02.16 Suicidal Behavior

Okay - for our last lesson on mental health conditions, we’re going to talk about suicidal behavior.

Someone with suicidal behavior is someone with constant feelings of hopelessness, guilt and/or worthlessness that are so overwhelming that they don’t want to live anymore and attempt to end their life. There can be a lot of stigma and controversy around suicide, so we’re going to focus objectively on how we care for someone who may be having thoughts of harming or killing themselves.

Let’s talk about clients who are at high-risk for suicidal behavior. Anyone with a family history or a personal history of suicide or suicide attempts is at higher risk statistically-speaking for committing suicide. Those with mental health disorders or terminal illness are also at risk. It’s hard to imagine what it must feel like to be out of control of your own body or mind. Physical disabilities, especially new or sudden changes, like an amputation, can put someone at higher risk. And, statistically speaking adolescents and the elderly are at higher risk as well.

There are some signs we can watch for in those around us or out patients that might be signs of an impending suicide attempt. If someone starts to give away prized possessions, especially sentimental things or things they’ve collected for years - that might mean they’re trying to give them a good home because they won’t be around to take care of them anymore. Also changing a will or life insurance policy, lose interest in their usual life, or even asking about methods like how to buy a gun or how much Tylenol would kill them. They may even write notes to loved ones weeks or months before the action. And the last one is one I really want you to get. If you have a client who is severely depressed and suddenly they’re happy. Like almost overnight. If you see this sudden, massive improvement in mood - it might be because they have finally resolved or decided to go through with it - or maybe they came up with a plan. It’s like a weight has been relieved off their shoulders and they’re almost relieved because they’ve figured out how to end it all. Sometimes this can be mistaken as someone getting better - but it NEEDS to be evaluated because that sudden improvement is almost always a bad sign.

So, you’ve heard us talk about self-harm assessments throughout this whole module - but nowhere is it more important than in a client at risk for suicidal behavior. The best tip we have for you is to be very direct and calm in your questioning. Don’t skirt around it trying to be politically correct. Ask - “Are you having thoughts of hurting yourself or someone else?” If they say yes, we ask directly “Do you have a plan for how to do that?”. If they have a plan, they are more likely to follow through. If they say yes, even if they don’t have a plan, you need to put them on Suicide precautions! This may look slightly different depending on your facility’s policies - but usually involves some sort of 1 to 1 observation, removing dangerous objects from their room like phone cords, monitor cables, etc. We also keep someone at arm’s length of them at ALL TIMES - this means they don’t even go pee by themselves, guys. We will also do a suicide contract. We literally have them sign a written contract saying they will not harm themselves while they’re in our care. Sometimes just the act of signing this makes them feel like they would let us down if they did, so many times they won’t do it. And some facilities also require that we screen visitors or some places don’t even allow visitors.

A couple of interventions, that probably make a lot of sense to you now - establish trust and rapport. We have to let them know that we are a safe space for them. We want to promote self-care, focus on their strengths, involve their support system, and encourage therapy for long-term success. But more than anything - we have to validate their feelings. I had a patient once that was a really sad case - she was beaten by her boyfriend, blamed herself because she had cheated on him, and tried to kill herself. As I was caring for her she was extremely tearful, and of course frustrated because we had to restrict visitors and take away her phone because the boyfriend was texting her awful things. As we were talking, she told me she felt like she’d never get out of the hospital because everyone just wanted her to be happy and she couldn’t do that. I sat down with her and I told her that no one expected her to be suddenly happy - but we did need to know she would be safe. I said listen “you don’t have to be happy, you’re allowed to be sad and hurt and frustrated, but you have to handle that in a way that is healthy”. We talked about journaling, which she started that night, and who she could call when she was feeling down, and by morning she was calm and ready to talk to the psychologist. So remember that we validate that it’s okay to feel sad, but we have to handle our sad in healthy ways.

So, as you might expect, priority nursing concepts for a patient with suicidal behavior are safety, mood/affect, and coping.

Just to recap quickly - suicidal behavior happens when someone has so much guilt, pain, sadness, fear, etc. that they just want to end it all by taking their own life. Clients with a history of suicidal behavior, terminal illness, or those tell-tale behaviors may be at higher risk. We always do a self-harm assessment and be very direct in our questions - ask if they have a plan. If they do have thoughts of hurting themselves, we institute suicide precautions following your facility’s specific protocol - usually 1 to 1 monitoring and other safety precautions. And we always want to encourage healthy coping - expressing feelings, involving a healthy support system, and utilizing some form of long-term therapy.

Caring for a client with suicidal behavior can be overwhelming, but if you follow these guidelines and remember to keep safety first, you can help get them through this difficult time. Go be THAT nurse for these patients. And, as always, happy nursing.