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| If you are thinking of hurting yourself, or if you are concerned that someone else may be suicidal, call the National Suicide Prevention Lifeline at 1-800-273-TALK (8255). |
John is a 52-year-old white male employed in a large steel mill. He has worked for the company for
close to 20 years. John recently separated from his wife and is now living by himself in an apartment
close to the foundry. He has no friends or family.
Over the past three weeks, John has visited the employee health clinic with ongoing complaints of
fatigue and gastric distress. He told Carmelita, the nurse, that he was worried that he had some
type of lingering flu.
On his last visit, John was particularly subdued. He avoided eye contact and spoke in a quiet
monotone. He told Carmelita that he knew she liked animals and asked her to take his pet dog
because he did not feel able to care for it since his separation.
Carmelita asked John how he was spending his time-was that what was interfering with his ability
to care for his dog? John said that he watched a lot of TV and thought a lot. He said that he felt
too "shaky" to go places other than work and that he didn't know anyone he could visit anyway.
When Carmelita asked if John had thought about harming himself, he looked startled at first, and
then admitted that he had; he just felt like he could not continue without his wife. Carmelita
realized that John was in crisis. She asked the clinic secretary to sit with him while she
discussed the situation with the physician and then made arrangements for an immediate assessment
by the local mental health counselor.
Since physical illness itself is a risk factor for suicide (Maris, Berman, & Silverman, 2000),
nurses and other health care providers are highly likely to see people who may be at risk of self-harm.
Because nurses spend so much time with patients, a trusting relationship can develop, which may
encourage patients to reveal their feelings to nurses even when they are reluctant to share this
information with their family or their physicians. As a nurse, you are in a unique position to do
several things:
People who are considering harming themselves may try to reach out to you-sometimes directly,
sometimes indirectly. Rarely will patients immediately volunteer the information that they are
thinking of harming themselves. Instead, they often describe their concerns in terms of
physical symptoms.
You should be especially alert for imminent warning signs of suicide, for example:
These signs are especially critical if the patient has a history or current diagnosis of a psychiatric
disorder, such as depression, alcohol or drug abuse, bipolar disorder, or schizophrenia.
Age is also a factor. Elderly patients are at an increased risk of dying by suicide. Research indicates
that many older adults who visited a primary care physician within a month of dying by suicide had an
undiagnosed mental illness associated with suicide, such as depression (National Institute of Mental
Health, 2003), or had a common medical condition associated with an increased risk of suicide, such
as congestive heart failure, chronic obstructive lung disease, urinary incontinence, anxiety disorders,
and moderate or severe pain (Juurlink, Herrmann, Szalai, Kopp, & Redelmeier, 2004). Nurses should pay
careful attention to elderly patients who are physically ill and who exhibit any of the following
warning signs of suicide (Holkup, 2002):
Adolescents are also at an increased risk of dying by suicide. School nurses, or other nurses working with adolescents, should be alert for these warning signs:
Recognizing the warning signs is the first step in preventing suicide.
Your response to any warning signs should be targeted at keeping the patient safe, providing
empathy and support, and ensuring that the patient receives the mental health and/or social
services necessary to reduce his or her risk.
Science has not yet provided us with fail-safe methods of assessing the risk of suicide.
However, if there's a chance that your patient may be at risk, you can ask the sometimes
difficult questions that will provide you with more evidence about the patient's state of
mind and intentions, for example:
In an inpatient or other clinical setting, mental health resources may be available on-site.
In other cases, you may have to call a mental health clinic or emergency hotline to obtain
assistance. Every health care facility, including private physician's offices, hospitals,
and school health clinics, should have a procedure for responding to persons at risk of
suicide and should know whom to call for assistance.
If you are alone with a client, as might be the case in a home care visit, a call to the
local mental health crisis line, emergency department, or National Suicide Prevention
Lifeline at 1-800-273-TALK (800-273-8255) can be helpful. Carry these numbers and have them
readily available, especially if you are a home care or private duty nurse. You should
also do the following:
If you have any suspicions that a patient is seriously considering harming him- or herself, let your
patient know that you care, that he or she is not alone and that you are there to help. You may have
to work with the patient's family to ensure that he or she will be adequately supported until a mental
health professional can provide an assessment. In some cases, you may have to accompany your patient
to the emergency room at an area hospital or crisis center. If the person is uncooperative, combative,
or otherwise unwilling to seek help, and if you sense that the person is in acute danger, call 911 or
1-800-273-TALK (800-273-8255). Tell the dispatcher that you are concerned that the person with you "is a danger
to [him- or herself]" or "cannot take care of [him- or herself]." These key phrases will alert the
dispatcher to locate immediate care for this person with the help of police. Do not hesitate to make
such a call if you suspect that someone may be a danger to him- or herself. It could save that person's
life.
As a nurse, you can play a powerful role in preventing suicides and detecting mental health crises among
your patients-but you should not have to handle these emergencies alone. If your place of work does not
have a crisis intervention plan or does not provide training for crisis intervention, advocate for the
implementation of a clear, concise crisis intervention plan. Ensuring that all members of a health care
team know what to do in a crisis situation helps to empower nurses and keep clients safe from self-harm.
