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Changes
in social behavior. Individuals
who are suicidal may show marked changes in social behavior, either dramatically
or gradually. Some of these are the following:
- Withdrawing and cutting off social ties
- Going into a frenzy of work and play to ward off depression
- Losing interest in former activities
- Avoiding, rejecting or clinging to family and friends
- Voicing negative and self-denigrating statements
- Alienating others by rendering them helpless and frustrated
- Not taking care of or having pride in personal appearance
- Declining ability to work in job, home and school
 Another
group of behaviors that may precipitate suicide are those of a person
who is becoming psychotic and losing the ability to test reality. The
person may dread the recurrence of a former psychotic episode and act
suicidally to avoid it. Or they may begin to hallucinate by hearing voices
telling them to kill themselves. People who become markedly paranoid fear
danger from many sources. They misinterpret other people and external
stimuli and may act in suicidal ways in a desperate attempt (paradoxically)
to be safe.
Changes
in social behavior may be subtly coded as to suicidal meaning. A person
may start philosophizing about life and death, become preoccupied with
morbid subjects, death poetry, or the afterlife. He/she may ask or comment
about a "friend" who is suicidal. Sometimes, planning a long trip or completing
a long-anticipated desire is a clue that the person is finishing up life's
unfinished business before a suicide attempt.
Making
of final plans.
Signs that suicide is being actively considered include such activities
as putting things in order, making or revising a will, taking out more
life insurance, checking about organ donations and arranging for a cemetery
plot. The suicidal person may make ritualistic last visits to favorite
places and friends, give away prized possessions and make arrangements
for pets.
Persons
who put their suicidal thoughts into writing or who draft a farewell note
are generally more intent on outcome. This is particularly true if they
ask forgiveness from the family for the shame and consequences.
Actually
obtaining the means to the suicide - buying a gun or hoarding pills -
is preparation to put the plan into action. The more specific and detailed
the plan is, the greater the risk of carrying it through.
Suicidal
history.
Another important element is a history of a previous attempt. Those who
kill themselves have often made one or more prior attempts. It is important
to find out what the situation was, the means of attempt, the impact on
others and the subsequent outcome.
Death
by suicide of a parent, family member or close friend may influence later
suicidal behavior. Children are particularly affected by the suddenness
and mystery surrounding this kind of death. They may feel confused, responsible
and guilty. The child may also identify with the dead parent and later
seek to rejoin the parent through suicide. This may occur on a conscious
or subconscious level. The anniversary of the date of the suicide and
the death age of the suicided loved one are crucial times. Recent tragic
death of one close to a person may precipitate suicide, especially if
there is guilt or a strong desire to reunite.
An
aging person with an increasing physical disability may go into a depression
and suicidal crisis when cut off from friends, family and work. Death
of a spouse may precipitate the wish for self-induced death.
There
may be no suicidal history at all as with those attempting suicide due
to a terminal disease such as cancer or AIDS. Over the years there has
been an increase in the number of people with AIDS who have attempted
and completed suicide.
Use
of drugs and alcohol. Many
people who are depressed and distressed use drugs and alcohol as self-medication.
This is potentially very dangerous. Alcohol and barbiturates increase
depressed feelings, lowering impulse control and reducing ordinary caution
in automobile driving. How many fatal car accidents are really suicide-related
is difficult to assess.
Alcohol
use is part of many attempted and successful suicides. A person may purposefully
or accidentally overdose on combinations of drugs and alcohol. This can
lead to a serious medical emergency which, if not treated in time, may
be fatal. Under the influence of alcohol or drugs, some individuals provoke
others to attack physically and even kill them. Serious fights in families
and standoffs with police may be part of this self-destructive pattern.
Intuition
of a person close to the individual.
A person who is emotionally close to an acutely suicidal person may pick
up subtle clues that disaster is pending. Intuition is partially the result
of the screening of many nonverbal messages. It is felt as a vague sense
of foreboding, apprehension, a "hunch" that something bad may
happen.
The
dreams of both the suicidal person and significant others may give warnings.
Typical suicide dreams include those of going into a dark, unknown territory,
which may be either threatening or comforting; opening a door to the unknown;
reuniting with a dead loved one; and jumping out a window or falling.
Of course, these themes have many other meanings, depending on the individual
involved.
Problems
and Goals
The
emergency aspect of suicidal behavior is that an individual has acted
or is about to act in a self-destructive, potentially fatal way. This
is the most immediate problem. The immediate goal is to preserve life.
The
specific problems that lead to suicidal behavior are highly individualized.
