SUICIDE
Suicide is the intentional act of
killing oneself. Suicidal thoughts
are common in people with mood disorders, especially depression. Each year,
more than 30,000 suicides are reported in the United States; suicide attempts
are esti-mated to be 8 to 10 times higher. In the United States, men commit
approximately 72% of suicides, which is roughly three times the rate of women,
although women are four times more likely than men to attempt suicide. The
higher suicide rates for men are partly the result of the method chosen (e.g.,
shooting, hanging, jumping from a high place). Women are more likely to
overdose on medication. Men, young women, whites, and separated and divorced
people are at increased risk for suicide. Adults older than age 65 years
compose 10% of the population but account for 25% of suicides. Suicide is the
second leading cause of death (after accidents) among people 15 to 24 years of
age, and the rate of suicide is increasing most rapidly in this age group
(Andreasen & Black, 2006).
Clients with psychiatric disorders, especially depres-sion, bipolar
disorder, schizophrenia, substance abuse, posttraumatic stress disorder, and
borderline personality disorder, are at increased risk for suicide (Rihmer,
2007). Chronic medical illnesses associated with increased risk for suicide
include cancer, HIV or AIDS, diabetes, cerebrovas-cular accidents, and head and
spinal cord injury. Environ-mental factors that increase suicide risk include
isolation, recent loss, lack of social support, unemployment, critical life
events, and family history of depression or suicide. Behavioral factors that
increase risk include impulsivity, erratic or unexplained changes from usual
behavior, and unstable lifestyle (Smith et. al., 2008).
Suicidal ideation means thinking about killing
oneself. Active suicidal ideation is
when a person thinks about and seeks ways to commit suicide. Passive suicidal
ideation is when a person thinks about wanting to die or wishes he or she were
dead but has no plans to cause his or her death. People with active suicidal ideation
are considered more potentially lethal.
Attempted suicide is a suicidal act that either failed or was
incomplete. In an incomplete suicide attempt, the per-son did not finish the
act because (1) someone recognized the suicide attempt as a cry for help and
responded or (2) the person was discovered and rescued (Sudak, 2005).
Suicide involves ambivalence. Many fatal accidents may be impulsive
suicides. It is impossible to know, for example, whether the person who drove
into a telephone pole did this intentionally. Hence, keeping accurate
sta-tistics on suicide is difficult. There are also many myths and
misconceptions about suicide of which the nurse should be aware.
A history of previous suicide attempts increases risk for suicide.
The first 2 years after an attempt represent the highest risk period,
especially the first 3 months. Those with a relative who committed suicide are
at increased risk for suicide: the closer the relationship, the greater the
risk. One possible explanation is that the relative’s suicide offers a sense of
“permission” or acceptance of suicide as a method of escaping a difficult
situation. This familiarity and accep-tance also is believed to contribute to
“copycat suicides” by teenagers, who are greatly influenced by their peers’
actions (Sudak, 2005).
Many people with depression who have suicidal ide-ation lack the
energy to implement suicide plans. The natural energy that accompanies increased
sunlight in spring is believed to explain why most suicides occur in April.
Most suicides happen on Monday mornings, when most people return to work
(another energy spurt). Research has shown that antidepressant treatment
actually can give clients with depression the energy to act on sui-cidal
ideation (Sudak, 2005).
Most people with suicidal ideation send either direct or indirect
signals to others about their intent to harm them-selves. The nurse never ignores any hint of suicidal
ide-ation regardless of how trivial or subtle it seems and the client’s intent
or emotional status. Often, people contem-plating suicide have ambivalent and
conflicting feelings about their desire to die; they frequently reach out to
oth-ers for help. For example, a client might say,
“I keep
thinking about taking my entire supply of medications to end it all” (direct) or “I just can’t take it anymore” (indirect).
Asking clients directly about thoughts of suicide is im-portant.
Psychiatric admission assessment interview forms routinely include such
questions. It is also standard practice to inquire about suicide or self-harm
thoughts in any setting where people seek treatment for emotional problems.
A few people who commit suicide give no warning signs. Some
artfully hide their distress and suicide plans. Others act impulsively by
taking advantage of a situation to carry out the desire to die. Some suicidal
people in treatment describe placing themselves in risky or dangerous
situations such as speeding in a blinding rainstorm or when intoxicated. This
“Russian roulette” approach carries a high risk for harm to clients and
innocent bystanders alike. It allows clients to feel brave by repeatedly
confronting death and surviving.
