Sa fe ty Pla ns fo r Risk o f Suic ide : Putting the Pe rso n in - - PowerPoint PPT Presentation

Sa fe ty Pla ns fo r Risk o f Suic ide :

Putting the Pe rso n in the Drive r’ s Se a t to a Sa fe De stina tio n

Susa n K impe r, MSN, RN-BC

DI RE CT OR OF PSYCHI AT RI C ME DI CI NE NCH HE AL T HCARE

DI SCL OSURE ST AT E ME NT

T he pre se nte r ha s no c o nflic ts o f inte re st to disc lo se .

Ob je c tive s

As a re sult o f this tra ining the pa rtic ipa nt will b e a b le to :

De sc rib e a t le a st 4 risk fa c to rs a nd 4 pro te c tive fa c to rs tha t sho uld

b e ta ke n into a c c o unt whe n fo rmula ting risk fo r suic ide .

I

de ntify the use o f the a c ro nym I S PAT H WARM in the de ve lo pme nt

• f wa rning sig ns fo r the pa tie nt’ s sa fe ty pla n.

De sc rib e the CASE

mo de l fo r a sse ssing suic ide risk.

De sc rib e a nd de mo nstra te the use o f the sa fe ty pla n fo r suic ide

risk.

T he Jo int Co mmissio n NAT I ONAL PAT I E NT SAF E T Y GOAL # 15 (2018)

T

he or ganization ide ntifie s c lie nts at r isk for suic ide .

De finitio n o f Suic ide

 Suic ide is “a n a c t o r o missio n is a suic ide if a pe rso n inte ntio na lly b ring s

a b o ut his o r he r o wn de a th, unle ss the de a th (a ) is c o e rc e d o r (b ) is c a use d b y c o nditio ns tha t a re no t spe c ific a lly a rra ng e d b y the a g e nt fo r the purpo se o f b ring ing a b o ut de a th” (Be a uc ha mp, 1996).

 Suic ide is the a c t o f killing yo urse lf, mo st o fte n a s a re sult o f de pre ssio n o r

• the r me nta l illne ss. (Ame ric a n Psyc ho lo g ic a l Asso c ia tio n 2017)

 Suic ide is de fine d a s de a th c a use d b y se lf-dire c te d injurio us b e ha vio r with

inte nt to die a s a re sult o f the b e ha vio r. (NI MH 2017)

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SUI CI DE ST AT I ST I CS 2017

Suic ide is the 10th le a ding c a use o f de a th in the U.S. in 20167. (NIMH)

2nd le a ding c a use of de a th in the U. S. for c hildr e n a nd a dole sc e nts.

T he re a re b e twe e n 25 a tte mpte d suic ide s fo r e ve ry suic ide de a th. (NIMH 2016) Bo rde rline pe rso na lity diso rde r pa tie nts ma y e xhib it no n suic ida l injury b e ha vio rs e .g . he sita tio n ma rks o f c utting mo st c o mmo n physic a l finding s. 464,995 pe o ple visite d a ho spita l fo r injurie s due to se lf-ha rm b e ha vio r in 2016 (o ne in 12 fo r e ve ry pa tie nt who die d b y suic ide .) 50% to 75% o f a ll pe o ple who try to die b y suic ide te ll so me o ne a b o ut the ir inte ntio n. So urc e : Ame r

ic a n F

• unda tion for

Suic ide Pr e ve ntion we bsite 2017

Suic ide Sta tistic s 2017

Mor tality All suic ide s Rate s have inc r e ase d in the last de c ade

Numb e r o f de a ths: 44,965 (2016) De a ths pe r 100,000 po pula tio n:

 1990-2000=10.4  2017 13.42 US  2017 13.92 F

L

Age :

Ra te o f de a th b y suic ide is hig he st fo r middle a g e me n ( white in pa rtic ula r)

So urc e : Ame r

ic an F

• undation for

Suic ide Pr e ve ntion we bsite 2017

SUI CI DE RAT E S BY AGE

Source: American Foundation for Suicide Prevention website 2017

SUI CI DE RAT E S BY RACE / E T HNI CI T Y

Source: American Foundation for Suicide Prevention website 2017

SUI CI DE ME T HODS

Source: American Foundation for Suicide Prevention website 2017

T he Se c re t L a ng ua g e o f Suic ide

 Pa tie nts who a re thinking a b o ut o r fe e ling tha t the y wa nt to die b y suic ide

ha ve a ve ry diffic ult time te lling o the rs.

