Etiology A. Genetic and Biologic Theories There is a genetic marker for suicidal ideation (a 5-HT2a receptor gene allele C of 102T/C polymorphism). Research has focused on the relationship between serotonin and postsynaptic frontal cortices’ binding sites, 5-HIAA, and serum cholesterol. B. Sociological Theory Emile Durkheim, a French sociologist identified society as an influencing factor on suicide rates. C. Psychological Theories Several causative psychosocial factors have been identified, including: failure to adapt; feelings of alienation or isolation; anger or hostility; reunion wish or fantasy; a way to end one’s feelings of hopelessness and helplessness; a cry for help; an attempt to “save face” or seek release to a better life.
Individuals at Risk for Self-Destructive Behavior Approximately 80% of those persons attempting suicide give clues, including: verbal clues, behavioral clues, or situational clues. A. Clients with a Psychiatric Disorder Among the most serious risk factors are those of various psychiatric disorders, such as major depression, schizophrenia, schizoaffective disorder, bipolar disorder, personality disorders, eating disorders, and alcoholism or drug abuse. B. Clients with Alexithymia Alexithymia is a term used to characterize persons who seem not to understand the feelings they experience, and who seem to lack the words to describe their feelings to others. Individuals who experience this phenomenon have been found to be at higher risk for self-mutilation and suicidal behaviors. C. Clients With a Medical Illness Individuals with chronic or terminal medical illnesses have verbalized several reasons for suicidal ideation: pain, suffering, fatigue, loss of independence, and decreased quality of life. 1. Euthanasia and Physician-Assisted Suicide (PAS) Euthanasia, defined as a health care provider’s deliberate act to cause a client’s death, and physician assisted suicide, defined as the imparting of information or means to enable suicide to occur, have become controversial issues in the health care industry. The increase in longevity, development of modern medical technology, and use of life-support systems have created an ethical dilemma for health care providers who are often confronted with their responsibility to relieve pain and suffering and their obligation to preserve life. Nurses who provide palliative care for dying clients have difficulty distinguishing among allowing, hastening, or causing death when their only goal is to help clients die with peace and dignity. D. Adolescent Clients According to the latest statistics for adolescents, the rate of suicide has quadrupled since 1950 from 2.5 suicides to 11.2 suicides per 100,000 adolescents in the year 2000. Additionally, more than 12,000 children and adolescents are hospitalized in the United States each year as a result of suicidal threats or behavior. Suicidal ideation, gestures, and attempts are associated with adolescent depression and have become a growing mental health problem. Suicidal behaviors are often linked to school performance, making potential high school dropouts a high-risk group. E. High-Risk Populations High-risk populations include adolescents, ethnic minorities, homosexuals, and the elderly.
The Nursing Process A. Assessment Suicide is considered more preventable than any other cause of death. Assessment includes applying close observational and listening skills to detect any suicide clues, plan, and degree of lethality. Some terms used to describe the range of suicidal thoughts and behaviors are: suicidal ideation; suicidal intent; suicidal threat; suicidal gesture; intentional self-destructive behavior. Assessment is an ongoing process, during which the nurse must establish a therapeutic relationship and encourage verbalization of negative feelings. There are many scales that may be useful in the assessment process. B. Nursing Diagnoses Diagnosis is based on the client’s potential for self-harm, level of coping skills, degree of hopelessness, and use of support systems. C. Outcome Identification Outcomes focus on the client’s safety, development of positive coping skills and self-esteem, ability to interact with staff and disclose feelings regarding suicidal intent or plan, and the client’s willingness to take steps to resolve any relationship or lifestyle issues that increase the risk of suicide. D. Planning Interventions E.
Implemplementation 1. Suicide Prevention Nursing interventions focus on the prevention of self-destruction and are classified as primary, secondary, and tertiary prevention depending on risk factors identified during assessment. 2. Suicide Precautions Clients at risk for suicide need either constant (one-to-one visual supervision) or close observation (visual checks every 15 minutes) in a safe, secure environment. 3. No-Suicide Contracts Contracting with the client to try and agree to control suicide impulses or to contact a nurse before attempting suicide must be used with caution. Contracts are often made with clients whose suicidal risks are underestimated. Secluseclusion and Restraint The use of restraints and seclusion is considered to be an intervention of last resort. Because they can be dangerous interventions and require one-to-one monitoring, they must be used with caution for individuals who are suicidal. 5. Medication Management Use of psychotropic medications to manage behavior is referred to as chemical restraint. Injections may be required. The nurse must monitor the client’s response to medication, including any adverse side effects. 6. Assistance Meeting Basic Human Needs Clients at risk for suicide often neglect personal care. The nurse provides assistance with ADL until the client is able to be responsible for self. 7. Interactive Therapies A variety of interactive therapies are helpful to assist the client in exploring reasons behind suicidal ideation and to provide stabilizing support. 8 . Continuum of Care Appointments are scheduled to continue with interactive therapies and medication management as needed. Support services, such as a 24-hour suicide hotline, are discussed with the client. F. Evaluation Evaluation of the client’s progress in attaining expected outcomes is an ongoing process; the client’s mood, affect, and behavior may fluctuate quickly and unpredictably. Reassessment includes reevaluation of the goals of therapy, the effectiveness of interventions, and the progress the client is making.
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