Suicide

[jdub6]

I'm not a psych nurse. I currently work ED and have great respect for you guys. I am wondering if you'd share your thoughts on something that's been troubling me.

Paramedic. 40. Divorced (10 years). Suicide attempt by hanging-nearly succeeded-very lethal attempt/intent. Is 9 years clean from drugs, suffers severe anxiety/depression despite being compliant with care from a psychiatrist and therapist and peer support groups. No meds have ever really helped. Inpatient twice, also reported no real effect on his depression. Has significant debt, will need to file bankrupcy. Homeless after foreclosure. Car now needs brakes-no money for that. Has never found another significant other (No recent break-up or rejection.)

This man was restrained in our ED for 2 days before transfer to psych because he desperately wanted to die. The EMTs who responded to the scene knew him so now he felt his career was toast, at least locally (from humiliation if nothing else.) He tried to elope each time he was unrestrained and said he would continue to do so. He was clear he wanted to leave and die.

I never see these patients when they are discharged from psych so don't see the change that happens. But it feels wrong to me to tie this man to a bed and keep him alive at all costs when we can't fix his life. It's not like he's in the middle of a divorce, or his mom just died, or he was good on med but stopped them. We can't find him a wife, he's given meds many tries, we can't get him out of debt, can refer to a shelter but not get him other housing, can't fix his car, cant make his colleagues un-see what they've seen. and now he will have a huge hospital bill.

It feels wrong to do everything to save his life, against his will, then after a week or so send him back to the same problems. Do you guys ever feel like that?

[PixieRN1]

I'm a Psych nurse; he may be a candidate for court ordered ECT...that is the only thing I have ever seen work true "miracles" in severe treatment resistant suicidal depression. Of course I'm not a physician and don't know this man, but I've seen many "lost causes" turn around with ECT, and it is not uncommonly court ordered.

ECT has around a 70% success rate for a one year remission of severe suicidal depression, depending on the study you look at. No, it won't fix his life, but if his depression is refractory, it's certainly worth an effort if the alternative is relatively certain suicide.

In Psych we also have dedicated full time case managers who work towards getting these people stabilized in the community; a group home or transitional living may be an option once he is more stable as well...it doesn't have to end in a trip to the shelter.

[Heylove, BSN, RN, EMT-B]

It is true about ECT turning around some (seemingly) hopeless cases. If he has documented care with a psychiatrist and medications, I, too thing ECT may be helpful.

I read the original post yesterday and have been thinking about it ever since. This is part of the reason that I prefer to work with the adolescents, is because I have SO much hope for them. They are young and have soooo much more living to do. We talk all the time about how no matter how big their problems seem right now, it's almost guaranteed that they will encounter bigger problems in life and that the skills they learn in their adolescence is going to to carry through into adulthood when they can keep building on these skills.

This particular patient is in a tough place. First and foremost, he needs some sort of support network. Even if he has lost everything and everybody, sometimes just the staff, even if it's for a short period of time, can be his support network to keep holding onto hope for him when he can't. Everybody from environmental services, dietary, RNs, social workers, caseworkers, pharmacy, CNAs, pastoral care...everybody...has a part in his recovery. We are obligated to keep him safe from himself while he is in our care. It is also important to realize that, in acute care, it is virtually impossible to solve the problems in just a few days that have taken a lifetime to acquire.

I was going to go into a long post about providing basic needs to these patients, but I know I would just be repeating what we all know. Just keep having hope for him.

[Orca, ADN, ASN, RN]

I'm a Psych nurse; he may be a candidate for court ordered ECT...that is the only thing I have ever seen work true "miracles" in severe treatment resistant suicidal depression. Of course I'm not a physician and don't know this man, but I've seen many "lost causes" turn around with ECT, and it is not uncommonly court ordered.