 78% o f pa tie nt who a re a ske d if the y pla n to hurt the mse lve s de ny. (APNA

2016)

 I

de ntifying a pa tie nt who is suic ida l is de sc rib e d b y Dr. Sha wn Christo phe r She a a s simila r to putting the putting pie c e s o f a jig sa w puzzle to g e the r. Yo u ha ve to ha ve a ll the pie c e s a nd the y ne e d to b e uprig ht o n the ta b le . (She a 2002)

 T

he y fe e l a la c k o f b e lo ng ing a nd ho pe le ssne ss. (Jo ine r 2005)

 25% o f suic ide s o c c ur in a no n-b e ha vio ra l he a lth se tting a nd the ro o t c a use

re ve a ls a la c k o f pro pe r a sse ssme nt.( NI MH 2017)

T hings to Re me mbe r is a Patie nt is At Risk for Suic ide

Remember that a patient who is having suicidal ideation or who has attempted to die by suicide is in a lot of psychological pain. They are not thinking clearly. Listen to them empathically non-judgmentally. BE KIND. Report any suicidal statements or behaviors immediately to the whomever you need to report to. Take them to someone who can do a more thorough assessment. Remember when a patient is under the influence of alcohol or drugs they may at a higher risk to attempt to die by suicide because of impaired judgement. The goal of a suicide assessment is not to predict suicide, but rather to...appreciate the basis for suicidality, and to allow for a more informed intervention” – (Jacobs, Brewer, & Klein-Benheim, 1999, p. 6).

I NAPPROPRI AT E WORDS T O USE WHE N DE SCRI BI NG SUI CI DE

 Co mple te d suic ide  Suc c e ssful suic ide  Unsuc c e ssful suic ide  Suic ida l g e sture / ma nipula tive a c t/ suic ide thre a t  F

a ile d suic ide

 Pa ra suic ide  Suic ida lity

Appro pria te : die d b y suic ide o r trie d to die b y suic ide

(APNA Advo c a te s fo r Ho pe Suic ide Risk Asse ssme nt T ra ining 2016)

SUI CI DE : PHE NOME NOL OGY

(Phe no me no lo g y studie s c o nsc io us e xpe rie nc e a s e xpe rie nc e d fro m the sub je c tive o r first pe rso n po int o f vie w i.e . wha t is it like to b e suic ida l o r wha t is it like to ha ve a re la tio nship with so me o ne who is wa nting to die b y suic ide )

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15

Wha t Are So me Co mmo n T he me s with Pa tie nts Who T rie d to Die b y Suic ide

 “ I do not be long.”  “I am a bur

de n.”

 “My life will ne ve r c ha ng e . I

t is just hope le ss”

 “Wha t’ s the po int o f living . I

’ ve ma de so ma ny mista ke s.”

 “I

t’ s to o la te fo r me .”

 “Yo u do n’ t g e t b la me d fo r ha ving a physic a l pa in b ut if yo u try to kill

yo urse lf b e c a use o f yo ur me nta l pa in e ve ryb o dy b la me s yo u a nd is a ng ry.

 “T

he y wo uldn’ t le t me se e my c hildre n like I wa s so me kind o f a da ng e ro us pe rso n.”

 “I

wa s to ld b y my pa sto r to find a no the r c hurc h.”

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16

Wha t Do Pa tie nts Sa y is He lpful

 Validation: “Go o d fo r yo u fo r c o ming fo rwa rd. I

t must ha ve b e e n diffic ult to a sk fo r he lp.

 Non- judge me nt: “ She invite d me to te ll my sto ry. She didn’ t sa y I

wa s c ra zy.”

