MANAGEMENT OF THE PATIENT AT RISK FOR SUICIDE
Patients at risk for suicide are cared for in multiple healthcare settings, including primary care, emergency departments, outpatient facilities, and inpatient facilities.
Primary Healthcare Settings
Standards for suicide prevention in primary care include primary care provider education, practice-wide implementation of screening, and effective interventions to reduce risk, including safety planning with removal of lethal means and providing caring contact around higher-risk care transitions, such as after psychiatric inpatient or emergency room discharge.
Following screening and risk assessment, referral to a higher level of care, such as behavioral health specialist and/or emergency services, is made for those with acute risk. Patients with nonacute risk are asked to complete a brief suicide safety assessment to determine if, and how soon, a comprehensive mental health evaluation is needed. Interventions for nonimminent risk that can be provided in the primary care setting include safety planning, removal of lethal means, and timely contacts following care transitions.
After a patient has been identified as at an elevated risk for suicide, safety planning during the visit is recommended. This consists of a written list of coping strategies and sources of support prioritized to assist patients with addressing a suicidal crisis, as well as with the removal or reduction of lethal means. Primary care providers can endorse public health interventions such as the pharmacy/police collection boxes for extra medications and firearms as safety measures (Spottswood et al., 2022).
Emergency Department Management
The emergency department is often the entrance into the medical system for individuals who have attempted suicide or are having suicidal thoughts.
Upon admission, a medical assessment is completed to evaluate for and treat acute medical issues. Vital signs, history of present illness, and focused physical and neurological examinations are conducted for every patient with a psychiatric complaint. One-to-one observation is ordered when there is any question of self-injurious behavior. In addition, a temporary emergency hold is ordered to ensure that the patient is not able to leave until there is an opportunity to complete a suicide risk assessment. Intoxicated patients who present with suicidal ideation are held until clinically sober and then reevaluated.
Following assessment, if the patient is deemed “low risk,” a safe discharge plan is developed and documented, clearly stating what protective factors justify the discharge (see below). If patients at any time are assessed as higher than “low risk,” a psychiatric consultation must precede any discharge. An emergency hold may be placed according to state requirements and the patient notified.
If a moderate- or high-risk patient does not opt for voluntary hospitalization or at any point withdraws their voluntary status and they are determined to pose a danger to themselves or others, they should be held under an emergency hold until a comprehensive evaluation can be completed.
It is important to document the determination of risk, noting protective and risk factors that justify the decision to either involuntary hold the patient for psychiatric consultation or discharge to home (Rohrer & Dudek, 2022).
EMERGENCY DEPARTMENT DISCHARGE PLANNING
Providers in the emergency department determine whether to discharge and refer the patient for outpatient treatment or to admit for inpatient care. When being discharged to outpatient care from the emergency department, each patient is provided a plan for follow-up. The following is a discharge planning checklist:
- Involve the patient as well as family and friends in the development of the discharge plan.
- Schedule an urgent follow-up appointment (preferably within 24 hours, or when possible, within 7 days of discharge) with a mental healthcare provider, primary care provider, or other outpatient provider.
- Verbally review and discuss the patient care plan, including a review of medications, and confirm that the patient understands them by using the teach-back technique. A safety plan may be used to address elements of patient care related to suicide risk (see box below).
- Discuss barriers, such as lack of health insurance, that may interfere with following the care plan and identify possible solutions or alternatives.
- Provide a crisis center phone number.
- Discuss limiting access to lethal means. (See “Reducing Access to Lethal Means” below.)
- Provide written instructions and educational materials.
- After obtaining consent, share the patient’s health information with referral providers.
