loss? Either of these two issues are highly correlated with suicidal thoughts and behavior. Significant changes in health status such as diagnosis of a terminal illness, relapse of a terminal illness, physical alterations (such as amputation or colostomy), or development of a disability affect identify and involve loss. Any of these are events to which individuals might react by experiencing suicidal thoughts or impulses. Other hospitalized individuals may have less obvious precipitating factors for their suicidal thoughts. In these cases, concern may arise because the patient presents with evidence of significant depression. Symptoms of depression include:
- Decreased appetite; weight loss
- Sleeplessness, especially early morning awakening
- Change in social patterns
- Psychomotor retardation – slow speech, thoughts, gait and movement
- Preoccupation with inner thoughts/conflicts
- Easily moved to tears
- Withdrawn, apathetic, apprehensive, anxious behavior
- Anhedonia (inability to experience pleasure)
It is helpful to consider some demographic parameters regarding suicide risk this early stage of evaluation.
- What is the patients’ age?
As mentioned earlier, adolescents have on of the highest rates of suicide. Often saddled with adult sized problems, adolescents do not possess adult coping skills. They to be rather concrete in their thinking and problem solving abilities, and are emotionally labile. Also at increased age-related suicide risk are the elderly who have often sustained multiple losses prior to the recent crisis and may harbor yearnings to be reunited in death with loved ones.
- What is the patient’s gender?
Statistically men are at greater risk of completed suicide across the life span. Although more women attempt suicide, men choose more lethal means and more often complete suicide attempts.
- What is the patient’s marital status?
Married persons with children attempt suicide less frequently than married individuals who are not parents. Married persons without children attempt suicide less often than single individuals. Single persons are at greatest risk.
- What is the patient’s socio-economic status?
Not surprisingly, lower income people are at greater risk for suicide. Their hopelessness about their options especially in a crisis situation influences their liability to use suicide as a problem solving tactic.
- Is the patient affiliated with a religious group?
Persons with religious affiliations are less likely to attempt suicide. Several prominent religious specifically prohibit or denounce suicide and this factor deters many individuals with strong religious connections.
Once the demographic predictor and the precipitating factors or event are noted, the remaining assessment is based on interviewing the patient for specific precise information. Probably the most significant information to be fathered is whether the individual has a plan to harm themselves. Eliciting this information requires making direct and specific inquiries. Questions such as:
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must be posed. Often caregivers feel extremely uncomfortable asking such direct questions. Each of us has our own beliefs and values regarding privacy, personal rights, freedom of action, suicide, etc. Asking these questions can cause a caregiver to experience internal conflicts, embarrassment or concern about overstepping our bounds. However, presence of a plan is rarely detected unless direct questions are asked and having a plan is the most significant predictor of suicidal behavior. Also, many people who harbor a suicide plan feel very ambivalent, guilty or depressed about keeping this secret. Often they feel extremely relieved when they are offered an opportunity to unburden themselves of these thoughts. They may also feel grateful that someone was adequately sensitive to recognize the signs and bring the topic out in the open. Another reaction is that the individual may have believed themselves to be “going crazy” to have developed these ideas and can be reassured that suicidal thoughts are not uncommon responses to a crisis.
If the individual admits to any type of suicidal thoughts or urges, then 3 parameters of any suicide plan must be evaluated:
- How specific is the plan?
- How lethal is the plan?
- Do the persons have the means available to carry out the plan?
At times these parameters appear to merge or overlap, but each one is an important and distinct factor.
Specificity refers to how definitely the details of the plan have evolved. Lethality refers to the likelihood of fatality if the plan is acted upon. And availability refers to the access the individual has to implement the plan.
A specific plan is detailed as to method, timing and availability of means. For example, a plan to overdose could be considered vague if a patient says, “Well, if I ever felt bad enough I’d go to a store and buy some pills.” verses a more specific plan such as, “I’ve been saving up many codeine and tranquilizers and I’m going to take them next Tuesday when my spouse is out of town and I’ll be home alone.”
Lethality is a major factor in predicting outcome of suicide attempts. Earlier in this section, it was noted that men more often complete suicide; this is because they choose methods of greater lethality. Gunshot wounds, for example, are highly lethal and are more often utilized in male attempts. Overdoses are less lethal related to type of medication; amount of medication ingested; if the overdose victim is found by someone; and the health of the victim. Women more frequently overdose in attempting suicide.
ASSESSMENT
LETHALITY ASSESSMENT SCALE
Danger of Self |
Typical Indicators |
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Has no notion of suicide or history of attempts, has satisfactory social support network, and is in close contact with significant others |
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Person has considered suicide with low lethal method; no history of attempts or recent serious loss; has satisfactory support network; no alcohol problems; basically wants to live |
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Has considered suicide with high lethal method but no specific plan or threats; or, has plan with low lethal method history of low lethal attempts, with tumultuous family history and reliance on Valium or other drugs for stress relief; is weighing the odds between life and death. |
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Has current high lethal plan, obtainable means, history of previous attempts, has a close friend but is unable to communicate with him or her; has a drinking problem; is depressed and wants to die. |
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Has current high lethal plan with available means, history of high lethal suicide attempts, is cut off from resources; is depressed and uses alcohol to excess, and is threatened with a serious loss, such as unemployment or divorce or failure in school |
Source: Hoff LA: People in Crisis, ed Addison-Wesley, 1989, page 209.
Availability of means is the third aspect of a plan. If an individual plans a suicide by gunshot wound, for example, it is essential to determine their access to gun and ammunition. Do they own a gun? Is the weapon loaded or is ammunition available? Is there a gun in their home or at work? Or, would they have to purchase of a gun in order to carry out this plan? Whatever the plan, it is important to determine if the means is at hand or how detailed is the plan to access the means necessary for completion.
