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Vicki Notes
Chapter 42 – Suicide
Incidence & Populations Affected
- Suicide continues as the eight leading cause of death among all age groups.
- It is the third leading cause among 15 to 24 y/o
- White people are twice as likely to die by suicide as nonwhite people
- More than 70% of all US suicides are committed by white men.
- The number of elderly suicides is rapidly increasing.
- The population of elderly American men is now the group at highest risk.
- Ethic groups with highest suicide rates are – Native Americans & Alaska natives.
- Geographically, rates are highest in the western mountain region & lowest along the Northeast seaboard.
Etiological Theories (What they think causes suicide)
- Possible reasons include:
- To escape from poor physical health
- chronic pain
- resolve social alienation
- unbearable intrapsychic pain
- escape from years of suffering with mental illness i.e. chronic schizophrenic.
- Age & gender related as mentioned above.
- Most people who attempt suicide have recently experienced a period of increased stress.
Sociological theories
- Durkheim proposed that individuals committed suicide because they:
- lacked purpose in life (egoistic suicide)
- sensed social normlessness (anomic suicide)
- gave up living for a greater good (altruistic suicide)
Psychological Theories
A. Psychoanalytic View
- Freud defined two drives – eros, the drive toward life & thanatos, the drive toward death à he proposed that suicidal behavior emerged when the ‘death drive’ took precedence over the ‘life drive’ & occurred in response to the real or imagined loss of a significant object.
- Contemporary assessment for risk of suicide requires evaluation of the extent of recent losses as part of the systemic development of a database.
B. Interpersonal View
- Views suicide as the result of an intrapersonal & intrapsychic crisis à where the person experiences interpersonal discord that leads to ambivalence about continuing to live à suicide becomes the means for resolving interpersonal conflict.
Biological Theories
- Serotonin provides inhibitory control over aggression in many animals à when insufficient serotonin is available in the brain; the result may be excessive aggressive behavior, including self-aggression.
- 5-HIAA (5-Hydroxyindoleacetic acid) is a metabolite of serotonin & is normally found in spinal fluid à some research has shown that low cerebrospinal fluid 5-HIAA predicts short-range suicide risk & supports the serotonin hypothesis of suicide risk.
- A recent study show that low serum cholesterol is connected with attempted suicide à cholesterol is believed to be a biological marker of serotonin.
Dynamics of Suicide
- People who consider suicide perceive themselves as isolated à they may distance themselves à they feel guilt, helplessness & hopelessness and worthlessnes which are the strong predictors of suicide.
- The emotional state is characterized by depression & anger.
- The persons desire to be free of pain is often coupled with the desire to be saved.
Application of the Nursing Process
Assessment
Estimation of Risk
- Assessment of the estimation of risk is the key to developing a nursing care plan for the suicidai person.
- Issues to be explored include:
- The person’s request for help.
- The presense & nature of the suicide plan.
- The person’s mental status.
- Their lifestyle & availability of support systems.
Risk Factors
- Identifying risk factors is a major part of suicide prevention especially in the following areas:
- Age
– Those less than 14 y/o rarely commit suicide – at 18 – 30 y/o the rate greatly rises – this age group often found in military, colleges or prison. As far as ‘heavy metal’ music being a cause – research shows that the people who are already at risk are draw to this music/subculture à it is not a direct cause. In elderly American men à the older the greater the risk.
- Gender
– Four time as many men commit suicide as women à however women are the majority who attempts it.
- Ethnicity
– Native American & Natives of Alaska are at highest risk possibly r/t stressful lifestyles & alcoholism.
- Mental Disorders
– At highest risk are men & women diagnosed with depression or bipolar disorder à followed by schizophrenia à then borderline personality disorder à and substance abuse.
- Medical Illness
– Many suicides completed by elderly with cancer or terminal illness à and recently there is an increase in the young with HIV.
- Feeling Tone
– The person who fully believes there is no future or who sees him or herself as worthless is viewed as the person at highest risk. Other feelings include helplessness & guilt à and are commonly expressed by people in despair
Clues to Suicide
- Some people leave suicide notes hoping to be discovered before dying.
- There may be cryptic verbal messages such as "Maybe things would be easier without me here."
Behavioral Changes
- Depressed & suicidal people often lack the energy to act on their thoughts until the vegetative symptoms, including fatigue, loss of appetite & psychomotor retardation, lift.
- As a person starts antidepressant therapy begins to feel more energetic they may be at greater risk because they now have the energy to carry out the suicide plan.
- Therefore drug therapy which has an effect in 2 –4 weeks may briefly increase the risk for suicide.
- Subtle changes that may indicate increased suicide risk include – anxiety, insomnia, poor concentration, anorexia or somaticism & expression of anger or despair, also giving away personal items, such as clothing especially if accompanied with comments like, ‘I won’t be needing these clothes any longer.’
Risk Periods
- High risk periods for inpatient settings include:
- Times between 10:30 pm and 5:30 am.