(NSPL, 2023)
SUICIDE SAFETY PLAN
Safety planning is a clinical process involving listening, empathizing with, and engaging the patient in the development of a series of action steps to be taken in the event the patient experiences suicide ideation, arranged in order of increasing response intensity. A safety plan also includes a collaboratively written list of coping strategies and sources of support the patient can use before or during a suicidal crisis. The plan is brief, written in the patient’s own words, easy to read, and involves the following steps:
- Warning signs or triggers (thoughts, images, mood, situation, behavior) that a crisis may be developing
- Internal coping strategies for diversion (relaxation technique, physical activity) without contacting another person
- People and social settings that provide distraction
- People whom the patient can ask for help when in crisis
- Professionals or agencies the patient can contact during a crisis
- Making the environment safe, including lethal means removal
- Optional step identifying reasons for living
When introducing the suicide safety plan process, the clinician takes these steps:
- Informs the patient that the purpose of the plan is to help them recognize when a crisis may escalate so that they know to refer to their plan and take action to reduce risk
- Helps the individual identify strategies that are simple and easy to use
- Obtains feedback from the patient about the likelihood of using the strategies
- Identifies barriers and problem-solves ways to overcome them
After the plan has been developed, the clinician does the following:
- Assesses the likelihood that the overall safety plan will be used
- Discusses where the safety plan will be kept and how it will be located during a crisis
- Reviews the plan periodically when the patient’s circumstances or needs change
(Stanley, 2021; Hindman & Fleming, 2022)
CASE
JACOB (continued)
The emergency department nurse, Avery, quietly spoke to Jacob, asking him if he knew where he was. When he didn’t reply, she told him he was in the hospital being treated for carbon monoxide poisoning. He said, “Then I didn’t die?” She replied, “No, you didn’t.”
Avery waited a second or two and then asked Jacob how he was feeling. He said he was feeling very sad and disappointed. Using active listening skills, Avery encouraged him to talk. He expressed feelings of sadness, anger, and frustration, and said, “Nothing is going right in my life. I just want to get out of it!”
Assuming a suicide attempt, Avery asked Jacob, “When did you first think of harming yourself?” He replied, “Yesterday. My girlfriend told me she wanted to break up and date someone else.” Avery said, “That must have been very hard for you.” He agreed that it was.
Avery asked him if he had ever had suicidal thoughts before, and he said that he “does every so often now.” She then asked him what he meant by “every so often now,” and he replied that he’s been thinking this way for the past few months, ever since the beginning of the school year.
Discussion
Because Jacob had used a high-risk method to attempt to kill himself, Avery considered him to be at high risk for self-harm. She helped him undress and put on a hospital gown. Then she called in an ED tech to stay with Jacob while she went to report his condition and discuss treatment with the ED team. Another team member went through Jacob’s belongings to remove any objects he might use to try to harm himself again.
A psychiatric evaluation was ordered for Jacob, following which it was determined that he had signs and symptoms consistent with the diagnosis of major depression. Jacob and his mother were informed that the safest place for Jacob at the time would be in the hospital, where he could begin treatment. He was admitted voluntarily to the hospital’s acute psychiatric unit.
(continues)
Outpatient Behavioral Health Management
Patients with elevated but not imminent risk of suicide require aggressive treatment that can be provided in an outpatient setting. Interventions are initiated at an intensity that is appropriate to the level of risk. Effective interventions in outpatient management include:
- Providing appropriate therapeutic treatment and aggressive treatment for psychiatric disorders
- Involving family members/caregivers or those close to the patient in regular monitoring until safety has been further established:
- Providing the patient and caregivers 24-hour access to clinical support in case of urgent need
- Instructing family/caregivers to take the patient to the emergency department if decompensation occurs or, if patient refuses, to call the police
- Informing the patient that safety takes precedent, and that even though the patient may object, a clinician may reach out to others for additional history to alleviate the risk of suicide
- Ensuring restriction of access to all lethal means of suicide, particularly firearms and medications; discussing with family members and/or police about temporarily making them inaccessible to the patient (see also “Reducing Access to Lethal Means” later in this course)
- Scheduling sufficient numbers of clinical contacts so that the patient will feel connected and supported
- Discussing how to identify and avoid triggers for relapse of suicidal ideation and to recognize warning signs
- Educating the patient and family/caregivers about the disinhibiting effects of alcohol and other drugs
- Discussing coping strategies and sources of support to distract from suicidal ideation
(Schreiber & Culpepper, 2022)
Inpatient Behavioral Health Management
Inpatient hospitalization is the most restrictive option and is nearly always indicated for patients with a recent suicide attempt or at high risk of imminent suicide. Involuntary hospitalization may be necessary for patients who do not agree with plans for hospitalization (see box below).