When a client admits to having a “death wish” or sui-cidal
thoughts, the next step is to determine potential lethality. This assessment involves asking the
following questions:
·
Does the client have a plan? If so, what is it? Is the plan
specific?
·
Are the means available to carry out this plan? (For ex-ample, if
the person plans to shoot himself, does he have access to a gun and
ammunition?)
·
If the client carries out the plan, is it likely to be lethal? (For
example, a plan to take 10 aspirin is not lethal, while a plan to take a 2-week
supply of a tricyclic antidepressant is.)
·
Has the client made preparations for death, such as giv-ing away
prized possessions, writing a suicide note, or talking to friends one last
time?
·
Where and when does the client intend to carry out the plan?
·
Is the intended time a special date or anniversary that has meaning
for the client?
Specific and positive answers to these questions all increase the
client’s likelihood of committing suicide. It is impor-tant to consider whether
or not the client believes her or his method is lethal even if it is not.
Believing a method to be lethal poses a significant risk.
Suicide prevention usually involves treating the underly-ing
disorder, such as mood disorder or psychosis, with psychoactive agents. The
overall goals are first to keep the client safe and later to help him or her to
develop new cop-ing skills that do not involve self-harm. Other outcomes may
relate to activities of daily living, sleep and nourish-ment needs, and
problems specific to the crisis such as stabilization of psychiatric
illness/symptoms.
Examples of outcomes for a suicidal person include the following:
·
The client will be safe from harming self or others.
·
The client will engage in a therapeutic relationship.
·
The client will establish a no-suicide contract.
·
The client will create a list of positive attributes.
·
The client will generate, test, and evaluate realistic plans to
address underlying issues.
Intervention for suicide or suicidal ideation becomes the first
priority of nursing care. The nurse assumes an authoritative role to help
clients stay safe. In this crisis situation, clients see few or no alternatives
to resolve their problems. The nurse lets clients know their safety is the
primary concern and takes precedence over other needs or wishes. For example, a
client may want to be alone in her room to think privately. This is not allowed
while she is at increased risk for suicide.
Inpatient hospital units have policies for general environ-mental
safety. Some policies are more liberal than others, but all usually deny
clients access to materials on cleaning carts, their own medications, sharp
scissors, and pen-knives. For suicidal clients, staff members remove any item
they can use to commit suicide, such as sharp objects, shoelaces, belts,
lighters, matches, pencils, pens, and even clothing with drawstrings.
Again, institutional policies for suicide precautions vary, but
usually staff members observe clients every 10 minutes if lethality is low. For
clients with high poten-tial lethality, one-to-one supervision by a staff
person is initiated. This means that clients are in direct sight of and no more
than 2 to 3 feet away from a staff member for all activities, including going
to the bathroom. Clients are under constant staff observation with no
exceptions. This may be frustrating or upsetting to clients, so staff members
usually need to explain the purpose of such supervision more than once.
No-suicide or no-self-harm contracts have been used with suicidal
clients. In such contracts, clients agree to keep themselves safe and to notify
staff at the first impulse to harm themselves (at home, clients agree to notify
their caregivers; the contract must identify backup people in case caregivers
are unavailable). These contracts, however, are not a guarantee of safety, and
their use has been sharply criticized (McMyler & Pryjmachuk, 2008). At no
time should a nurse assume that a client is safe based on a single statement by
the client. Rather a complete assessment and a thorough discussion with the
client are more reliable.
Suicidal clients often lack social support systems such as
relatives and friends or religious, occupational, and com-munity support
groups. This lack may result from social withdrawal, behavior associated with a
psychiatric or medi-cal disorder, or movement of the person to a new area
because of school, work, or change in family structure or financial status. The
nurse assesses support systems and the type of help each person or group can
give a client. Mental health clinics, hotlines, psychiatric emergency
evaluation services, student health services, church groups, and self-help
groups are part of the community support system.
The nurse makes a list of specific names and agencies that clients
can call for support; he or she obtains client consent to avoid breach of
confidentiality. Many suicidal people do not have to be admitted to a hospital
and can be treated successfully in the community with the help of these support
people and agencies.