They will be identified through a careful history taking and an understanding
of the larger picture. The long-range goal is that the person will develop
alternative ways to cope with the conditions that led to the suicidal
state.
These
goals include:
- Increased impulse control
- Increased willingness to live, even with difficulties
- Increased hope, self-esteem and sense of mastery
- Improved communication and interpersonal relations
- Increased ability to deal with feelings: love, anger, depression,
grief, loneliness, guilt
- Increased understanding of self-destructive patterns
Persons
who are suicidal come to the attention of health professionals by several
means. They may be patients in active treatment in either an inpatient
or outpatient setting for physical or psychiatric reasons. There may be
a change in their condition, life circumstances, and ability to cope.
Often, depression is linked with an upsurge in suicidal ideation.
Many
people who make suicide attempts go to an emergency room first. They may
seek out this help or be brought by family. Cut wrists are sutured; early
overdoses, lavaged. If the physical condition is serious, the patient
is admitted for intensive care or lifesaving surgery. Psychiatric evaluation
must wait until the person is medically clear.
Many
emergency rooms ask for a psychiatric evaluation for each attempt or threatened
attempt, if possible. After assessment, psychiatric treatment, either
inpatient or outpatient, may be recommended.
Indications
for psychiatric hospitalization include continued high risk of acting
on suicidal impulses based on regrets that the attempt was unsuccessful
and strong feelings of hopelessness and of being overwhelmed; increased
depression, despite initiation of treatment; lack of available support
system of family and friends; subtle suicide encouragement by family;
severe personality disorganization or psychosis; gross disturbance of
physiological balance; and need for specialized treatment, such as electroconvulsive
therapy.
The
patient may not follow through with psychiatric treatment once the emergency
is over. The stigma of mental illness stops many people from seeking help
with their problems. They may be afraid to change or they may not be ready
to face difficult interpersonal problems.
Another
means by which a suicidal person comes for treatment is through telephone
contact by self or others. Crisis centers and suicide prevention programs
offer 24-hour services to the distressed. The professionals and volunteers
in these programs are carefully trained to do assessment and treatment
recommendation. They are also often available to do telephone consultation
with other health workers. The police are another helping group who bring
people in for help when needed.
A
very important aspect in working with suicidal people is for the staff
to talk with one another. It is necessary to compare observations and
information, as well as to share the many feelings that are evoked. Some
suicidal patients are very trying and provocative; this behavior can be
frustrating to those trying to help them.
Nursing
Actions in Caring for Acutely Suicidal Patients
A
psychiatric unit is usually the most appropriate treatment setting for
seriously suicidal people during an acute crisis. The nursing staff helps
to protect these patients from hurting themselves while they carry on
the tasks of daily living, such as eating, hygiene, exercise, sleep and
communication. If depression is part of the picture, these activities
may be greatly impaired.
Nurses
form a human lifeline to distressed patients. They encourage use of the
ward treatment program, which has been planned to increase self-esteem
and to allow safe expression of feelings of anger, fear and guilt. The
interest and care of the nursing staff give hope to the patient, increasing
the motivation to live.
Problem:
- Acute suicidal thoughts, feelings and impulses
- Decreased impulse control
Goal:
To
prevent physical and psychological injury
Action:
- Be available to patients as helpers who stay with them, provide structure
and assistance, meet physical needs and talk with them about the current
crisis.
- Provide one to one staff supervision, if needed; keep patient in observable
place.
- Restrict to ward or accompany to necessary appointments.
- Supervise eating, toileting, smoking, sleeping.
- Assess and evaluate changes in behavior, depressed behavior, suicidal
ideation, plans, feelings and response to treatment.
- Help patient to evaluate strengths and other ways to cope.
- Increase level of patient observation at change of shift, weekends,
mealtimes.
- Provide a safe environment in which the patient is protected and cared
for until self-destructive impulses are under control.
a. Maintain a basically safe unit - shatterproof, lockable windows;
no exposed pipes or hooks; safe area.
b. Remove potentially harmful objects and supervise use of razors,
glass, sharp or pointed objects, drugs, chemicals
c. Use seclusion if patient is actively harming self; restrain
if unable to control.
d. Monitor visits as needed.
Suicide
Precautions
Many
hospitals have specific procedures for "Suicide Precautions," which can
be ordered on a psychiatric or general unit. Patients who are too sick
physically to be on a psychiatric unit may be acutely suicidal. If treated
in an intensive care unit, they are probably relatively safe because of
the degree of incapacitation and the constant observation and surveillance.
