During a recent presentation on suicide prevention, I showed two pictures to the audience. The first was of a well-dressed, middle-aged man, smiling and sitting in the park on a sunny day. The second was of a neatly dressed, elderly gentleman sitting in a wheelchair, glancing out of his window on a dull gray day. I asked the audience Which patient is at more risk for suicide? The unobvious answer is both you can never assume what is going on in someone’s mind unless you are on the front line, asking the appropriate questions and observing the cues.
The National Centers for Disease Control and Prevention lists suicide as the 11th most frequent cause of death in the United States, with more than 31,000 successful attempts each year. Who were those people? Many of them have been patients on our units. The chances are high that a number of future suicide victims will be patients on our units and in our clinics in a non-psychiatric setting, given the high rate of mental health comorbidity in the U.S. population at large.
These events prompted me to present the topic of suicide prevention in the non-psychiatry setting for Nursing Grand Rounds at my facility, James J. Peters Veterans Affairs Medical Center in the Bronx. Addressing this topic proved both timely, in that it supported The Joint Commission 2007 National Patient Goals, Goal #15, The organization identifies safety risks inherent in its patient population (extending assessment of the risk for suicide to general hospitals), and eye-opening, given the fact that our veteran population is also at risk.
Using Nursing Grand Rounds as the vehicle for education enabled me to reach out to all nurses – those working on both the front lines in the non-psychiatry setting, as well as in a psychiatry unit.
Nursing’s hands-on approach to patient care and our ability to create therapeutic connections with patients enables us to pick up on key cues. Identifying these cues starts with understanding that suicidal behaviors are neither considered an illness nor a condition, but rather a complex set of behaviors that actually exists on a continuum that ranges from ideas/thoughts to eventual actions (www.mayoclinic.com).
When these cues are identified and determined to be significant they become part of the care plan and are reported and acted upon by the healthcare team.
Reading the signs
Identification of potential suicide behaviors starts with understanding the signs and symptoms that may be overlooked in a non-psychiatric setting. Picking up on these cues starts with excellent assessment skills and an assessment tool that is designed to cover the important risk factors and warning signs. According to the Mayo Clinic, these include –
A prior suicide attempt
Having a psychiatric disorder, such as depression, schizophrenia, or bipolar personality disorder
Alcohol substance abuse
A family history of mental disorders or substance abuse
A family history of suicide
Firearms in the home
Family violence, including physical or sexual abuse
A significant medical illness, such as cancer or chronic pain
Recent losses – physical, financial, personal
Age, gender, race (elderly or young adult, unmarried, white, male, living alone)
Recent discharge from an inpatient psychiatry unit (www.mayoclinic.com)
Although risk factors in themselves do not conclusively identify a patient at risk, they do help to screen patients who are admitted to our units or visit our clinics. Those at risk, who exhibit any of the following warning signs, should clearly raise a red flag –
Withdrawal from social contact
Desire to be left alone
Preoccupation with death and dying, or violence
Risky or self-destructive behavior, such as drug use or unsafe driving
Changes in routine, sleeping patterns
Changes in routine including eating
Giving away belongings or getting affairs in order
Personality changes, such as becoming very outgoing after being shy
Saying goodbye to people as if they won’t be seen again
Talking about suicide, including such statements as I’m going to kill myself, I wish I were dead, or I wish I hadn’t been born.
What you can do
If the patient is talking about suicide specifically, don’t ask tentative questions. Ask the patient directly whether he or she is having any thoughts of harming him or herself. It is imperative that you be straightforward by asking such substantial questions as Do you want to hurt yourself? and Do you want to kill yourself? If the patient answers yes, do not leave the patient, and have someone contact his or her primary care provider, who should order a psychiatric consult. Psychiatry then can suggest that the patient be placed on a 1:1 observation.
Be sure to remove all items from the patient’s possession that might pose a risk, such as shoelaces, sharps, razor blades, belts, pills, intravenous tubing, telephone cords, and extra bed sheets and search the room, including adjacent bathrooms.
Nurses are in a unique position to assist in curbing the suicide rate in this country. Remember the gentlemen in those two photos. You will never know what is going on unless you ask the appropriate questions and you can’t help unless you act on the cues.