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Managing care for suicide-related behaviour

Continued management of suicide-related behaviour

Continued management of patients who are at risk of suicide or have exhibited suicide-related behaviour in the past involves collecting assessment information on an ongoing basis. This includes assessing risk and protective factors, suicidal ideation and behaviours and warning signs of imminent risk, as well as obtaining records and information from collateral sources.

One continued management strategy involves using open and closed risk markers (Rudd et al., 2006). Every time a risk factor is identified and documented, a marker of risk is opened. That open marker will need to be addressed in subsequent entries until the risk is either resolved or deteremined to be of minimal consequence in the clinical scenario.

One way to open and close risk markers is to document all of the variables that have been identified as elevating the patient's suicide risk. Afterwards, go back through the chart and identify the dates of entries indicating when the risk was addressed and resolved. Failure to address identified risk variables is the foundation of negligence and malpractice claims.

The open-close marker approach to risk assessment and management leads to greater clarity in the risk assessment process as well as to better clinical care. It prompts clinicians to monitor more closely those variables that have been identified as most important and to respond to them in a timely way.

Always close open markers of risk!
 

Practical management of patients with suicide-related behaviour

Environmental factors may be more relevant in managing suicide-related behaviour than for other types of care. McDowell et al. (2011) describe how to manage patients who demonstrate suicide-related behaviour while they are in your care or awaiting transfer to another care setting:

  • Assess clinical situations as needed, and increase the level of physiological monitoring on the basis of changing presentations.
  • Consider the possibility that some patients being evaluated for suicide risk may have overdosed or harmed themselves immediately before seeking care. 
  • During emergency evaluations, monitory patients more closely before and during transitions between care settings. Evaluate the potential of using medical equipment (e.g., intravenous tubing) or the patient's own belongings in a suicide attempt. Although it is uncommon, suicides can occur in the emergency department, general hospital and outpatient offices.
  • If evaluation in the emergency department or hospitalization is deemed necessary, transfer the patient by ambulance.
  • Although family or friends may offer (and prefer) to provide transport, the patient should be transferred safely using trained personnel following standard protocols.
     

Consultation with health care professionals

Every clinician needs to identify and have access to health care colleagues who can provide short-notice consultation for cases of suicidality.

Rudd (2006) outlines these important points about consultations for suicidality:

  • Appropriate clinical consultation reviews clinical indicators of suicide risk and related management decisions, as well as identifying and responding to any troublesome countertransference issues.
  • Always document the consultation. Be sure to document the issues addressed and any related confirmation or questions raised by the consultant.
  • Inform the consultant that you are requesting "formal" consultation that will be documented.
  • Have a standard approach to the requested consultation, presenting and reviewing the case in a set fashion and incorporating the risk assessment framework provided.
     

Keeping a treatment and management tracking log

A tracking log is designed to display critical information in a sequence of treatment sessions with patients at risk of suicide. This form is used to quickly update the clinician on the patient's suicide status and also reminds the clinician about recent interventions or problems with treatment.

An example of a tracking log can be found here.
 

References

McDowell, A.K., Lineberry, T.W. & Bostwick, J.M. (2011). Practical suicide-risk management for the busy primary care physician. Mayo Clinic Proceedings, 86, 792-800.

Rudd, M.D. (2006). The Assessment and Management of Suicidality. Sarasota, FL: Professional Resource Press.

Rudd, M.D., Mandrusiak, M. & Joiner, T.E. (2006). The case against no-suicide contracts: The commitment to treatment statement as a practice alternative. Journal of Clinical Psychology, 62, 243-251.