If transferred to units with less staff, they may require a special nurse,
a "sitter," or constant observation by family and friends. It is important
during this period to initiate and establish professional mental health
referrals, if possible.
When
a patient is suicidal, how closely is the patient to be observed by the
nursing staff? This is a question that requires careful consideration.
A nineteen-year-old female was admitted to a leading psychiatric facility
in New York City. She had told the nursing and medical staff many times
that she planned to kill herself. On a daily basis she would describe
to the nursing staff what she planned to do. The nurse assigned to her
was told in detail about dreams the patient had in which she put a plastic
bag over her head and ended it all. Her father had recently died and she
said that she wanted to die, too. She attempted suicide by drinking a
bottle of rubbing alcohol. Even then she was not observed closely. Two
weeks later, during nursing report, she committed suicide. She accomplished
this by placing a plastic bag over her head, tying a sheet around her
neck and tying the sheet to the plumbing on the toilet. Who is responsible
for her death? In a court of law who is negligent: the attending psychiatrist,
the nurse or the hospital administration? The following guidelines are
legal descriptions of degrees of suicidal observation. It is very important
for each nurse and staff member to understand and follow these guidelines.
Constant
Supervision - Level One. A staff member is assigned to the
patient at all times and is responsible for the safety of the patient.
Nursing documentation must reflect information based upon this guideline.
The staff must be in an eye's view and seconds away from the patient under
observation. The hospital and the medical and psychiatric nursing administration
are responsible for assuring that this guideline is carried out. The goal
of this observation is to preserve life. The nursing staff
is responsible to assure that all the contraband is removed from
the immediate environment of the patient's room or anywhere the patient
is during this strict period of observation. When the patient is considered
a danger to self, the following items are removed: glasses,
belts, shoelaces, bras, pantyhose, plastic bags, string, razors, knives,
electric cords, hair pins and even money. Nursing observation focuses
on statements of the patient, indications that the patient is actively
hallucinating or hearing voices suggesting self harm, thoughts of danger
from others, and other significant behaviors - laughing inappropriately,
withdrawal, lack of interaction with staff or others, poor appetite, or
poor sleeping patterns.
Fifteen-Minute
Observation - Level Two.
A staff member is assigned to the patient under observation. The patient
is again maintained in eye's view and seconds away. The patient is encouraged
to interact with other patients and staff. The staff member is responsible
to interact with and observe the patient every fifteen minutes. During
the fifteen-minute intervals the patient is encouraged to participate
in activities with other patients and staff. Documentation is carefully
kept during these intervals and the staff member assigned is responsible
to report the patient's behavior based upon the criteria described in
the above guideline. Degree and frequency of suicidal ideation is reported
and documented. Accurate documentation is necessary. If the patient
exhibits behaviors that demonstrate an increase in suicidal ideation or
recurrence of hallucinations, then the patient will be placed back on
Constant Supervision.
Altered
Observation - Level Three.
Again, all dangerous objects are removed from the patient's immediate
environment. The patient is still considered a danger to self.
Legal documentation is required. The patient need not be assigned to one
staff member at this time, however. All staff are responsible for the
safety of the patient. If the patient begins to report voices and hallucinations
telling him to hurt himself, he is returned to the Fifteen-Minute Observation.
The
psychiatrist is responsible for accurate assessment of the degree of suicide
potential of the patient. It is the nursing staff who are responsible
to assure that the proper suicidal observation is carried out in the clinical
setting. The Constant Supervision may begin in the psychiatric
emergency room when the patient is in the storm of psychiatric crisis.
In a court of law, the judge will utilize these guidelines in most states
to evaluate negligence. Nursing and medical staff should be aware of the
legal aspects of psychiatric nursing practice, but the most important
concern is the safety of the patient and the Preservation of Life.
These
guidelines may also be implemented in other areas of the hospital. Nurses
are responsible in critical care units, intensive care units, medical/surgical,
oncology and all areas of the hospital to document and communicate suicidal
ideation of patients to the appropriate channels for consultation. If
the clinical specialist in the critical care unit identifies suicidal
behavior in a post myocardial infarction patient, the medical department
must carry out proper protocols for suicidal behavior in a cardiac patient.
The nurse must document and provide safety for the patient, and the physician
must respond. If they fail to respond, they may find themselves in court
even if the patient does not attempt suicide, but only interferes with
medical treatment and develops complications as a result.
References:
Review of decisions regarding suicide and malpractice, New York University
Law Library.
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National Center
of Continuing Education
An agitated, impatient, insistent attitude that something must
be done immediately to reduce the anguish and to remedy the situation.
The person needs immediate relief.