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

In primary settings, the emphasis is on identifying those at risk for suicide, enhancing safety for those at risk, and referring to specialized care. Screening is recommended using a standardized scale. When screening results in a positive identification of an individual at risk, it is critically important for the primary care provider to further assess the patient’s level of risk to determine if referral for a comprehensive mental health evaluation and risk formulation is warranted or to directly refer the high-risk individual to an emergency department for intervention. All patient information should be transferred on referral to ensure continuity of care.

For those who are not at high risk, the primary healthcare professional considers appropriate interventions to provide support to the patient. A brief safety planning intervention is conducted prior to discharge and, with the patient’s consent, discussed with the family to gain support for safety activities. Part of the safety plan includes lethal means counseling and arranging for and confirming the removal or reduction of lethal means, as feasible. (See also “Suicide Safety Plan” and “Reducing Access to Lethal Means” later in this course.)

At discharge, the patient is provided with appropriate resource information, including crisis line contact details and support resources.

At-risk patients also receive a post-discharge follow-up caring contact within 48 hours of a visit or the next business day. This can include:

  • Postcards and/or letters containing brief expressions of caring
  • Texts or emails
  • Telephone follow-up contacts
  • Telephone calls combined with in-person contact
    (NAA, 2018: SPRC, 2020)
MAKING A REFERRAL TO MENTAL HEALTH SERVICES

Clinicians who are the initial contact for patients who are at risk or who have made a suicide attempt most often refer them to one of the available treatment options. This requires a smooth and uninterrupted transition of care from one setting to another. In order to ensure that the patient is linked to appropriate care, the referring clinician follows these steps:

  • Refer the patient to an outpatient provider for an urgent appointment for a date within a week of discharge.
  • If unable to schedule the first follow-up appointment for a date within a week of discharge, refer for follow-up with a primary care provider and contact the primary care provider to discuss the patient’s condition and reason for referral.
  • Institute or revise a patient’s safety plan before discharge or referral.
  • Ensure that the patient has spoken by phone with the new provider.
  • Send patient records several days in advance of the appointment to the new treatment provider and call to review patient information prior to the first appointment.
  • Troubleshoot the patient’s access-to-care barriers (e.g., lack of health insurance, transportation needs) using information from the community resources list.
  • Contact the patient within 24 to 48 hours after they have transitioned to the next care provider and document the contact.
    (SPRC, 2019d)

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. For patients who have attempted suicide, a focused medical assessment is completed to identify medical issues requiring emergent or urgent management. This relies primarily on a history and physical examination, including evaluation of cognitive and emotional status, identification of drugs ingested, trauma, or other medical conditions that may affect the patient’s mental status. In addition, toxicology screening is often requested by mental health consultants.

Upon admission to the emergency department, patients who have harmed themselves, have mental illness or substance use disorders, or are receiving behavioral health treatment or psychiatric medications undergo screening using a standardized scale. For those found at risk for suicide, rapid referral for in-hospital or outpatient care is made as deemed appropriate. In instances where rapid transfer for inpatient management is not possible, the patient is placed in a space that is monitored and free of any items that can be used to harm oneself or others.

Following assessment and interventions, discharge planning is done to determine disposition (treatment and treatment setting). A small number of low-risk patients can be managed by the ED professional and discharged to home without a mental health consultation. The majority, however, do require a comprehensive risk assessment to adequately inform decision-making concerning disposition. Once disposition has been determined, a referral will be made (see box “Making a Referral to Mental Health Services” above) (SAMHSA, 2018; Betz & Boudreaux, 2016; NAA, 2018).

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, a plan for follow-up is provided. 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. 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.
  • Share the patient’s health information with referral providers.
    (NSPL, 2020)
SUICIDE SAFETY PLAN

Safety planning is a clinical process involving listening, empathizing with, and engaging the patient in the development of a safety plan, which is a collaboratively written list of coping strategies and sources of support a patient can use before or during a suicidal crisis. The plan is brief, written in the patient’s own words, and easy to read. It involves the following steps:

  1. Warning signs or triggers (thoughts, images, mood, situation, behavior) that a crisis may be developing
  2. Internal coping strategies for diversion (relaxation technique, physical activity)
  3. People and social settings that provide distraction
  4. People whom the patient can ask for help when in crisis
  5. Professionals or agencies the patient can contact during a crisis
  6. Making the environment safe, including lethal means removal
  7. Optional step identifying reasons for living

When introducing the suicide safety plan process, the clinician:

  • Explains how suicidal crises fluctuate over time and problem-solving capacity diminishes during crises
  • Explains how the safety plan helps to prevent acting on suicidal feelings
  • Explains when the safety plan should be used
  • Explains how using the strategies enhances self-efficacy and sense of self control
  • Identifies obstacles to carrying out the steps and problem solve around them
    (ICRC-S, 2017)
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 need 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:

  • Provide appropriate therapeutic treatment and aggressive treatment for psychiatric disorders.
  • Involve family members/caregivers or those close to the patient in regular monitoring until safety has been further established:
    • Provide patients and caregivers 24-hour access to clinical support in case of urgent need.
    • Instruct family/caregivers to take the patient to the emergency department if decompensation occurs. If patient refuses, police should be called.
    • Inform 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.
  • Ensure restriction of access to all lethal means of suicide, particularly firearms and medications; discuss 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.)
  • Schedule sufficient numbers of clinical contacts so that the patient will feel connected and supported.
  • Educate the patient and family/caregivers about the disinhibiting effects of alcohol and other drugs.
  • Discuss coping strategies and sources of support to manage suicidal ideation.
    (Schreiber & Culpepper, 2019)

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 below).

