Is your patient at risk of suicide
Is your patient at risk of suicide
Look for signs, messages, then intervene
The prospect of facing a long, painful death is so overwhelming that patients sometimes contemplate dying on their own terms, be it with a gun, a drug overdose, or some other way. Distraught family members are equally at risk.
This is a reality that hospice workers face every day. The very nature of patient circumstances puts them at risk of suicide. So it makes sense for experts to talk about suicide intervention as part of overall patient care.
Denise Stone, RN, MS, children’s services coordinator for Hospice of Health First in Orlando, FL, has seen her share of patient suicides in hospice care, including two that occurred 36 hours apart from each other, leaving workers and families stunned.
"While I was at hospice, we had six suicides over the 10 years by patients and four by surviving family members," Stone said during a session of the National Association of Home Care’s annual conference last October. "We had a suicide policy that had been in place for eight years. We learned as we went through [the suicides] that we needed to polish our policy. Suicide is an occupational hazard for the work we do in hospice. We’re dealing with people in crisis, their loss of good health. It’s something home health and hospices need to be aware of."
Awareness includes disposing of common misconceptions about suicides, she said, including:
• Suicides are sudden occurrences that commonly happen without warning. The truth is that 95% of all suicides occur with prior warning, including statements to loved ones about their desire to end their own lives.
• People commit suicide because they want to die. In reality, they don’t want to die; they want to be rescued from their difficult situation. People are motivated to attempt suicide for a number of reasons — the desire to join a deceased loved one, to punish others, to avoid a worse experience, to control the death experience, or to end a conflict.
• People who contemplate suicide are suicidal for long periods. Most suicidal people entertain thoughts of killing themselves for brief moments. The key is intervening in that critical point of time. "If you can intervene and offer an out, you can prevent the suicide from happening," Stone explained.
Hospice workers have a greater challenge in spotting potential suicide victims because they are dealing with patients already in the throes of devastating circumstances. It’s easy for signs of grief to be dismissed as a natural byproduct of a bad situation.
Hospice workers are essentially looking for the same symptoms that mental health professionals look for in people outside the health care setting. "They have lost all hope that life is going to get better," Stone said. "There is no light at the end of the tunnel; there is no hope. There is probably a lot of family dysfunction, weak support systems, a sporadic work history. They feel they have lost control of their life."
Because some at-risk symptoms mimic behavior that is encouraged by hospices to assist patients in achieving a peaceful death, Stone said hospices workers must look at the prevalence of a number of at-risk characteristics, rather than just one or two. Hospices routinely encourage patients to talk about death as a way to open up a dialogue and encourage patients to reorganize their life as they prepare to die.
Those symptoms include:
• insomnia;
• inability to concentrate;
• anorexia or weight loss;
• loss of sex drive;
• lethargy and withdrawal;
• preoccupation;
• dwelling on problems;
• living in the past;
• morbid outlook;
• drug and alcohol abuse;
• agitation;
• discouragement;
• difficulty in performing activities of daily living;
• crying;
• feeling defeated.
Once hospice workers identify a cluster of at-risk behaviors, they need to listen for verbal warning signs, words directly from the person’s lips that indicate thoughts of suicide. In general, these statements are dismissed or discounted. In a hospice setting, these statements may seem understandable given the person’s situation. Stone emphasized the importance of taking these comments seriously so hospice workers don’t miss an opportunity to intervene. Telling statements include those listed below:
• "I can’t go on like this."
• "I can’t go on without [significant other]."
• "I hate my life."
• "You won’t see me around here anymore."
• "Life has lost its meaning."
• "I’m worthless."
• "Nobody needs me anymore."
• "If [significant other] dies, I’ll just kill myself."
Other signs that patients are contemplating suicide include giving personal objects away; a history of suicide attempts; recent loss of a loved one; resigning from obligations, such as boards and committees; composing their own obituary; and a sudden, unexplained recovery from depression.
Once workers discover a patient or family member is at risk for suicide, what should they do? "Once the interdisciplinary team gets together and starts comparing notes, you’ll all know something is up," Stone said.
The next step is to apply a quick assessment of the person’s risk for suicide. If the person has had previous attempts at suicide, use the acronym DIRT to determine whether they are actively suicidal:
Dangerous. Ask the patient about his or her previous attempt at suicide. Determine when, where, and how it took place. Look at the severity of that previous attempt. If the 40-year-old woman said she took five aspirin when she was 14, the danger of that previous attempt was low compared to having taken a handful of barbiturates. The greater the degree of danger in the previous attempt increases the risk of suicide ideation, said Stone.
Impression of the degree of risk. If at 14 years old, the woman thought five aspirin was a lethal dose, then the risk of suicidal ideation goes up.
Rescue. Did the previous attempt leave an opportunity for rescue? Was the attempt made with family in the next room or in a motel in another town?
Timing. How long ago was the previous attempt? If it was 20 years ago and the person hasn’t had a suicidal thought recently, the risk is diminished. The more recent the attempt, the higher the degree of risk.
If a patient or family member is identified by team members as being in need of suicide intervention, the hospice worker must approach the person in a warm, accepting, nonjudgmental manner. The worker should ask directly whether the current situation has been getting him down so much that he is thinking of harming himself.
If the answer is yes, that he has entertained thoughts of suicide, the worker needs to ask how the patient is planning to carry it out. Having a plan is an important factor. It distinguishes between those who are having suicidal thoughts from those who are actively suicidal.
Thoughts of suicide are not uncommon among people facing death or death of a loved one. As they go through the life-changing process of death, patients and their family members may be looking at their life options, including suicide.
"It’s not unusual after a long-term relationship and the death of a loved one for the other to have a suicidal thought," Stone said. "The key difference between suicidal ideation and active suicide is if they have a method." If the patient gives an affirmative answer to the question of having a method of suicide in mind, then hospice workers should follow the SLAP acronym:
Specificity of the plan. How detailed is it? The presence of vivid details shows the amount thought the person has put into the plan and indicates the amount of resolve the person has in carrying out the plan.
Lethality of the method. How quickly will death be accomplished with this plan? For example, does she plan to use a gun or starve herself to death? With a gun there is little reaction time compared to starvation. The lethality of the method will help determine the treatment plan, including determining whether support resources, such as other family members, need to be put in the home.
Availability of the method. If the person says he plans to use a gun, find out whether there is a gun in the house or if he has access to a firearm. Of if the person says she plans to take an overdose of pills, check the house for drugs and determine whether she has access to other drugs, such as unfilled prescriptions.
Proximity of helpful resources. Is there family available to stay with the person as he goes through this crisis? Gauge how soon these resources can mobilize if there is a crisis.
Once intervention has begun its important for the hospice worker to understand what the suicidal person is expecting from those who are trying to thwart their plan.
"Sometimes you have to begin at square one and establish a relationship with the person, especially if you are the on-call nurse when the call comes in and you have never met this person," Stone said. "Get basic details, where they are at, who is with them, who is available to show support. Reinforce the positive, that he or she had courage for making the phone call, for instance. Above all, don’t be judgmental and show confidence that you can help. Identify the person’s major problem, but don’t dwell on it. Once the hospice worker knows what the problem is, he or she can begin explaining it can be fixed.
"They need guidance," Stone said. "They are looking for someone to fix it. You need to portray that you can help them."
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