Suicide or completed suicide is the act of intentionally ending one’s own life and opting for nonexistence. Suicide is the eleventh leading cause of death in the United States, and the third leading cause of death for adolescents 15 to 24 years of age (Black & Andreasen, 2011). According to the Department of Veterans Affairs, one in five deaths in young veterans is a result of suicide (Glantz, 2010). Adults over 80 years of age have one of the highest suicide rates of any group.

Although suicide is a behavior that needs careful assessment in depression, alcoholism/substance abuse, schizophrenia, and personality disorders (borderline, paranoid, and antisocial), suicide or attempted suicide is not always associated with mental disorders.

Physical illness (e.g., pain, recent surgery, chronic physical illness) can play a role in suicide behavior. Suicide seems to be most prevalent among patients with diseases that result in suffering and dependency, such as AIDS, cancer, and Alzheimer’s disease. Nurses might encounter suicidal individuals in outpatient settings, intensive care units, nursing homes, medical/surgical units; during home visits; or even among their own circle of family and friends. Individuals who are taking medications that contribute to depression and psychotic symptoms are also at risk.

Suicide seems to cluster in some families, so family history is pertinent. This could be caused by learned problem-solving behavior within the family or by inherited markers for depression. Inherited low cerebrospinal fluid (CSF) levels of 5-hydroxyindole-acetic acid are associated with a higher risk for attempted suicide as are some other genetic factors (Lindqvist et al., 2011).

Suicidal individuals share other commonalties. They are often poor problem solvers, have troubled emotional lives (e.g., experience depression, anger, anxiety, guilt, and/or boredom), have a low threshold for emotional pain, are often impulsive, and might engage in extreme solutions sooner than individuals who are not suicide prone. Suicide potential is apt to be higher among individuals facing negative life events. For example, the suicidal individual may lack social supports; be impoverished/homeless or unemployed; or be recently divorced/separated or bereaved. In fact, individuals who are experiencing severe life stress at any age may be at risk.

Individuals who are isolated (have poor social supports) and those who are experiencing severe life stress at any age may also be at risk.

• Family history of suicide attempts or completion

• History of being bullied and/or victimized in any fashion

• History of a mood disorder, drug or alcohol abuse, or schizophrenia

• History of chronic pain, recent surgery, or chronic physical illness

• History of personality disorder (borderline, paranoid, antisocial)

• Patient is bereaved or experiencing another significant loss (divorce, job, home)

• Legal/and or discipline problems

Presents with:

• Suicidal threat—communicates desire to harm/kill self

• Suicide attempt, failed—attempted to kill self

• Deliberate self-harm syndrome—patients who mutilate their bodies

• High degree of hopelessness, helplessness, and anhedonia, which are crucial factors in suicide

• Has a plan for how to kill self

2. Determine the appropriate level of suicide precautions for the patient (physician or nurse clinician), even in the emergency department. If the patient is at a high risk, hospitalization may be necessary. For example, if individuals state they have a plan for how to kill themselves, it is important to ascertain concrete behavioral information to assess the measure of lethality. Some guidelines include:

• Determine how far the individual took suicidal actions or made plans to take action.

• Determine how much of the individual’s time is spent on these plans and accompanying ruminations about suicide.

• Determine how accessible and lethal the mode of action is.

3. A red flag is raised if the patient suddenly goes from sad/depressed to happy and seemingly peaceful. Often a decision to commit suicide “gives a way out of severe emotional pain.”

4. If the patient is to be managed on an outpatient basis, then:

• Assess friends’ and family’s knowledge of signs and symptoms of potential suicidal behavior (e.g., increasing withdrawal, preoccupation, silence, and remorse).

• Identify community supports and groups the patient and family could use for support.

A sound assessment provides the framework for determining the level of protection the patient warrants at the time. Therefore, Risk for Suicide is the first area of concern.

Believing that one’s situation or problem is intolerable, inescapable, and interminable leads to feelings of hopelessness. Therefore, Hopelessness is most often a crucial phenomenon requiring intervention.

A third area of intervention is to tackle the phenomenon of the “tunnel vision” suicidal patients have during times of acute stress and pain. That is, problem-solving skills are poor, and suicidal people have difficulty performing flexible cognitive operations. Teaching the patient or reinforcing the patient’s own effective problem-solving skills and helping him or her reframe life difficulties as events that can be controlled is a strategic part of the counseling process with suicidal patients. Therefore, Ineffective Coping can be viewed as the third point of intervention. Other potential nursing diagnoses include Risk for Loneliness, Situational/Chronic Low Self-Esteem, Deficient Knowledge, Social Isolation, Disabled Family Coping, and Spiritual Distress.

• Suicide precautions range from arm’s-length constraint (one-on-one with staff member at arm’s length at all times) to one-on-one contact with staff at all times but may attend activities off the unit maintaining one-on-one contact to knowing the patient’s whereabouts at all times on the unit and accompanied by staff while off the unit.

• Keep accurate and thorough records of the patient’s verbal and physical behavior as well as all nursing and physician actions.

• If there is fear of imminent harm to self, restraints may be required.

• Follow unit protocol, and keep detailed records in the patient’s chart.

• When the patient is to be managed on an outpatient basis (Slaby, 1994), then:

• Initiate appropriate psychopharmacotherapy, psychotherapy, or sociotherapy.

• Provide the patient and his or her family and friends the psychiatric clinician’s telephone number as well as that of a backup clinician or emergency department where he or she can go if the clinician is unavailable.

• Schedule a return visit (as early as the next day, if decisions concerning hospitalization need to be reconsidered).

• Alert friends and family to signs such as increasing withdrawal, preoccupation, silence, remorse, and sudden change from sad to happy and “worry-free.”

• In all instances, ensure that careful records are kept documenting specific reasons why a patient was or was not hospitalized.

• If the patient is to be managed on an outpatient basis, medication should be given in limited quantity (e.g., 1- to 3-day supply with no refill).

• List support people and agencies to use as outpatient and crisis hotline numbers for the patient/family/friends.