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What means by direct self-destructive behavior ?
suicidal activity with intent to cause death, e.g., suicide ideation, threats, attempts, completed suicide
Attempt suicide→non-fatal suicide attempt
Completed suicide→died by suicide
What means by indirect self-destructive behavior ?
any activity detrimental to person’s physical well-being that may result in death
e.g. drink alcohol
How should we interpret the myths:
“People who talk about suicide won’t really do it.”
Don’t ignore any statement related to death or suicide !
How should we interpret the myths:
“Anyone who tries to kill him/herself must be crazy”
Extreme distress and emotional pain are not necessarily signs of mental illness
How should we interpret the myths:
“If a person is determined to kill hi,/herself, nothing is going to stop them.”
He/she has mixed feelings about death, they want the pain to stop rather than death
How should we interpret the myths:
“People who die by suicide are people who were unwilling to seek help”
Studies found 70% of them had sought medical help prior to their death
How should we interpret the myths:
“Talking about suicide may give someone the idea”
You don’t give a suicidal person morbid ideas… they have this idea by their common sense
Oppositely, you open the discuss about the patients suffers
Suggest the risk factors for suicidal behaviour (7)
Previous suicidal attempt (Self-destructive behavior)
the strongest predictors of future suicide attempts
Family history of suicide
Psychiatric diagnosis
Over 90% who died by suicide have psychiatric illness
Personality traits and disorders
Marital status: higher risk in single or divorced
Psychosocial factors: intolerable lift situations / stressors (e.g. widow)
Physical illness: e.g. cancer
Substance use
What are the warning signs of suicidal behaviour ? (8)
Preoccupation 全神貫注 with death
No hope for the future
Self-hatred / Feeling like a burden
Verbal cues 交代身後事
“Take care of my family for me” (indirect cues) / “I wish I were dead” (direct cues)
Behavioral cues
Getting affairs in order- e.g. Giving away prized possessions. Making arrangements for family members
Withdrawing from others, Sudden sense of calm
Seeking out lethal means
Self-destructive behavior: Increased alcohol or drug use, reckless driving, unsafe sex
Examples L8 p.12-13
What are the questions list for suicidal assessment ?
Assess risk factors (observe & inquire)
Psychiatric treatment compliance [if have psychiatric history)
Suicide ideation
any self-reported thoughts of suicide ; may be Fleeting (passive) or Constant (active)
Have you ever think about killing yourself?
How frequent / persistent are they?
When does the idea start?
Suicide plan
a proposed method/systematic plan of carrying out a design that will lead to a potentially self-injurious outcome
Specific plan: time, place, person, methods
Readily of means
How do you get the means for suicide
Have your already got the drug/string for hanging?
Suicide-related actions
How long did you plan the suicide?
How do you get the information about methods of suicide?
Have you made the preparations for your death?
(e.g., have you make a will, updated life insurance, made arrangements for funeral ?)
What is active suicidal ideation ?
Thoughts of taking action to kill oneself
“I want to kill myself”
“I want to end my lfe and die”
What is passive suicidal ideation ?
Wish or hope that death will overtake oneself
“I would be better off dead”
“I hope I go to sleep and never wake up”
What is the goal of suicidal management in both in-patient and out-patient (community) settings ?
The patient will not physically harm himself or herself
In community management, if the individual have active suicidal ideation, with a suicide plan, and have the intention to kill self, what should be the level of care (appropriate action) ?
Assure immediate safety and arrange for transfer to emergency department for further assessment for possible inpatient hospitalisation
In community management, if the individual have active suicidal ideation, with a suicide plan, but still do not have the intention to kill self, what should be the level of care (appropriate action) ?
See if the patient can adhere to a safety plan that specifies how the patient will manage suicidal ideathion
E.g. copy bible, play instrument
In community management, if the individual have active suicidal ideation, with a suicide plan, but cannot adhere to a safety plan to manage suicidal ideation, what should be the level of care (appropriate action) ?
Assure immediate safety and arrange for transfer to emergency department for further assessment for possible inpatient hospitalisation
In community management, if the individual have active suicidal ideation, without a suicide plan, and willing to adhere to safety plan, what should be the next step of consideration ?
Whether the patient have support from family and/or others ?
In community management, if the individual have active suicidal ideation, without a suicide plan, willing to adhere to safety plan, and with family support. What should be the next step of consideration ?
Outpatient clinic (within 1 - 2 weeks)
In community management, if the individual have active suicidal ideation, without a suicide plan, willing to adhere to safety plan, but without family support. What should be the next step of consideration ?
Partial hospital / community / day program or intensive outpatient program (within 1 - 2 weeks)
List the choices of out-patient management for suicidal behaviour. (5—>16)
Get professional help (A&E, 999…)
Ensure safety at home and in the community
Remove all dangerous objects
Never leave the person alone.
Ask for help from friends or other family members.
Family Education
Understand patient’s condition, warning signs
Communication skills [Don’t directly ask 點解要自殺, 當返正常相處就OK]
Identify warning signs and the corresponding referrals and management
Providing support
Active listening
Do not convince suicide is wrong
Do not judge
Facilitate emotional expression/provide psychological support
Avoid discuss details of suicidal attempts and underlying reasons repeatedly which strengthen the idea of suicide
Strengthen protective factors
Build up relationship
Explore and engage in social activities
Attend treatments, psychosocial interventions and follow-up
Religious belief
What are the in-patient intervention / management ? (14)
Assess the suicidal potential daily
Determine the appropriate level of suicide precautions
Remove all dangerous objects such as plastic bag, cutter and medication
check the possibility of hoarding 囤積 drugs
The client’s room should be near the nurses’ station
Make sure that the client cannot open windows
Designate a specific staff person to be responsible for the client at all times
Arrange for the client to stay with family or friends
Put on suicide observation (visual check of mood, behavior and verbatim statement) ; explain to the client
Check the client at frequent, irregular intervals (make sure unpredictable time)
Avoid promising to keep secrets on patient’s suicidal thoughts
Maintain especially close supervision when busy hour or decreased in the number of staff (e.g. change of night shift, mealtime)
Construct a no-suicide contract
Restraint when suicidal action [if only ideal thought —> no restraint !]
List the aftermath of suicide in the hospital ()
Identify team leader to oversee all components of institutional response (IC). 即刻叫人 + call police
Keep the physical and environmental evidence
Photo taking for scene investigation
Release patient from hanging, KEEP the knot
Resuscitation when appropriate
Identify individuals in need of clinical attention:
Witnesses to the event, including family and visitors
Other patients at risk for suicide, Other patients close to the individual, Staff who cared for the patient
Documentation , Enter final clinical note and sequester chart.