Clinical tip #1 -- So-called “No-Suicide Contracts”
Despite clinical lore there is no scientific evidence that so-called “no suicide” contracts actually save lives or prevent suicide attempts. Despite their widespread use, specific training in their purpose, utility, and employment is largely unavailable.
The use of a no-suicide contract as a defense against a complaint of suicide malpractice is at best dubious and at worst negligent. However, experts generally agree that the refusal of a suicidal person to enter into a good-faith agreement to remain safe (which implies a willingness to participate in recommended treatment), suggests the risk for a suicide attempt may be higher than first assessed.
Documentation of clinical status, including the results of a mental status examination, together with a detailed suicide risk assessment are the best evidence that due clinical diligence was undertaken. Care planning, level of monitoring, frequency of visits, and similar interventions hinge on the quality of the initial and subsequent reassessment of suicide risk. For the most recent literature review, please see Lisa McConnell Lewis, LCSW’s “No-Harm Contracts: A Review of What We Know, Suicide and Life-Threatening Behavior, vol. 7, #`, February, 2007.
Clinical Tip #2 -- Documenting Reasons to NOT Hospitalize
When deciding not to hospitalize a patient at risk for suicide, it is important that the clinician conduct a risk-benefit analysis. The reasons for hospitalization may include the relative assurance of a safer, more controlled environment, a beneficial milieu, multidisciplinary staff evaluation, initiation of stabilizing medications, etc. The reasons not to hospitalize a suicidal person might include potential loss of self-esteem, stigmatization, risk of losing a job, fostering unwanted dependency, failure to benefit from prior hospitalizations, etc. When confronted with a possible hospitalization, the patient may also express a willingness to participate in outpatient treatment and adhere to a medication regimen.
Whatever your reasons to not hospitalize a consumer who has expressed suicidal ideations, prior plans or suicide attempts, it is strongly recommended that the primary care provider seek consultation and/or supervision regarding the decision and to carefully document the reasons for this decision. In a world of increasing litigation for suicide malpractice, and if a bad outcome is experienced, an uniformed jury will need to be convinced that 1) you thought the problem through, 2) you weighed the risks and benefits carefully with the patient and his or her family, and 3) you took a reasonable and prudent course of action.
Clinical Tip #3 -- Quick and Effective Response can Save Lives ...
The vast majority of all residential and inpatient suicides occur by hanging. From the restrictive closure of the air passage, unconsciousness occurs in 30 seconds, death in four minutes. Saving a life from a hanging attempt requires quick and efficient action. Emergency rescue tools have become a standard piece of equipment for responding to such events, including the now widely used "911 rescue knife." These are specially designed knives with a hooked and protected blade that allow the victim to be cut down quickly and without injury. Because the blade is located inside the frame of the tool it cannot be utilized as a life-threatening weapon in the hands of a potentially violent person. Fire fighters and paramedics have used them for years to cut seat belts off trapped victims.
If you work in a residential or inpatient facility, consider securing 911 rescue knives and training staff in how to access and use them quickly. When a consumer is found hanging, every second counts. Once a victim is discovered any time lost trying to remove a ligature by hand - and especially if unassisted - may delay rescue and lead to a preventable injury or death. More precious time may be lost if staff cannot locate the knife or, once in hand, they are unfamiliar with how to use it. Good safety management practices require knowledge and practice. If fire drills save lives, so can "cut down" drills.
Clinical tip #4 -- Reassessing suicide risk
Suicide risk changes with time and circumstances. A single, initial assessment of suicide risk is seldom adequate for safe practice. Suicide risk assessments should be repeated both a fixed intervals and during times of increase stress. Based on the literature and the clinical experience of several of the QPR Institute faculty, we suggest four non-exhaustive circumstances where re-evaluating suicide risk is indicated:
• Changes in health status, e.g., diagnosis of a life-threatening illness, exposure to HIV, continued experience of chronic pain, and when the consumer is faced with significant surgery or has suffered a significant physical injury.
• Stressful life-transitions, e.g., loss of a major relationship, change in living arrangements, treatment transitions (between therapists or programs), threats to housing, income or access to care.
• Response to treatment, to include side effects of psychotropic medications, non-therapeutic response to medication or other intervention failures, including impasse in therapy or conflict with therapist
• Substance abuse dramatically increases suicide risk. Relapse from recovery, binge drinking or drugging, relapse of one’s sponsor, and any significant use of intoxicants, even by non-addicted consumers.
A number of other circumstances suggest the need for a reassessment of suicide risk. These include reports by third parties that suicide warning signs have been observed, any report of violent behavior, the sudden loss of a loved one through death, divorce, desertion and especially suicide. Finally, anytime a consumer of any age is facing what may be a personal and public humiliation, suicide risk may be sharply elevated.
Basically, suicide risk increases dramatically with multiple successive losses, co-morbidity of illnesses, acute environmental stressors, and anytime the consumer begins to feel he or she is becoming a burden on others or care providers. If in doubt, reassess!
Clinical tip #5 -- Communicating Suicide Risk
The nature of modern clinical care by multiple providers requires clear communication to assure consumer safety. Not only do prescriptions need to be clearly written, but progress notes must be legible to all providers of care. In the root cause analysis of 400 consumers in active care who attempted or died by suicide while inpatients, communication failures ranked at the top of the list of contributory causes (National Center for Patient Safety, 2006).
To improve communications between clinicians regarding suicide risk, there is little consensus about a) how to assess immediate risk or b) how to determine its severity. Still, risk stratification decisions and clinical judgments must be made every day as these assessments necessarily guide our interventions, monitoring levels, and frequency of contact. For a variety of reasons, suicidal consumers may not be entirely helpful in disclosing their suicidal intent, desire and plans. If, after an assessment, you are not confident of your conclusions, it may be helpful to others on your team to add a chart note to this effect.
An explanatory note of “low confidence” would be warranted when the consumer:
· Has been uncooperative and refused to collaborate in the assessment process
· Has or may have psychotic symptoms, especially paranoia
· Is or has been recently intoxicated
· Has a history of impulsivity
· Is faced with an uncontrollable external event, such as the serving of divorce papers or an arrest warrant
In sum, a note of low confidence in the assessment suggests higher risk and that reassessment is indicated in the near term (not more than 24 hours), as well as the need for a second opinion, greater vigilance, and more frequent observation.
The QPR Institute (www.QPRinstitute.com) provides Online Advanced Suicide Prevention Courses for a wide range of professionals including: Mental health professionals, school counselors, crisis line workers, substance abuse professionals, EMS/firefighters, law enforcement, primary care providers, nurses and correctional workers. For more information please visit our full library of advanced courses!
Paul Quinnett, PhD., Founder & CEO QPR Institute, www.QPRInstitute.com