Suicide is the ultimate rejection of family and friends. Implicit
in the act of suicide is the message to others that their help was incompetent,
irrelevant, or unwelcome. Some suicides are done to place blame on a certain
person—even to the point of planning how that person will be the one to
discover the body. Most suicides are efforts to escape untenable situations.
Even if a person believes love for family members prompted his or her
sui-cide—as in the case of someone who commits suicide to avoid lengthy legal
battles or to save the family the finan-cial and emotional cost of a lingering
death—relatives still grieve and may feel guilt, shame, and anger.
Significant others may feel guilty for not knowing how desperate
the suicidal person was, angry because the per-son did not seek their help or
trust them, ashamed that their loved one ended his or her life with a socially
unac-ceptable act, and sad about being rejected. Suicide is news-worthy, and
there may be whispered gossip and even news coverage. Life insurance companies
may not pay survivors’ benefits to families of those who kill themselves. Also,
the one death may spark “copycat suicides” among family members or others, who
may believe they have been given permission to do the same. Families can
disintegrate after a suicide.
When dealing with a client who has suicidal ideation or attempts,
the nurse’s attitude must indicate unconditional positive regard not for the
act but for the person and his or her desperation. The ideas or attempts are
serious signals of a desperate emotional state. The nurse must convey the
belief that the person can be helped and can grow and change.
Trying to make clients feel guilty for thinking of or attempting
suicide is not helpful; they already feel incom-petent, hopeless, and helpless.
The nurse does not blame clients or act judgmentally when asking about the
details of a planned suicide. Rather, the nurse uses a nonjudg-mental tone of
voice and monitors his or her body lan-guage and facial expressions to make
sure not to convey disgust or blame.
Nurses believe that one person can make a difference in another’s
life. They must convey this belief when caring for suicidal people.
Nevertheless, nurses also must realize that no matter how competent and caring
interventions are, a few clients will still commit suicide. A client’s sui-cide
can be devastating to the staff members who treated him or her, especially if
they have gotten to know the per-son and his or her family well over time. Even
with ther-apy, staff members may end up leaving the health care facility or the
profession as a result.
Assisted suicide is a topic of national legal and ethical debate,
with much attention focusing on the court deci-sions related to the actions of
Dr. Jack Kevorkian, a physi-cian who has participated in numerous assisted
suicides. Oregon was the first state to adopt assisted suicide into law and has
set up safeguards to prevent indiscriminate assisted suicide. Many people
believe it should be legal in any state for health care professionals or family
to assist those who are terminally ill and want to die. Others view suicide as
against the laws of humanity and religion and believe that health care
professionals should be prosecuted if they assist those trying to die. Groups,
such as the Hemlock Society, and people, such as Dr. Kevorkian, are lobbying
for changes in laws that would allow health care profes-sionals and family
members to assist with suicide attempts for the terminally ill. Controversy and
emotion continue to surround the issue.
Often, nurses must care for terminally or chronically ill people
with a poor quality of life, such as those with the intractable pain of
terminal cancer or severe disability or those kept alive by life-support
systems. It is not the nurse’s role to decide how long these clients must
suffer. It is the nurse’s role to provide supportive care for clients and
fam-ily as they work through the difficult emotional decisions about if and
when these clients should be allowed to die; people who have been declared
legally dead can be discon-nected from life support. Each state has defined
legal death and the ways to determine it.
Sakauye (2008) reports that depression is common among the elderly
and is markedly increased when elders are medically ill. Elders tend to have
psychotic features, par-ticularly delusions, more frequently than younger
people with depression. Suicide among persons older than age 65 is doubled
compared with suicide rates of persons younger than 65. Late-onset bipolar
disorder is rare.
Elders are treated for depression with ECT more fre-quently than
younger persons. Elder persons have increased intolerance of side effects of
antidepressant medications and may not be able to tolerate doses high enough to
effectively treat the depression. Also, ECT pro-duces a more rapid response
than medications, which may be desirable if the depression is compromising the
medical health of the elder person. Because suicide among the elderly is
increased, the most rapid response to treatment becomes even more important
(Sakauye, 2008).
Related Topics
Privacy Policy, Terms and Conditions, DMCA Policy and Compliant
Copyright © 2018-2023 BrainKart.com; All Rights Reserved. Developed by Therithal info, Chennai.