Holkup, P. (2002). Evidence-based protocol-Elderly suicide: Secondary prevention.
Iowa City, IA: University of Iowa Gerontological Nursing Interventions Research Center.
Retrieved March 23, 2005, from
http://www.guideline.gov/summary/summary.aspx?
doc_id=3308&nbr=2534&string=Elderly+AND+suicide
Juurlink, D. N., Herrmann, N., Szalai, J. P., Kopp, A., & Redelmeier, D. A. (2004).
Medical illness and the risk of suicide in the elderly. Archives of Internal Medicine, 164(11), 1179-1184.
Maris, R. W., Berman, A., & Silverman, M. M. (Eds.). (2000). Comprehensive textbook of
suicidology. New York: Guilford Press.
National Institute of Mental Health. (2003). Older adults: Depression and suicide facts.
Rockville, MD: National Institutes of Health. (NIH Publication No. 03-4593, revised May 2003.)
Retrieved March 23, 2005, from
http://www.nimh.nih.gov/publicat/elderlydepsuicide.cfm
Holkup, P. (2002). Evidence-based protocol-Elderly suicide: Secondary prevention.
Iowa City, IA: University of Iowa Gerontological Nursing Interventions Research Center.
Retrieved March 23, 2005, from
http://www.guideline.gov/summary/summary.aspx?
doc_id=3308&nbr=2534&string=Elderly+AND+suicide
Office of Quality and Performance, Veterans Health Administration. (2000). Major
Depressive Disorder (MOD) clinical practice guidelines: Module A. Primary care.
Retrieved March 23, 2005, from http://www.oqp.med.va.gov/cpg/MDD/MDD_Base.htm
These guidelines were developed for clinicians by the Department of Veterans Affairs
and the Department of Defense. They draw heavily from the American Psychiatric Association
and Agency for Health Care Policy and Research Clinical Practice Guideline No. 5: Depression in
Primary Care. The guidelines include information on assessment and treatment of potentially
suicidal patients, patient handouts on depression, and guidelines for treatment of depression.
The guidelines, supporting documents, and tools are available online at the URL listed above.
Quinnett, P. (2000). Counseling suicidal people: A therapy of hope. Spokane, WA: QPR
Institute. Retrieved March 23, 2005, from http://www.qprinstitute.com/
This book was written for therapists, mental health workers, physicians, nurses,
and others who are not clinical suicide counselors, but who might find themselves
counseling people at risk of suicide. It provides tools and strategies for risk
assessment and intervention.
Registered Nurses Association of Ontario. (2002). Crisis intervention. Toronto:
Author. Retrieved March 23, 2005, from
http://www.guideline.gov/summary/summary.aspx?doc_id=3718
Suicide Prevention Resource Center (http://www.sprc.org/). The Suicide Prevention Resource Center (SPRC) provides prevention support, training, and materials to strengthen suicide prevention efforts. Among the resources found on its website is the SPRC Library Catalog (http://library.sprc.org/), a searchable database containing a wealth of information on suicide and suicide prevention, including publications, peer-reviewed research studies, curricula, and web-based resources. Many of these items are available online.
American Association of Suicidology (http://www.suicidology.org/). The American Association of Suicidology is a nonprofit organization dedicated to the understanding and prevention of suicide. It promotes research, public awareness programs, public education, and training for professionals and volunteers and serves as a national clearinghouse for information on suicide.
American Foundation for Suicide Prevention (http://www.afsp.org). The American Foundation for Suicide Prevention (AFSP) is dedicated to advancing our knowledge of suicide and our ability to prevent it. AFSP's activities include supporting research projects; providing information and education about depression and suicide; promoting professional education for the recognition and treatment of depressed and suicidal individuals; publicizing the magnitude of the problems of depression and suicide and the need for research, prevention, and treatment; and supporting programs for suicide survivor treatment, research, and education.
National Center for Injury Prevention and Control (http://www.cdc.gov/ncipc/). The National Center for Injury Prevention and Control (NCIPC), located at the Centers for Disease Control and Prevention, is a valuable source of information and statistics about suicide, suicide risk, and suicide prevention. To locate information on suicide and suicide prevention, scroll down the left-hand navigation bar on the NCIPC website and click on "Suicide" under the "Violence" heading.
National Suicide Prevention Lifeline (http://www.suicidepreventionlifeline.org/). The National Suicide Prevention Lifeline provides immediate assistance to individuals in suicidal crisis by connecting them to the nearest available suicide prevention and mental health service provider through a toll-free telephone number: 1-800-273-TALK (800-273-8255). Technical assistance, training, and other resources are available to the crisis centers and mental health service providers that participate in the network of services linked to the National Suicide Prevention Lifeline.
Suicide Prevention Action Network USA (http://www.spanusa.org). Suicide Prevention Action Network USA (SPAN USA) is the nation's only suicide prevention organization dedicated to leveraging grassroots support among suicide survivors (those who have lost a loved one to suicide) and others to advance public policies that help prevent suicide.
This page was modified on October 9, 2008
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This effort has been funded in part with Federal funds from the National
Institute of Mental Health,
National Institutes of Health, under Contract No. N44MH22044.
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