Case Study 4 (Continued)
Discussion: Upon reviewing Mrs. B.’s history, the attending physician noted that she had reported that her husband had been engaged in an extramarital affair three months earlier. Mrs. B provided several “hints” in her discussion with the nurse, which were not included in her chart, and they included: her parents’ relocation, lack of time spent with husband /affair of her husband, isolation, lack of sleep, and poor appetite. She had tried to cope with these stressors on her own, and although she saw a counselor monthly, she intentionally kept that information from the counselor at her last visit two months prior. Also, she had canceled her last two counseling sessions but did call a suicide hotline three weeks before her attempted suicide. The suicide hotline tried to follow up and check in with her, but she was dismissive and refused to take their calls. In addition to her primary care physician, she saw her gynecologist four weeks before her suicide attempt. Her gynecologist noticed that she was not her usual self, but when she pressed her, Mrs. B. reported that her therapist was adjusting her antidepressant dose and that she would be fine in a few weeks. In conclusion, Mrs. B. had four interactions with healthcare professionals within the three months leading up to her suicide attempt. Although two of those providers recognized a change in her presentation, they did not fully appreciate the severity of her distress. The challenge with caring for patients who see multiple providers is that communication among providers in different health systems can be highly challenging. Often, providers have to rely on the patient’s self-report for accurate communication of updates and pertinent findings. In retrospect, her son—who knew that his mother had previously attempted suicide —was aware that she had contacted the suicide hotline before her second attempt, but he did not want to betray her confidence by reporting his suspicion to anyone who could have potentially intervened. Clearly, there is a need for continued education regarding mental illness and how it affects families. Also, patients with children who are old enough should be encouraged to share their diagnosis with families and encourage their families to use a support system as much as they feel comfortable. Lastly, the nurse could have been more proactive and screened Mrs. B. for suicidal ideation and intent during her last visit. She had some context and a better understanding of Mrs. B.’s history than the physician filling in. She chose to defer to Dr. Cook’s authority and failed to act on her clinical judgment. In addition, she could have reported her suspicions to Dr. Duke when he returned from his vacation four days after her visit.
Documentation
When an individual attempts suicide, medical stabilization at a hospital is the priority. If the patient experiences physical trauma, the appropriate surgical service should be contacted. If the attempt involves drug ingestion, the patient must undergo detox and receive antidotes. 5 Levels of Care There are four levels of care for a patient with varying levels of suicidality as it pertains to ideation, plan, intent, preparatory behaviors, and previous attempts 5 : • Outpatient. • Intensive outpatient program. Outpatient Treatment The appropriateness of outpatient treatment is contingent on a thorough assessment of a patient endorsing suicidality to include current stressors in a safety plan. Patients who are eventually discharged from the inpatient setting must have an appropriate outpatient follow-up with mental health providers. 51 Follow-up should be set up as soon as possible, within a few days of discharge. Given that compliance with follow-up appointments may be low, family members’ use in helping patients comply is greatly encouraged. Family members and friends can also be engaged to help reduce a patient’s access to lethal means of suicide. Particular attention should be paid to the patient’s documented suicide plan, and appropriate interventions should be implemented. These strategies include removing potential means of suicide from the home—guns, medications, or other toxic substances—as appropriate. Finally, proper documentation of the patient’s progress in the inpatient setting will help guide and inform decisions in the outpatient setting. 51 • Partial hospital program. • Inpatient hospitalization.
Healthcare Professional Consideration: When documenting a patient’s risk for suicide, the healthcare professional should also document their communication to the treatment team and appropriate persons (i.e., on-duty doctor, nursing supervisor).
Careful documentation of assessing and managing a patient’s illness is part of legal and ethical psychiatric care. 50 It also allows communication about changes of a patient’s risk level that can inform their treatment plan. 5 Documentation of Risk Assessment Documentation must be thorough and objective. Healthcare providers should never express opinions or make judgments, such as, “Patient is completely irrational.” Instead, inputting the patients’ exact words in quotation marks (e.g., Patient states, “You are the ones who are crazy, and I am going to kill myself to get away from everyone and everything.”) is recommended. Sadek details the important components of documentation, which includes 50 : • The date of an assessment. • The reasons for the assessment. • Risk factors for suicide. • Protective factors that may reduce suicide risk. • The patient’s suicide risk level. • Basis for the risk level and plan. • Action taken regarding firearms and other means of suicide. • The steps put in place given the patient’s specific constellation of risk and protective factors. • Contact details for the patient, relatives, and treating professionals. Documentation is a clinical tool critical to the initial assessment and periodic reassessment informed by the patient’s risk level. Because risk fluctuates over time, suicide assessment should not be seen as a one-time, isolated event. If an individual is determined to be at elevated risk for suicide, appropriate consultation, referral, and follow-up is important to continue to monitor across time.
Treatment and Management of Suicide
The treatment and management of suicide are complex, and clinicians must develop a biopsychosocial treatment plan which is critical for the appropriate management of patients at elevated risk for suicide. A thorough biopsychosocial assessment can help inform the healthcare worker’s conceptualization and facilitate a discussion on social support resources available to the patient. Under some circumstances, it can be beneficial for the healthcare worker to include family members or other supportive resources in the patient’s treatment plan. Patients seen in any medical setting who present as imminent harm to themselves or others must be immediately referred to a psychiatrist, psychologist, or other qualified healthcare provider. As an example, first responders and emergency room staff should be appropriately trained to care for patients at elevated risk for suicide. An empathic approach is indispensable in this case. Emergency room staff and first responders must be aware of any biases toward persons living with suicidal thoughts or behavior, including religious or philosophic beliefs, lack of formal psychiatric training, or limited resources, including time or staffing shortages. The challenge is identifying patients safe enough to be discharged without hospitalization in an emergency setting. Some emergency departments have mental health professionals on call to help evaluate patients identified as at risk of suicide and determine those safe enough to return home. 51
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