Inpatient mental health treatment involves admission to a hospital or clinic for at least one overnight stay. Key suicide prevention strategies considered in this setting include staff trained in suicide risk assessment, modification of the physical environment to ensure patient safety, and provision of increased monitoring during high-risk periods. It is also critical that patient discharge plans ensure continuity of care for suicide risk (SPRC, 2020a; Schreiber & Culpepper, 2022).
INVOLUNTARY HOSPITALIZATION
Involuntary hospitalization (or commitment) means placing a person in a psychiatric hospital or unit without their consent. The laws governing involuntary hospitalization vary from state to state, but in general, they confine involuntary commitment to persons who are mentally ill and/or under the influence of drugs or alcohol and are deemed to be in imminent danger of harming themselves or others. In most states, an involuntary psychiatric commitment cannot extend beyond 72 hours without a formal hearing. This 3-day period allows patients to receive basic medical treatment.
According to Washington State Law, Title 71, Chapter 71.05 RCW, an individual can be involuntarily committed when the person refuses voluntary admission and the healthcare professionals “regard such person as presenting as a result of a behavioral health disorder an imminent likelihood of serious harm, or as presenting an imminent danger because of grave disability.” A petition is a legal request filed by a designated mental health professional for not more than 120 hours (5 days, excluding weekends and holidays) for evaluation and treatment before a probable cause hearing must be held. Following the 72-hour hold, if needed, a court hearing can result in additional commitments of 14, 90, or 180 days. The goal is to stabilize the patient sufficiently so that they can return to the community as quickly as possible (AFSP, 2022b; Washington State Legislature, n.d.).
(See also “Ethical Issues and Suicide” later in this course.)
A decision to admit a patient to a psychiatric hospital is mainly based on an assessment of the danger a patient represent to themselves or others. The safety of the patient, therefore, is an essential prerequisite for admission, being aware that inpatient psychiatric suicide accounts for approximately 5% of all suicides. Several factors are involved, including a severe mental disorder in an acute phase, a recent suicide attempt, and the effects of stigmatization, especially in the case of involuntary hospitalization.
Patients in a psychiatric hospital setting require four levels of observation:
- General observation, with staff knowing a patient’s location at all times
- Intermittent observation, by monitoring the patient’s location every 15 minutes (and performing these checks at varying intervals of less than 15 minutes so that the patient cannot predict the exact time of the next check)
- Within sight, maintained 24 hours a day when there is a high risk of a self-aggressive act
- Within reach, requiring the patient to be within reach of a clinician at all times, including in the bathroom, when there is the highest risk
INPATIENT TREATMENT PLANNING
On admission to an acute psychiatric unit, a nurse meets with the patient to complete a nursing assessment and to orient the patient to the unit. During this interview, the presenting problem is identified and a nursing diagnosis is made. The most important concern on admission is patient safety. This may be written as: “Risk for suicide, or risk for self-directed violence related to (likely cause), as manifested by (specific behaviors).”
The initial care plan typically includes:
- Prevention of self-harm, suicide attempts, or escalation of either
- Monitoring the patient 24 hours a day
Within 24 hours, the patient is evaluated by the admitting psychiatrist and a multidisciplinary team that often includes a psychologist, medical practitioner (physician, physician’s assistant, or nurse practitioner), an RN, a social worker, and an occupational therapist. Following evaluation, the team meets with the patient to discuss the treatment plan. The plan should identify short- and long-term goals, steps to achieve them, and the professionals responsible for helping to achieve them. During hospitalization, some form of psychotherapy will also be provided.
The treatment plan outcome criteria for a patient with suicidal intent might include:
- Patient remains safe and free from harm.
- Patient cooperates with level of observation and supervision.
- Patient cooperates with healthcare team members to discuss suicidal ideation, intentions, or plans.
- Patient will be involved in appropriate interventions and treatment.
- Patient will state willingness to learn new coping strategies.
- Patient will express a positive future orientation and the will to live.
- Patient returns to a safe environment when discharged.