 L

e tting me talk about it. “T

he y we re so g re a t. T he y a c tua lly to ld me the y we re inte re ste d in he a ring wha t ha ppe ne d. Ope nly a nd witho ut fe a r. T his is hug e .”

 Ask que stions: “I

think the b e st re a c tio n wo uld b e if so me o ne a ske d me wha t I ne e de d a nd ho w the y c o uld he lp me .”

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17

WHAT ’ S GOI NG ON?

Me nta l he a lth a sse ssme nt: L iste n to the ir sto ry, b ig pic ture , ho listic , ma y use sc re e ning to o ls a nd e vide nc e b a se d q ue stio ning Princ iple o f a sse ssme nt, o b se rva tio n, da ta c o lle c tio n:

 T

e ll the m yo ur purpo se , c re de ntia ls, b uild trust; find o ut who is in the ir life pe rso na lly a nd psyc hia tric a lly Pro c e ss o f a sse ssme nt:

 Build ra ppo rt, use la ng ua g e e ng a g e me nt stra te g y, pa c e a nd fo llo w, o b se rve

a nd de sc rib e , “ wha t the pa tie nt sa ys.”

 Me nta l Sta tus e xa m: F

• llo w APA pra c tic e g uide line s (2013)

E vide nc e Ba se d Sc re e ning T

• o ls fo r

Suic ide Risk Asse ssme nt in the L ite ra ture



Ac c o rd ing to the Suic id e Pre ve ntio n Re so urc e Ce nte r re vie w o f e xpe rt pa ne l summa rie s to o ls: mixe d re se a rc h find ing s o n the a b ility o f b o th sc re e ning a nd a sse ssme nt to a c c ura te ly pre d ic t who ma y b e a t risk o f suic id e b ut fo und tha t sc re e ning c a n b e he lpful in pre ve nting suic id e . ( SPRC 2012)



Suic id e risk a sse ssme nt ne e d s to b e tho ro ug h, pe rso n-c e nte re d , a nd simple . It ne e d s to inc o rpo ra te multiple a ppro a c he s to a sc e rta in a pe rso n’ s le ve l o f d istre ss a nd risk o f suic id e . (Pe a rlma n 2011 p.65)



PhQ-9 to o l fo r d e pre ssio n. (Spitze r 2015)



Co lumb ia Suic id e Se ve rity Ra ting Sc a le : CSSRS Asks spe c ific q ue stio ns re g a rd ing suic id e risk (Po sne r 2009)



Ask Suic id e Que stio ns (ASQ) Sc re e ning T

• o l: Suic id e Risk Asse ssme nt Sc re e ning T
• o l K

it (2015)



T he Suicide Risk Assessment Inventory: A Resource Guide for Canadian Health care Organizations. Toronto,

ON: Ontario Hospital Association and Canadian Patient Safety Institute has a list of all the risk assessment tools, authors, contact information, cost etc.

Suic ide Sc re e ning T

• o l in a n E

le c tro nic Me dic a l Re c o rd

RI SK F ACT ORS F OR SUI CI DE

Risk fa c to rs de finitio n: T he se a re fe a ture s o r situa tio ns tha t ma y inc re a se the po ssib ility o f a pa tie nt wa nting to o r trying to die b y suic ide .

HEALTH

E NVIRONME NT AL HIST ORI CAL

Me ntal He alth Conditions/ Addic tions Poor r e lationships Pr e vious suic ide atte mpts * De pr e ssion, sc hizophr e nia, BPD Pr

• longe d str

e ss, bullying, une mployme nt F amily histor y of suic ide Bipolar , c onduc t disor de r , Ac c e ss to le thal me ans inc luding fir e ar ms, dr ugs Child abuse , ne gle c t or tr auma Dr ugs and/ or alc ohol L ife e ve nts whic h may inc lude de ath, divor c e Non- suic idal har mful be havior Se r ious c hr

