Back in July I wrote a bit of a long rant titled: “On Evidence, Education, Errors, Ego and Expert Intuition” in which I tried to outline my approach to clinical decision-making, the use of evidence and the role of simple safety principles when we are dealing with high-risk clinical scenarios. As I was writing this I knew that there was at least one serious chink in the armour – one problem that continues to trouble me. Suicide.
Suicide risk, assessment and deciding what to do with patients presenting to us remains for me one of the toughest decisions in my job. Why does it bother me?
- We know the stats – suicide is common. In my community it is the #1 killer of young people.
- Mental health continues to be poorly resourced when compared ot other specialties.
- We have really not got any decent evidence to follow, or to back us up when we make calls around suicide risk
- I stated in my essay that inuition was unreliable – and this is especially true when talking about suicide risk – however it seems prudent to listen to one’s inner alarm bells if they are ringing as you consult with a patient.
- Like it or not – people kill themselves, often without any medical involvement. We are a small part of the picture when it comes to suicide prevention
- We don’t have much in the way of treatment to offer in the acute sense. Meds, beds – not really changing things if you look at the data.
- I have seen it go wrong too many times. I think we need to rethink our approach to suicide in the ED and acute care
So my approach? Well, that is a tough one.
- Start with a thorough history, mental state exam and get as much collateral / family / other background data as you can.
- Actively asking about Suicidal ideation is key: patients will not usually bring it up unless invited to do so – this should be part of any mental health history
- You have to commit time to this – it cannot be done in 5 or 10 minutes
- Sit down somewhere quiet and go through a systematic analysis of the information that you have just collected.
- Use an aide memoir or pre-formatted checklist to assist in your formulation of the information you have. e.g.. TRAPPED SILO SAFE
- Work out the background risk – based upon:
- Previous suicidality
- chronic disease
- Mental illness – esp. major depression, schizophrenia or bipolar
- Are there any deal-breakers, any factors which if present constitute a “must act” situation:
- Access to lethal means with a plan
- Presence of persistent suicidal ideation, with intent to act
- Presence of “hopelessness” – the sense that there ‘is no way out’
- Command hallucinations or delusions that are urging suicide or homocide
- The absence of any social support / a safe environment to discharge
- Acute intoxication especially with evidence of impaired decision-making or disinhibition
- Failure to establish any sort of rapport or therapeutic relationship
- Is this is “transient risk period”? e.g. : currently drunk and impulsive, recently aggrieved, temporarily at a loose end? with finance / relationships etc?
- If so then admission may help “cover” this acute risk period.
- Things often seem a lot better with the light of day, this is the time for “harm minimisation”
- Stop and ask yourself: do I feel comfortable with sending this patient home? This is entirely subjective, based upon the very human “spider-sense” that we all possess. It is not objective – completely intuitive – and unfathomable. But in the absence of an effective, validated clinical prediction tool I think that you need to use your ‘onboard computer’ to help you. BE clear – this is only useful if you decide you are not comfy sending them home – then act. Listen to your internal alarm system or gut if it is saying ‘Something aint right’.
- Now to be practical – if there are no strong reasons to admit for safety. Then discharge must be into an appropriately supervised and supportive environment.
In this mammoth podcast I enlist the help of Dr Rob Orman (ER Cast, EM: RAP ) to help. Rob has been posting on and discussing suicide risk assessment for a while and has come up with some pretty neat risk-assessment tools. You should click on this link to his site and check it out as we mention the TRAPPED SILO SAFE mnemonic a few times in the podcast.
Now, I usually try and keep my podcasts to 20 minutes – but this one is really good stuff. Suicide is a really tricky area and I think you will find the hour is packed with pearls and really practical advice from Rob on how to get info, formulate it and make those difficult decisions around suicide risk and keeping patients safe.
OK here is the PODCAST for download. Or you can download it from iTunes or into your favourite podcasting app.
This is one of those posts that has been in my brain bouncing around for months and I hope you get something out of it – as always comments and feedback much appreciated.