_____________________________________________________________ Suicide Assessment and Prevention
firearms at a gun shop or pawn shop, asking law enforcement to take possession of firearms, or storing personal firearms at military unit arms rooms [79]. The least restrictive and most acceptable means of removing easy accesses to lethal means should be employed in order to assure an individual welcomes the intervention. It is important to avoid implying that an individual is incapable of firearm possession or that they are unfit in a legal sense. CONSIDERATIONS FOR VETERANS With military service members, the command element should also be involved in education, safety planning, treatment plan- ning, and implementation of duty limitations. Additional areas to address are the patient’s medical and other specific needs. These may be psychosocial, socioeconomic, or spiritual in nature [79]. The VA/DoD has made the following recommendations when creating a treatment plan for veterans and active service members [79]: • Providers should take reasonable steps to limit the disclosure of protected health information to the mini- mum necessary to accomplish the intended purpose. • Providers should involve command in the treatment plan of service members at high acute risk for suicide to assist in the recovery and the reintegration of the patient to the unit. For service members at other risk levels, the provider should evaluate the risk and benefit of involving command and follow service department policies, procedures, and local regulations. • When performing a medical profile, the provider should discuss with command the medical recommen- dation and the impact on the service member’s limita- tions to duty and fitness for continued service. • Providers should discuss with service members the benefit of having command involved in their plan and assure them their rights to protected health informa- tion, with some exceptions, regarding to the risk for suicide. • As required by pertinent military regulations, communi- cate to the service member’s chain of command regard- ing suicidal ideation along with any recommended restrictions to duty, health and welfare inspection, security clearance, deployment, and firearms access. Consider redeployment to home station any service member deployed to a hazardous or isolated area. • Service members at high acute risk for suicide who meet criteria for hospitalization and require continuous (24-hour) direct supervision should be hospitalized in almost all instances. If not, the rationale should specifi- cally state why this was not the preferred action, with appropriate documentation.
Safety planning is a provider-patient collaborative process —not a “no harm” contract. The safety planning process results in a written plan that assists the patient with restricting access to means for completing suicide, problem-solving and coping strategies, enhancing social supports and identifying a network of emergency contacts including family members and friends, and ways to enhance motivation. These plans are tailored to the patient by assisting with identifying his or her specific warning signs and past effective coping strategies [79]. The safety plan should include the following elements, as appropriate: • Early identification of warning signs or stressors • Enhancing coping strategies (e.g., to distract and sup- port) • Utilizing social support contacts (discuss with whom to share the plan) • Contact information about access to professional help • Minimizing access to lethal means (e.g., weapons and ammunition or large quantities of medication) The safety plan should be reviewed and updated by the health- care team working with the patient as needed and shared with family and other supportive third parties if the patient consents. Safety plans should be updated to remain relevant during changes in clinical state and transitions of care [79]. Providers should document the safety plan or reasons for not completing such a plan in the medical record. In addition, patients should receive a copy of the plan [79]. Limiting Access to Lethal Means Restricting at-risk patients from access to lethal means is considered an essential part of suicide prevention and safety planning. Methods of ensuring persons with suicidal intent do not have access to lethal means include restriction of access to firearms and ammunition, safer prescribing and dispensing of medications to prevent intentional overdoses, and modifying the environment of care in clinical settings to prevent fatal hangings [79]. For military service members, concerns about firearms should include privately owned guns and ammunition. It is also important to educate caregivers, family members, and/or other supportive third parties regarding the potential dangers of lethal means and how to keep these items or sub- stances from the patient. Storing firearms away from suicidal individuals can reduce gun deaths [79]. It must be stressed that the firearms are still the property of the individual, and they are not “giving them away.” Options for safe storage of firearms include removing ammunition from an individual’s possession, asking a friend or relative to take possession of firearms, disassembling firearms and storing various parts in different locations, storing firearms at a storage unit or gun locker at a shooting range, storing
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