- Between Friday morning & Monday evening.
- May be r/t availability of staff at those times.
- Other risk periods include:
- Certain times of the year – springtime, traditional holidays & anniversaries of significance to the person.
- These seem to be times that prompt feelings of loneliness, despair & isolation.
Goals of Assessment – Are to:
- Establish the probability that the individual will act to harm her or his self.
- Determine the meaning of the wish to do self-harm.
- Gather information for initiating a therapeutic relationship.
- Determine the extent of protective nursing care that will be necessary
- Information is obtained through direct interview with patient & family.
Interviewing Strategies
- Establish a warm atmosphere – communicates concern & interest.
- Call the patient by name – shows an attitude of respect & offsets feelings of worthlessness
- Verbally state the patient’s perception of the situation, fears & sense of desperation – conveys a willingness to understand the situation.
- Touch if accepted – can establish a bond of reassurance & support.
- Directly stating, ‘Are you feeling suicidal?’ conveys to the patient that you understand how desperate they feel.
Interviewing the Family
- Family & friends should be included in discussions about the risk of suicide as they can provide insights.
- When obtaining needed information from anyone always question in a manner to protect confidentiality.
Values & Attitudes
- As a nurse it is important to identify your feelings & reactions to the suicidal person.
- Self-awareness can help you respond to your patient with greater objectivity & empathy.
- Ask yourself these questions & discuss them with your peers:
- Do you believe that suicide is ever justifiable?
- Do you believe that people who attempt suicide are trying to gain attention?
- Do you think that suicide is not really preventable?
Content of the Assessment – Must include the following
- How the client entered the health system – Did the person call a suicide hotline? Or a physician? Ask a friend to take them to the hospital. The greater the volition in seeking help the better the chance for effective early intervention will have for preventing the suicide.
- The client’s intent when he or she used self-destructive behavior
– Does the person want to die or are they seeking relief from unbearable stress? Obtaining this will help provide safety & meet the expressed needs of the patient. Since this patient will display severe anxiety & poor concentration only the conscious motives of suicide will be discussed with then in crisis à more in depth exploration will be attempted at a later time.
- Presence of a suicide plan
– Ask directly, ‘Are you planning to kill yourself?’ This directness lets the patient know they are being taken seriously & you understand the level of their distress. If they admit to a plan à found out how they plan to carry it out à the more lethal the method the greater the risk (use of a gun, hanging, self-immolation & jumping from a height) à then assess whether or not the resource is available. For example: Do they have a gun & ammunition at home? Or do they not have a gun? à What is their intended location? Where they are likely to be rescued? Or in a remote wooded area?
- The rule of thumb is the more specific the plan, the greater the risk of suicide.
- Remember 3 critical factors: Lethality of the plan, Availability of resources & Likelihood of being rescued
- Current mental status – examination should include the person’s level of anxiety, mood & thought organization. Note that immediately prior to a suicide gesture, the anxiety of the client may drop because he or she now has a plan that will eliminate the pain à the mood by then is depressed & hopeless.
- Availability of support systems
– Presence of family & friends tends to lower the risk of suicide but monitor for relationships that may have precipitated the suicidal gesture. The patient from a sense of isolation & alienation may be unable to know or make therapeutic use of these available support people.
- The client’s predominant lifestyle
– What types of coping mechanisms do they use? Has there been a change in appetite, interest in sex, sleep patterns, or relationships? A marked change could signal changing suicidal intent. Do they have a stable lifestyle? Is the change sudden or has the person been dysfunctional for some time?
- CAREFUL ACCURATE DOCUMENTATION of ALL the above six factors is important to care & the nurse’s legal responsibilities
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Estimation of the Risk for Suicide
- It is better to assume a greater risk than a lesser risk until staff members have a better understanding of the patient’s potential for committing suicide.
Formulating a Nursing Care Plan
Nursing Diagnosis – Example for the suicidal patient:
- Hopelessness r/t rejection by spouse.
- Ineffective Individual Coping r/t impulsivity, characterized by multiple suicide attempts.
- Risk for Injury r/t high risk for suicide.
Planning
- Focus here includes the measures needed to protect the patient while maximizing his or her autonomy. It is important to never underestimate the patient’s need for safety, to include those that had made repeated nonlethal suicide attempts.
Short Term Goals
- Focus on providing safety & interpersonal support.
Long Term Goals
- Focus on helping the patient resolve the issues that precipitated the suicide crisis & develop less destructive coping mechanisms
Intervention
- Focus is to reduce the risk of suicide, explore with the patient the lifestyles or stressors that precipitated the suicidal crisis & assist the patient to develop new ways of coping.
The following are interventions that may be used by all nurses & are listed by setting.
Community Intervention
- It is important to understand the meaning of the crisis - that it is time limited & demands change.
