Suicide Risk Assessment and Care Planning

[Popwhizbangz, LPN]

Suicide Assessment

Suicide assessment is one of the most important and challenging aspects of working in mental health. The combination of uncertainty and liability can be intimidating. For your own protection and peace of mind, assess and document carefully in this area: not a matter of writing a lot of words, but instead of writing the correct words. Aim to minimize the odds of suicide as much as possible, and to make it clear in the record that you did so. No one can perfectly predict or prevent all suicides, but we can do the best job possible. Remember, suicide is both common and lethal: tens of thousands of death in the U.S. every year.

Assessment aims at exploring the risk of an attempt, the dangerousness of such an attempt, and the available resources to mitigate risk. There are many pertinent questions, listed below (Stern et al 15-19). For many providers, the main need is to detect risk and steer patients at risk to a mental health specialist.

Ideation: are they thinking about it? How much? How seriously?

Intent? Do they plan to take action? When?

Somehow expressed intent precedes up to 80% of deaths by suicide

About 50% of people who kill themselves see a health care provider in the month prior. BUT of those who do see a provider first, only 60% express SI or intent at that time.

Can the patient contract for safety?

Is there a suicide plan? How viable is the plan, how lethal is it? How well thought out, how detailed? Are the means readily available, e.g. a gun (very high lethality).

Likelihood of rescue? If they were to make an attempt, would anyone be available to help them?

Hopelessness? Do they see any future for themselves? Anything and/or anyone to live for?

Impulsivity? Can they be trusted to stop themselves form harming themselves or others?

Mental status: E.g. Are they intoxicated? Psychotic? Psychiatric illness? Are they too impaired, or paranoid, etc. to keep themselves safe?

Risk factors, i.e. those that increase the odds of an attempt:

History: Any past Attempts: impulsive or premeditated? Any family history of suicide? History repeats itself:

50% of completed suicides have a prior attempt history

Of those with past attempts, 10-20% eventually die by suicide

Risk is esp. high for a year after most recent attempt, with elevated risk for 10 years

Any precipitants recently? Anniversaries of losses, job loss, break-ups, etc.

Stressors and supports? E.g.:

Medical disorders

Widowed, divorced, separated

Isolation

Recent losses

Unemployment

Financial and/or legal problems

Demographic risk factors? E.g. Elder white men are the single highest risk group demographic group, while married adults with young children are at lowest risk.

H/O Unstable childhood circumstances: parental death or separation, abuse, neglect. Raises level of risk.

All these factors help us gauge, however imperfectly, the risk of suicide and of death.

Care Planning for Suicidal People:

Finally, staff response is crucial: What do you plan to do to minimize risk?

In terms of care planning, it all boils down to trust, based on your assessment.

What is needed to maintain a person's safety?

Part of your trust involves your assessment regrading your patient as an historian:

- Are they competent?

Are they honest? Are they manipulative? Do they trust you enough to tell you the uncomfortable truth?

Who do they trust? Maybe you should seek information through more trusted sources

Are they threatening vs. others?

Are they cooperative?

The less you trust a patient's safety and/or predictability, the more protection you provide.

Aspects of your plan include:

- Patient contracting. A Contract for Safety (CFS) with the patient, promising to keep safe and come to staff if losing confidence in the contract. Can you trust the patient to keep such a promise?

- Setting and supports: e.g. locked inpatient unit, staying with friends or family, day programs, etc.

- Monitoring - checks: weekly, daily, 5 or 15 minutes, by phone or in person, one-to-one specials, a sitter, etc.

- Restrictions: locked unit, no sharps or flames, QR, restraints

- Ease suffering:

Medical care: esp. re. pain, anxiety, depression, and other suffering

Supportive education and counseling, e.g.

Depression cause hopelessness, and it is very treatable, given a bit of time. So we have every reason to expect things to look better, soon.

Build the rapport, maximize effective supports

Stern, T.A., Herman, J.B., and Slavin, P.L. The MGH Guide to Psychiatry in Primary Care. New York: McGraw-Hill.

Hope somebody out there finds this useful:redbeathe

[NYRN08]

Thank-You, Pop! I find it very useful. In fact I noticed that you put the name of the book, I believe you got the information from. I've been meaning to find some pysch books to read. This is one that I will be looking into. :)

[Loreta]

:):)Thankyou for such a great tool!!!, very useful

[exchangeofideas, NP]

This is a great resource. I was wondering about liability. If the patient mentions SI and follows through with the suicide what should the nurse have done to protect themselves (perhaps filling out a contract and notifying the doctor)? I understand that as a provider, they can call 911 in an outpatient office. 

[verene, MSN]

On 6/9/2021 at 4:46 PM, exchangeofideas said:

This is a great resource. I was wondering about liability. If the patient mentions SI and follows through with the suicide what should the nurse have done to protect themselves (perhaps filling out a contract and notifying the doctor)? I understand that as a provider, they can call 911 in an outpatient office. 

The most important thing to do with a patient mentioning SI is to clearly assess -- is this a vauge and passive "wish I don't wake up tomorrow" level of SI or an imminent detailed plan with high lethality means? What are the protective factors that would cause a patient to pause or prevent them from acting on these thoughts? Are there are large number of these protective factors or can the patient not identify a single reason not to die?  Appropriate action is based on the severity of risk after assessment.  Exact policies on how to follow up will depend on your setting and resources available.  In some settings RNs can initiate a mental health hold, in others you would need to call MD/NP or call a crisis line or 911 to get additional assistance.   

If the patient isn't at imminent risk it is important to make a safety plan (this isn't the same as a contract - contracts for safety don't work and are essentially meaningless).  Work through - what are "higher risk" situations - when do they feel most depressed and most likely to act on SI - how can they avoid these situations? What are there reasons not to die? - write them down.  If feeling depressed - what are their resources for support and distraction? Are they okay with these resources being brought in an aware of their safety plan? (E.g. "If feel better when I call my mom on the phone - can we let mom know that patient is going through a rough time and their protective factor is to call mom?)  Who is the second person to call if that person isn't available? Post the plan (risk situations, how to avoid, reasons to live, coping skills to manage the impulse, and resources for help) and these contact numbers in multiple places - e.g. copy on fridge, copy in car, copy in purse. AND consider giving a copy to 1-2 support individuals for patient. Make sure they also have copies of local crisis resources and know locations/contact of walk-in/urgent care mental health clinics.  Also reach out to the mental health team (if involved) and see if the patient can't be moved to more frequent check-ins - potentially including phone check-ins for support and safety.  These plans work best when the patient is an active participant in their creation as they need to be personalized and meaningful to the individual. 

In out patient setting we sometimes would have patients call office daily if we were worried about them, and the patient had agreed that if we didn't hear from them - we would send a welfare check to their home. 

A lot of the specific details may vary based on your practice setting, community resources, and the individual patient.