During hospitalization the risk of suicide is reduced, but the patient may be at higher risk immediately following discharge. Reasons for this are not known, and some studies hypothesize that there may be some harmful aspect to the experience of hospitalization itself or that patients perceive they have lost a therapeutic support system upon discharge. Therefore, hospitalization requires careful consideration (SPRC & NAASP, 2019; Schreiber & Culpepper, 2019; ICRC-S, 2017; AFSP, 2020b).

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 the United States, the maximum initial time for involuntary commitment is usually 3 to 5 days. If the person is not discharged on or before the 3- to 5-day limit because more treatment is necessary, a court order may be sought to extend the involuntary commitment.

According to Washington State Law, Title 71, Chapter 71.05 RCW, an individual can be involuntarily committed if found to be mentally ill and either presents a likelihood of serious harm or is gravely disabled. A petition is a legal request filed by a designated mental health professional for not more than 72 hours (not counting weekends and holidays). Following the 72-hour hold, the court can order the person to be committed for an additional 14-day involuntary intensive treatment or 90 additional days of a less restrictive alternative outside the confines of the hospital (Caruso, n.d.; Washington State Legislature, n.d.).

(See also “Ethical Issues and Suicide” later in this course.)

Management in the hospital is centered on the safety needs of the patient. The American Hospital Association and The Joint Commission require the following steps be taken to ensure that the physical environment is safe:

  • On admission, the patient is searched and all belongings removed, labeled, itemized, and safely stored in a secure patient belongings locker.
  • Environmental and housekeeping services are notified of a high-risk patient; they complete a behavioral health room safety check that includes ensuring cleaning supplies are kept secure and carts are always attended, which requires removing:
    • Plastic trashcan liners and replacing with paper liners
    • Extra items from closets (e.g., hangers, rods, items that can be used for hanging or strangulation)
    • Rubber gloves
    • Hand sanitizer from cage and soap in bathroom
    • Extra bed linens from the room
    • Extra chairs
    • Privacy curtains and supporting structures
  • Nutrition services should be notified to provide disposable tray meals.
  • Sitter or hospital staff should count disposable utensils before entering and before exiting the room.
  • Nursing staff should:
    • Remove unnecessary IV poles and medical equipment from the patient’s environment.
    • Remove any items in the room with a cord (phone, appliances).
    • Lock all cabinets with zip ties.
    • Place door designation signage.
    • Request safety soap from supply.
    • Change bed linens to flat sheets only to prevent the use of the elastic hem of a fitted sheet as a ligature.
    • (Danovitch & Arnold, 2017)

A review completed by The Joint Commission has found that hanging is by far the most common method of inpatient suicide, and over half occur in the shower. Other ligature fixture points have been identified as a door, door handle, or door hinge. The Joint Commission requires that inpatient units must be ligature-resistant in patients’ rooms and bathrooms, common patient areas, corridors, and transition zones between patient rooms and patient bathrooms, and that patient rooms and bathrooms must have a solid ceiling. In addition, in those areas where medical care is being delivered, one-to-one monitoring must be done, careful assessment of objects brought into the room by visitors must be done, and protocols for transporting patients to other parts of the hospital must be in place (Williams et al., 2018).

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 of patient 24 hours a day

The intervention includes implementation of suicide precautions that include one-on-one continuous monitoring, or observation every 15 minutes for mood, behavior, and verbatim statement depending on the level of suicide potential, as well as use of restraints if necessary and according to protocol.

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 will refrain from attempting suicide.
  • Patient will refrain from self-harming behavior.
  • Patient will identify situations that trigger suicidal thoughts.
  • Patient will state willingness to learn new coping strategies.
  • Patient will express a positive future orientation and the will to live.
    (APNA, 2015; Martin 2016)
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. It includes:

  • The patient is medically stable and treatment of any underlying psychiatric diagnoses has been arranged.
  • A completed comprehensive suicide assessment and risk assessment is completed at the time of discharge, and an appropriate treatment plan is in place.
  • Other collaborators and 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.
  • 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.
  • Contact information for outpatient and scheduling a follow-up appointment has been made within seven days of discharge.
  • Follow-up with the patient will be conducted, ideally within 48 to 72 hours.
    (APNA, 2015; Martin 2016; OAHHS, 2016; VSG, 2019)