(APNA, 2023; Elsevier Clinical Skills, 2020)
CASE
JACOB (continued)
Robert, the psychiatric nurse who received Jacob’s admission orders, greeted Jacob on his admission and helped him get settled and oriented to the unit. Jacob’s belongings were checked in, and his belt and shoelaces were removed. Robert then spent the next hour interviewing Jacob about the events surrounding his suicide attempt. Following the interview, Robert’s nursing diagnosis was: “Risk for suicide related to depression and adverse life events as manifested by his attempted suicide by carbon monoxide poisoning.”
The initial treatment plan involved establishing suicide precautions and assigning a psychiatric technician for 24-hour monitoring. Robert, as RN, was to monitor and record Jacob’s mood, behavior, and pertinent verbatim statements every 15 minutes.
In the morning, Robert presented Jacob’s history to the team that included the psychiatrist, Dr. Ramos; the social worker, Marion; and the occupational therapist, Nancy. Following their discussion, Robert and Jacob met with Dr. Ramos, who continued the assessment of Jacob’s depression and possible need for medication. Jacob was also seen by the social worker for evaluation and input into the treatment plan.
With Jacob’s collaboration, the treatment team wrote the following treatment plan:
Problem
Depression as manifested by sadness, frustration, anger, low energy, withdrawal, sleep and eating disturbances, and suicidal ideation with suicide attempt.
Long-Term Goal
Symptoms of depression will be significantly reduced, with absence of suicidal ideation by discharge.
Short-Term Goals
- Jacob will not self-harm and will report an absence of suicidal ideation by the end of one week.
- Jacob will sleep six to eight hours each night by the end of two weeks.
- Jacob will consume three meals each day plus snacks by the end of one week.
- Jacob will begin psychotherapy to learn to identify negative and maladaptive thoughts and how to replace them with more positive and adaptive thinking.
- Jacob will begin to learn new coping skills, including problem solving and emotional regulation.
- Jacob will actively take part in the unit milieu.
- Jacob will actively take part in occupational and/or creative art therapies.
Interventions
- Individual therapy will be provided by the social worker or clinical psychologist to help Jacob learn and implement coping skills and to help him identify, process, and resolve his feelings and concerns.
- Family therapy will be provided by the social worker to develop a post-discharge crisis plan, to provide psycho-education about depression and suicide, and to increase Jacob’s parents’ ability to support and encourage him to use new coping skills.
- Occupational therapy will help Jacob identify those aspects of his activities of daily living that are in need of change and will make recommendations to the treatment team regarding discharge planning.
- The psychiatrist and the RN will provide medication management.
Evaluation
Ongoing evaluation of Jacob’s mental status and effectiveness of the treatment plan is conducted and the treatment plan modified as needed.
INPATIENT DISCHARGE PLANNING
Discharge planning is begun at the time of admission and revised throughout the stay. A written discharge plan is developed along with the patient, family member, or other authorized representative and the treatment team. Requirements of the discharge plan include:
- The patient is medically stable, and treatment of any underlying psychiatric diagnoses has been arranged.
- A comprehensive suicide assessment and risk assessment is completed within 24 to 48 hours prior to discharge.
- At the time of discharge an appropriate treatment plan is in place.
- Other collaborators and consultants are in agreement with the discharge arrangements.
- A needs assessment, including questions regarding the patient’s income, housing situation, insurance, and aftercare support, has been completed.
- Education regarding suicide, stigma, treatment options, and management strategies have been provided.
- An effective, collaboratively written safety plan is in place, and all attempts to remove potentially lethal means of harm have been made.
- A family member, friend, or other support person who will provide assistance to the patient following discharge has been identified and notified in advance of the patient’s discharge.
- The patient and caregiver/family have been provided an explanation of the next planned level of care with written copies of the treatment plan, including details of any medications, safety plan, date of follow-up appointments, and crisis contact numbers.
- Patient has contact information for outpatient support, and a follow-up appointment has been scheduled within seven days of discharge.
- Follow-up with the patient will be conducted, ideally within 48 to 72 hours.
(APNA, 2023; USDHHS, n.d.)