• nic he alth c onditions humiliation, shame or

job loss. involving a hospitalization.* E spe c ially with pain E xposur e to anothe r pe r son’s suic ide or gr aphic * we ak c or r e lation with highe r r isk Aggr e ssion, r e c kle ssne ss or se nsationalize d ac c ounts of suic ide . Unwilling to se e k he lp: Stigma T r aumatic br ain injur y Abse nc e of a suppor t syste m Cultur al/ Re ligious/ Br ainwashing MAL E S: MORE L E T HAL ME ANS WOME N: MORE AT T E MPT S RACE : CAUCASIAN AGE :>45

Pr

• te c tive F

ac tor s A numb e r o f pro te c tive

fa c to rs ha ve b e e n ide ntifie d (DHHS 2016):

 E

ffe c tive c linic a l c a re fo r me nta l, physic a l, a nd sub sta nc e a b use diso rde rs

 Ac c e ss to c a re , a suppo rtive e nviro nme nt a nd pe rmissio n to a c c e ss

he lp.

 F

a mily a nd c o mmunity suppo rt

 Suppo rt fro m o ng o ing me dic a l a nd me nta l he a lth c a re g ive rs  Skills in pro b le m so lving , c o nflic t re so lutio n, a nd no nvio le nt ha ndling

• f dispute s

 Cultura l a nd re lig io us b e lie fs tha t disc o ura g e suic ide a nd suppo rt

se lf-pre se rva tio n instinc ts

I s Pa th Wa rm: WARNI NG SI GNS

An a c ro nym tha t c a n he lp ide ntify wa rning sig ns whe n yo u a re liste ning to the ir sto ry. Ame ric a n Asso c ia tio n o f Suic ido lo g y

2011)

IT E M PAT IE NT ’S ST ORY

• 1. I-I

de a tio n Sa ys she thinks a b o ut suic ide a ll the time . She is no t pla nning to die b y suic ide no w.

• 2. S- Sub sta nc e Ab use

Histo ry o f a lc o ho l a nd c o c a ine use

• 3. P- Purpo se le ssne ss

Ma ny sta te me nts ma de re la te d to purpo se le ssne ss 4- A- Anxie ty F

• o t ta pping , sa ys she so me time s fe e ls

a nxio us

• 5. T
• T

ra ppe d Se e s suic ide a s the o nly wa y o ut o f he r stre ss a nd lo ne line ss 6. H- Ho pe le ss Wishe d she ha dn’ t live d a fte r trying to die b y suic ide 7. W- Withdra wa l Do e sn’ t ha ve a ny frie nds a nd do e sn’ t g o o ut

• 8. A-Ang e r

E xpre ssing a ng e r with he r husb a nd 9 R- Re c kle ssne ss Using a lc o ho l a nd c o c a ine whe n she ’ s

SUI CI DAL ASSE SSME NT PROT OCOL (She a 2012)

RI SK F ACT ORS PROT E CT I VE F ACT ORS SUI CI DAL I DE AT I ON/ I NT E NT CL I NI CAL F ORMUL AT I ON OF RI SK

CASE MODE L QUE ST I ONS

Yo u wa nt to ma ke the pa tie nt unde rsta nd b y me ta c o mmunic a tio n tha t it’ s o k to ta lk a b o ut this sub je c t. ( She a 2012) QUE ST IONING T E CHNIQUE DE SCRIPT ION

• 1. NORMAL

I ZAT I ON “ So me time s whe n pe o ple a re de pre sse d the y find the mse lve s thinking a b o ut killing the mse lve s. Ha ve yo u b e e n ha ving tho se tho ug hts? ”

• 2. SHAME

AT T E NUAT I ON “With e ve rything yo u’ ve b e e n g o ing thro ug h o r a ll the pa in yo u a re ha ving ha ve yo u b e e n ha ving a ny tho ug hts o f killing yo urse lf? ”

• 3. BE

HAVI ORALI NCI DE NT : fa c t finding o r se q ue nc ing “ T a lk to me a b o ut wha t ha ppe ne d. Just the fa c ts” o r T e ll me the first thing yo u re me mb e r a nd the n wha t ha ppe ne d?