I have seen some miraculous transformations from ECT, with patients who were profoundly depressed and for whom nothing else had worked. One patient made a very lethal suicide attempt (self strangulation) while on my unit before ECT was done. After the treatment, she was smiling and she even joked about the memory loss (usually patients lose the day of treatment and they have no recollection of it). Another was an elderly female who wouldn't get out of bed, she slept with the covers over her head, and she closed the curtains whenever anyone opened them. She left acting very social with her family and apparently ready to get on with her life.

[Flo., BSN, RN]

Sometimes we have to hold the hope for our patients when they can't see it themselves. ECT works micracles and he can declare bankruptcy, move to another area and restart his life.

[Meriwhen, ASN, BSN, MSN, RN]

It feels wrong to do everything to save his life, against his will, then after a week or so send him back to the same problems. Do you guys ever feel like that?

Unfortunately, if he truly wants to die, he will find a way to kill himself no matter what we or anyone else does. There is only so much we can do. He may decide to play "I'm better!" while inpatient so he can get out. And if he's a good enough actor--or staff is too inexperienced to catch the clues that he may be faking--he could very well play well-enough to get that discharge with no question, and then do the deed. It's happened at a previous facility that I worked it.

Going on to ECT...I've also seen it do wonders for chronically depressed patients. However, based on what I've read, it sounds like there's no way this patient is going to sign up voluntarily. Involuntary ECT can be pursued, but that will involve multiple psychiatric consults and going to court...and even then, there's a chance that involuntary ECT may not be granted.

[jdub6]

Unfortunately, if he truly wants to die, he will find a way to kill himself no matter what we or anyone else does. There is only so much we can do. He may decide to play "I'm better!" while inpatient so he can get out. And if he's a good enough actor--or staff is too inexperienced to catch the clues that he may be faking--he could very well play well-enough to get that discharge with no question, and then do the deed. It's happened at a previous facility that I worked it.

I guess that's part of my issue-that guy was honest with us, i think because he felt he had nothing to lose or didn't care. But if he had summoned the energy to try to get out i feel he would have just lied his way out so he could kill himself. In a way it feels messed up that someone's options are to either be tied down in the hospital for being honest or to lie so he can leave and kill himself. I know we have to keep him safe but it sucks to feel like we're just keeping him safe till he lies his way home.

Honestly I think I feel this way because all we see where I work are the people who either make a really serious attempt or the ones who cycle in and out over and over with either psych issues or addiction (how many times can you CIWA the same person before you want to just start an alcohol instead of ativan taper/schedule? And you ask what they're going to change this time and they either say nothing or they don't know and have minimal interest in figuring it out.) The ones who do well once on meds and get discharged and then are back just as psychotic when they stop taking the meds, AGAIN.

It sometimes seems like if the first detox stay or med trial doesn't make some kind of real change (even if it takes a couple tries to get it perfect) then nothing does. I'm sure its because I just don't get to see the success stories and I'm glad you guys mentioned ECT because I'd never really seen it in action but it's nice to know that some people do make turnarounds like that.

I guess my question isn't so much, what to do with THAT particular patient (got transferred to another hosp for psych involuntarily and that's the last I heard..) but more him as an example to ask how you deal with taking away people's rights when it sometimes feels you really can't fix some patients? Tying someone down and jabbing needles into them is one thing if their psychosis improves and they're thankful 3 weeks later. But when you just don't have anything else to offer, how do you guys deal with that? Or maybe even just if you can share more success stories so those of us on the front end know that sometimes things do get better for these people...

[jdub6]

A similar question with that would be the personality disordered individuals who come neck time and again with either non-lethal attempts or those who have many moderately lethal attempts? When all meds and therapies have been tried and they still have literally dozens of suicide attempts? How do you interact with these people? Is it just give the meds, be respectful and let them cycle through again? Or do you actually have techniques to try to help?

I swear I don't believe all psych patients are hopeless...it's just felt that way lately in my ED! I have so much respect for what you guys do and I'm just looking to learn more about how you do it...