- Coping skills must be mobilized – by helping the person to identify the meaning of this life event (this is done by exploring precipitating stressors & responding to words & feelings of the person). Also decide if adequate support systems are available & if the person can cope adequately outside the hospital. Contact with the suicidal person should not be terminated until he or she can state a specific plan of action for preventing self-destructive behavior.
- The Need for hospitalization - A person at high risk should be encouraged to enter a psychiatric inpatient hospital unit or other treatment facility. If they refuse determine who can remain with the person until crisis has passed.
- Never indicate that the person can be magically protected from their impulses.
Hospital or Treatment Center Intervention:
Providing Environmental Support
- People at high risk for suicide are placed in a protective environment such as a closed unit.
- Access to hazardous objects are restricted i.e. scissors, razors, light bulbs & knives.
- To preserve dignity as many personal items as possible remain with the person à belts are removed.
- Monitor to be sure all medications are swallowed & not saved by the person for later suicide attempt or while on home visit.
Demonstrating Concern & Offering Help
- Therapeutic interpersonal contacts decrease the patient’s sense of isolation.
- Verbal contact q 1 – 2 hrs reinforces interest & concern.
- Reassure that staff is immediately available until the suicide crisis passes or to help resist urge.
- Help focus on ADLs (hygiene, eating & dressing).
- Avoid extensive discussion or exploration about reasons for suicidal behavior at this time (until risk has decreased).
- Highly impulsive patient’s may be observed closely with ‘one on one’ observation.
- Impulsive behavior may at times be controlled through use of ‘quiet rooms’ à be sure the patient understands that it is to reduce stimuli & is not used as a punishment. Tell them ‘Time out will have you gain control’ à which lets them know you believe they can control their behavior.
Establishing a ‘No Suicide’ Contract
- A ‘no suicide’ contract must be established with a patient who is now at moderate risk. The contract must be repeated ‘exactly’ to the nurse à failure of the patient to repeat the exact words or rephrase indicates an unwillingness to keep the contract & the above mentioned supports must continue.
Promoting Decision Making & Autonomy
- Simple decisions are difficult for the suicidal person because they are preoccupied with suicidal thoughts. Therefore encourage them to make simple decisions i.e. when to bathe & what to wear. Aiding them to make decisions decreases isolation by providing contact & helps maintain a sense of dignity through self-direction & tends to decrease feelings of helplessness.
Exploring Client Strengths
- It is important to acknowledge the patient’s pain bur also their strengths à by helping them to identify stressors that lead to the suicide crisis. In knowing stressors others ways & useful methods of the past, of coping can begin to be identified.
Protecting the Thought-Disordered Client
- Patient’s with thought disorders may be more at risk for impulsive & self-destructive behaviors à Schizophrenic’s may try reality testing – cutting their wrists to see if blood will flow à or the voices may tell them to ‘kill yourself.’
Postsuicide Intervention
- Prevention is the primary goal of treatment.
- Postvention services assist survivors of suicide adjust to the loss.
Suicide Prevention Services
- Suicide centers were developed in the 1950s.
- Crisis intervention services aid in helping potentially suicidal individuals postpone the decision to kill themselves.
- Centers, volunteer groups & professional clinics offer crisis services that include anonymous telephone hotlines & limited face-to-face counseling to people at risk.
- The willingness of a volunteer to listen may communicate to a suicidal person that he or she has worth & that life is not hopeless.
Survivors of Suicide
- Those left behind experience anger, frustration, guilt, & ambivalence à as well as grief associated directly with the death. Families may experience shame & embarrassment following a suicide. Friends & relatives may be standoffish because they do not know how to respond.
Resynthesis of Survivor-victims
- Using Resnick’s model of resynthesis survivor-victims go through these stages:
- Resuscitation – involves the first 24 hours, is spent dealing with the shock followed by funeral & burial arrangements.
- Rehabilitation – here mourning is encouraged as well as the expression of all feelings & reactions.
- Renewal phase – acceptance begins & the survivors are helped to integrate the suicide into their lives.
Health Care Survivor-Victims
- Caregivers need the same opportunities to grieve.
- This may be accomplished by a ‘psychological autopsy’ – here the staff gathers to review the patient’s behaviors & actual death act à it does not attach blame to any member of the health care team à but allows staff to discuss the death & their reactions to it.
Evaluation
- Evaluation of nursing care is based on:
- The clues being identified early enough to permit intervention.
- The interventions being appropriate & effective.
Professional Practice Issues
Legal Issues
- Some suicidal patients who have refused treatment may be hospitalized under state commitment procedures.
- Hospital inpatient units will have written policies & procedures that guide nursing practice. These policies usually define the frequency for assessment of suicide risk & the extent to which a client is protected.
- Documentation of assessments & of nursing care provided is essential.
Ethical Issues: Assisted Suicide
- The professional nurse is ethically bound to protect patients who are at risk for self-harm.
- Research findings indicate that – 95% of all suicidal patients have a diagnosable psychiatric disorder. Treatment for many of these individuals often results in elimination of suicidal ideation & a greater desire to live, despite serious illness.