• 4. SYMPT

OM AMPL I F I CAT I ON “ On yo ur wo rst da ys ho w muc h time do yo u think a b o ut killing yo urse lf 50%, 70% 90%?

• 5. DE

NI AL OF T HE SPE CI F I C HE

L PS T O UNCOVE R SUI CI DAL PL ANS Do yo u c a nno n the q ue stio ns.

“ Ha ve yo u ha ve tho ug hts o f o ve rdo sing ? ” “ Ha ve yo u ha d tho ug hts o f sho o ting yo urse lf?

• 6. GE

NT L EASSUMPT I ON “Ho w ma ny time s ha ve yo u e ve r tho ug ht o f killing yo urse lf? Ho w ma ny re c e ntly?

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HOW T O E L I CI T SUI CI DE AL I NT E NT I ON

L ike putting pie c e s o f a jig sa w puzzle to g e the r, (a da pte d fro m She a 2012) Stra te g ie s to Use : no rma liza tio n, sha me a tte nua tio n, b e ha vio ra l inc ide nt, g e ntle a ssumptio n, de nia l o f the spe c ific ( a dults), sympto m a mplific a tio n. T I ME F RAME T O USE

Pa st > 2 mo nths L a st 2 mo nths Pre se nting issue No w a nd ne xt

Se c tio n 1 Sta rt he re Se c tio n 3 Spe nd the le a st a mo unt o f time he re Se c tio n 2 Spe nd a lo t

• f time

he re Se c tio n 4 la st F uture sa fe ty pla nning

Risk Pr e dic tion Safe ty Plan

SAF E T Y PL AN OF CARE

F

• c us o n skill b uilding , tre a tme nt a dhe re nc e , e mo tio na l

re g ula tio n, pe rso na l re spo nsib ility, g ive c o ntro l b a c k to the pa tie nt

Writte n sa fe ty pla n( sho w vide o ) T

he y write it a nd in the ir o wn wo rds

E

nviro nme nta l sa fe ty pla n ( pa rt o f the sa fe ty pla n)

Do c ume nta tio n

E XAMPL E OF A SAF E T Y PL AN Must b e de ve lo pe d b y the pe rso n ( yo u c a n c o a c h)

1 WARNI NG SI GNS: T hink I S PAT H WARM 2 PE RSONAL COPI NG T O CAL M OR COMF ORTSE L F 3 ACT I VI T I E S F OR DI ST RACT I ON (SOCI AL SE T T I NGS) 4 PE OPL EI CAN T AL K T O Na me Pho ne # Na me Pho ne # Na me Pho ne # 5 PROF E SSI ONAL S Na me Pho ne # Na me Pho ne # Na me Pho ne # 6 ST E PS T O MAK E MY E NVI RONME NT SAF E 7 HOSPI T ALE ME RGE NCY ROOM lo c a tio n a nd pho ne numb e r

References

American Foundation for Suicide Prevention (AFSP): https://afsp.org 2) American Association of Suicidology (AAS): www.suicidology.org 3) Suicide Prevention Resource Center: www.sprc.org. 4) Training Institute for Suicide Assessment and Clinical Interviewing (TISA): www.suicideassessment.com APNA Position Statement Competencies for Nurse-Assessment and Management of Inpatient Suicide Risk (2015) Ellis, T.E., Green, K.L., Allen, J.G., Jobes, D.A., & Nadorff, M.R. (2011). Collaborative assessment and management of suicidality in an inpatient setting: Results of a pilot study. The Menninger Clinic. Ferguson, M. (2015). Are there warning signs for suicide? Australian Nursing & Midwifery Journal, 23(5), 31. Hermes, B., Deakin, K., Lee, K., and Robinson, S. (2009). Suicide risk assessment: 6 steps to better

• instrument. Journal of Psychosocial Nursing, 47(6), 44-49.