There are a few other pieces of information an inquirer would gather in completing a suicide assessment. The first is to determine if a history of previous attempts exist. Once an individual attempts to commit suicide they break the societal taboo against such behavior and no longer have the protection this invisible barrier affords. Most People who successfully complete suicide attempts have contemplated ad/or attempted suicide previously.
Another avenue of inquiry involves recent changes in behavior especially behaviors that may signify or accompany life closure. An obvious example would be writing or updating ones’ will. Some less obvious examples are giving away treasured personal items or having serious conversations with family members, friends or even caregivers which express appreciation and have an overt or covert good-bye theme. Such behaviors may be observed or overheard by the caregiver or reported by the family. In some instances, recognition of such behavior as a closure gesture may be the tip-off which alerts a sensitive health care provider to the patients; state of mind.
COPING WITH A SUICIDAL PATIENT
Once a care provider establishes that a risk for suicidal behavior exists it is imperative that this information is communicated to the other members of the health care team. Immediate response is essential to protect the patient as well as those who are responsible for the patients care and well-being. Usually, the information is communicated to the clinical manager of the department and/or the hospital supervisor in addition to the primary physician on the case. Hospitals typically have policies which address the care of suicidal patients. Often a patient who has suicidal thoughts or impulses may not be left alone and arrangements must be made for a “sitter” to remain in the patient’s room at all times. In some institutions, family members may act in this role while at others the hospital requires staff to function in this capacity. Another typical response is that an assessment by a psychiatrist is required as soon as possible to evaluate for transfer to a psychiatric service.
When making inquiries to determine suicidal risk, it is essential not to promise confidentiality or convey in any way that your conversation with the patient will remain confidential. While individuals may feel guilty or ashamed of such thoughts, and therefore desire they be kept secret, it is obvious that the patient’s safety require communication with the health care team. If a patient asks for promises of confidentiality the nurse can empathize with this desire or explore the feelings which motivate the need for secrecy. This may be an opportunity to assure the individual that such feelings are experienced by many people in response to devastating changes in health status or other life crisis. The nurse might say, for example, “I can understand your desire to keep your suicidal feelings confidential, but I must act in the best interest of your safety and well-being. You know I’m not surprised that you feel this way because I know that suicidal feelings are not uncommon for people who are confronted with situations like yours. Our staff is prepared to help you deal with your feelings as well as your physical health.” This kind of reaction could begin to normalize a response that feels frightening, shameful or crazy to the patient and offer the non-judgmental support.
A no-harm contract may be implemented once a determination is made that suicide risk is evident. This is a written statement in which the patient makes a commitment not to act upon suicidal feelings or impulses and to verbalize such thoughts when they occur. A staff member, often the caregiver who interviewed the patient regarding their suicidality, will develop with the patient a mutually agreed upon statement and sign the statement as a witness to the patient’s commitment to avoid suicidal actions. This simple intervention is often highly effective in preventing suicidal behavior. Some reasons for its effectiveness include:
- It conveys a powerful message about the seriousness of suicidal thoughts and impulses.
- It conveys the health care team’s concern for the patient.
- It facilitates the patient making a formal commitment not to act upon their feelings. In fact, the nurse may state, “It is alright to have such feelings but it is not alright to act upon them.”
- It conveys the staff’s awareness that the patient is ultimately in control and the staff’s confidence that the patient can and will control their behavior.
When a not-harm contract is used it may be reviewed and signed again at regular intervals such as every shift or every day until the acute suicidality of the patient is resolved. (See Self-Harm/No Suicide Contract Suggestions page 33.)
INTERVENTION
Do’s and Don’ts of No Self-Harm/No-Suicide Contracts No self-harm/no-suicide contracts are effective in many situations, and they work well with certain groups of clients. They can be used in hospital or outpatient settings as a means of providing additional support to people who are likely to harm themselves. It is imperative to establish a trusting relationship with the person prior to making a contract. Do’s
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Don’ts’
Sample No Self-Harm/No Suicide Contract
Signed
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Dealing with a suicidal patient is another circumstance which a caregiver may encounter infrequently. Yet it is one that must be handled immediately and appropriately. N order to respond quickly and decisively it is important to be aware of the relevant policies that provide direction for staff action in your institution. When this circumstance arises it usually is experienced by staff as a crisis and may provoke feelings of anxiety and inadequacy. Having a knowledge base which includes an understanding of the institutions’ expectations for staff response will help diminish discomfort and increase effectiveness.
Unfortunately, despite awareness, assessment and interventions, suicides do occur even in hospital settings. Perhaps no other type of death affects the survivors in quite the same way. Family members, significant others and caregivers all respond in like manner to a completed suicide – guilt, anger, feelings of inadequacy and self blame often predominate. Everyone seems to feel there must have been something left undone – something which could have prevented this act.
Social work services may be prepared in a hospital setting to give appropriate referrals to family members for support group or counseling services. However, the staff on a hospital unit where a patient commits suicide need support and an opportunity to verbalize their responses to this event, as well. In this circumstance resources for staff might come from the psychiatric unit or crisis service if the suicide occurred on a non-psychiatric setting,. Other resources might be a hospital based or community based critical stress debriefing team, a psychiatric-clinical liaison nurse or staff from a near-by-psychiatric service or mental health clinic, or hospitals’ EAP service.
In addition to their own feelings, unit staff may be called upon to answer questions or assist family members or other patients in the unit deal with their own reactions and feelings. Such tasks can be extremely stressful for the nurse who is already experiencing his or her own emotional pain due to this traumatic event. It is essential that support be provided for the staff as a group to process their reactions, memories, feelings and concerns after a patient suicide.
Next: PSYCHOPHARMACOLOGY