Horowitz, L. M., Bridge, J. A., Teach, S. J., Ballard, E., Klima, J., Rosenstein, D. L.& Pao, M. (2012). : a brief instrument for pediatric emergency department Ask Suicide Screening Questions(ASQ)) Archives of pediatrics & adolescent medicine, 166(12), 1170-1176. Jacobs, D (2007) Screening for Mental Health A Resource Guide for Implementing the Joint Commission

• n Accreditation of Healthcare Organizations 2007 National Patient Safety Goals on Suicide Featuring

the Basic Suicide Assessment Five Step Evaluation (B-Safe)

References

Jobes, D (2006) Managing Suicidal Risk; A Collaborative Approach. Guildford Press: New York. Joiner, T (2005) Why People Die by Suicide, President and Fellows of Harvard College, Boston Knesper ,DJ, American Association of Suicidology, Suicide Prevention Resource Center. Continuity of care for suicide prevention and research: Suicide attempts and suicide deaths subsequent to discharge from the emergency department or psychiatry inpatient unit. New, MA Education Development Center,

• Inc. 2010. http://www.sprc.org Accessed January 3 2012

Michel, K.,Gysin-Maillart, A (2015) ASSIP Attempted Suicide Short Intervention Program, Hogrefe Publishing, Boston Newton, A. S., Soleimani, A., Kirkland, S. W., & Gokiert, R. J. (2017). A systematic review of instruments to identify mental health and substance abuse problems among children in the emergency

• department. Academic Emergency Medicine, 24(5), 552-568.

Patient Health Questionnaire-9 (PHQ-9). Developed by Drs. Robert L. Spitzer, Janet B.W. Williams, Kurt Kroenke and colleagues (accessed Aug. 17, 2015).

References

Perlman CM, Neufeld E, Martin L, Goy M, & Hirdes JP (2011). Suicide Risk Assessment Inventory: A Resource Guide for Canadian Health care Organizations. Toronto, ON: Ontario Hospital Association and Canadian Patient Safety Institute. Pompili, M.(ed) (2018) Phenomenology of Suicide. Springer International Publishing, Switzerland Posner, K, Brown, G, Stanley, B,(2011) Am J Psychiatry 168:12, Procter, N. & Ferguson, M. (2015). Rudd, M.D., Goulding, J.M., Carlisle, C. J. (2013). Stigma and suicide warning signs. Archives of Suicide Research, 17, 313-318 Sakinofski,I Preventing Suicide Among Inpatients Psychiatry (2014) ;59(3):131-140 Schimelpfening,N How to Create a Suicide Safety Plan. Retrieved 1/19/2016 from Http: //depression.about.com/od/suicide prevention/a suicidesafetyplan.htm Shea, S.C. (2004). The delicate art of eliciting suicidal ideation. Psychiatric Annals, 34 (5), 385-400. Shea, SC: (2012)Interpersonal art of suicide assessment: interviewing, techniques for uncovering suicidal intent, ideation and actions. In: Simon RI, Hales RE: editors The American Psychiatric Publishing Textbook of Suicide Assessment and Management 2nd editions. Washington, DC American Psychiatric Publishing

Re fe re nc e s

Shea, SC; Barney, C: Teaching clinical interviewing skills using role-playing: Conveying empathy to performing suicide assessment-a primer for individual role-playing and scripted group role playing. Psychiatric Clinics of North America 38 (1): p147-183 2015 The Joint Commission, Sentinel Event Alert 56: Detecting and treating suicide ideation in all settings https://www.jointcommission.org/sea_issue_56/ Accessed September 5 2016 The Joint Commission, Behavioral Health Care 2013 National Patient Safety Goals http:www.jointcommission.org/standards_ information/npsgs.aspx. Accessed June 15 2015

• U. S Department of Health and Human Services (HHS Office of the Surgeon General and National

Action Alliance for Suicide Prevention. 2012 National Strategy for Suicide Prevention: Goals and Objectives for Washington, DC: HHS September 2012 Suicide Prevention Resource Center (SPRC) & American Association of Suicidality (AAS) (2008). Assessing and managing suicide risk: core competencies for mental health professionals. Rockville, MD: Substance abuse and Mental Health Services Administration.