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Table of Contents
Year : 2013  |  Volume : 5  |  Issue : 1  |  Page : 53-55

Prevention of inpatient suicide: Saving Lives : Preventing Avoidable Deaths in Hospital

1 Staff nurse, dept of nursing, NIMHANS, Bangalore-29, India
2 Additional professor, dept of nursing, NIMHANS, Bangalore-29, India
3 Associate Professor dept of psychiatry, NIMHANS, Bangalore-29, India
4 Senior Professor and HOD dept of nursing, NIMHANS, Bangalore-29, India
5 Asst. Professor, dept of CHN, Tulaja Bhavani CON, Bijapur, India

Date of Web Publication28-Jun-2019

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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/2231-1505.261781

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How to cite this article:
Shindhe SS, Nagarajaiah, Reddemma K, Suresh B M, Sindhe S. Prevention of inpatient suicide: Saving Lives : Preventing Avoidable Deaths in Hospital. Indian J Psy Nsg 2013;5:53-5

How to cite this URL:
Shindhe SS, Nagarajaiah, Reddemma K, Suresh B M, Sindhe S. Prevention of inpatient suicide: Saving Lives : Preventing Avoidable Deaths in Hospital. Indian J Psy Nsg [serial online] 2013 [cited 2023 Jun 1];5:53-5. Available from: https://www.ijpn.in/text.asp?2013/5/1/53/261781

  Introduction Top

Health is fundamental human right and a worldwide social goal. An understanding of health and disease along with delivery of affordable quality health care is the basis of all healthcares.[1] Mortality rates are used as global measures of a population’s health status and as indicators for public health efforts and medical treatments. In psychiatric epidemiology, death is one of the few really hard items of data which can be used more precisely for both in research and service planning.[2]

The word “suicide” first used by Sir Thomas Brown in 1642, in his “Religio Medici”. Suicide as such means an intentional determination to end one’s life, and unexpected way of death, where the willingness to die originates within the person and there is presence of known or unknown causes to end one’s life.[3]

Numerous researchers conducted study on inpatient suicide and the results of the study shown that suicide was associated more commonly with diagnosis of severe depression, schizophrenia, increased duration of admission, previous deliberate self-harm, suicidal ideation at the time of admission and during the admission, suicide attempts during the admission, unstable (fluctuating) suicidal ideation during the admission. More commonly patients used hanging as mode of committing suicide in the inpatient setting. The researchers concluded that psychiatric units should be developed away from readily available methods of suicide. Patients with previous or intra-admission suicidal ideation or attempts, or unstable suicidal ideation, should be carefully observed to avoid absconding. Suicide risk should be carefully evaluated in such patients prior to approving periods of leave.[4],[5],[6],[7],[8]

Heidi combs and Sharon (2007) conducted a literature review on psychiatric inpatient suicide. The researcher conducted a thorough search of data base in pubmed and psych-info. The investigator included 41 articles published between 1982 and 2007 documenting 5,386 patients successful in ending their lives. The findings of review shown affective disorders and schizophrenia are most frequently associated with inpatient suicide. Suicides on-ward was usually accomplished by hanging; most patients denied of suicidal ideation prior to the act. The first week of hospitalization and the days immediately after discharge were risk for patient to end their lives.[9]

According to Lynch MA, et al (2008) root causes of inpatient suicide were factors related to the treatment environment, failure to assess patient behavioral characteristics, and staff reliance on no-suicide contracts. The researcher recommended

  • Including the assessment of suicide risk regularly throughout hospitalization, including on admission, during changes in a patient’s mental or physical status, after a change in observation level, and before discharge.
  • Nurses can incorporate them into a comprehensive menta health assessment to formulate appropriate nursing diagnoses and interventions for hospitalized high-risk patients
  • Orientation and in-service education for all staff regarding suicide prevention.[10]

Hence suicide is considered as an unnatural death, one which is avoidable and preventable. In each case of suicide there is a belief among medical and nursing staff that they should have done better they should have assessed the patient more carefully; been more aware of hints of suicide; provided closer supervision. These events in medical and nursing practice can create a sense of failure and guilt. So it is evident from above literatures that many suicidal risks can be identified well in advance and medical and nursing care can bring down the occurrence of inpatient suicide. Hence initial attempt made to provide guidelines in regard to identification of suicidal risk, prevention of suicidal act and documentation.

  1. Nurse should take in to account previous history of suicide attempt because it is an established risk factor, particularly if the method used had been intrinsically dangerous and also recent bereavement or separation, social isolation, chronic physical illness and abuse of drug or alcohol will predispose to further suicidal acts.[8]
  2. In some suicidal patient’s mental state appear to be improved prior to suicide. Hence nurses must be aware of an apparent clinical improvement if associated situational problems remain unresolved, these include, broken relationships, financial problem, etc
  3. Vigilance regarding development of malignant alienation should be taken care of.[9]
  4. Patients with a history of violence should be assessed for suicidal ideation at regular intervals.[7]
  5. Nurses need to be alert about decreased communication, conversation about death, low frustration tolerance and dissatisfaction with dependency.[11]
  6. Nurse should make note that the cognitive element common to many suicides is probably ambivalence rather than undiluted intent. Many give warnings of their thoughts of killing themselves prior to doing so. The absence, of prior warnings of suicide does not eliminate the potential for suicide, as some patients may prefer not to disclose their intentions. In a few cases, patients experience auditory hallucinations commanding them to kill themselves and not to tell others about it.[9],[10],[11]
  7. Continuous eye ball to eye ball observation of patient even when patient is going to bath room and also they have to stay with the client when she/he is meeting the personal hygiene.[11]
  8. Hospitalized patients who are believed to be at high risk for committing suicide are regularly placed on observation protocols. The protocol may require continuous observation (either visual or at arms length, depending on risk), or periodic checks, such as every 15 minutes. Intervals longer than 15 minutes are inadequate, and it is important to realize that much can be done, even in 15 minutes if the patient times the checks carefully. Death by asphyxiation may occur in as little as 5 minutes. Periodic checks should be done in a variable, unpredictable fashion, for example, a 15-minute check could be followed by a 6-minute check, followed by a 10 minute check, and so forth. Randomly varied checks make it more difficult for a hospitalized patient to plan a suicide, and make it more likely that the plan will be discovered.[9],[10],[12]
  9. Suicidal patient should be placed in rooms closest to the nursing station, and should have roommate.[11]
  10. An inventory of a patients personnel item including clothing, should always made on admission, and a decision regarding the utility of each item should be made. Additionally, careful clinical assessment of which patients are to share a room will minimize the risk of roommate’s item being used for self harm.[10],[11]
  11. Physical aspects of the unit access to potential points from which a ligature could be attached, electrical wiring, glass from a breakable window or heights from which to jump should all be eliminated[12]
  12. Nurses has to remove all sharp objects and potentially dangerous items from patient possession and they have to place in hospital gown without ties, belts, shoe laces, sharp instruments, stockings etc.[11]
  13. Nurses should keep checks on items that can be used by patient for hanging or strangulation and should avoid such objects or devices in the wards. These items include drapery cords, belts, shoe laces, ties, bathrobe sashes and drawstring pants, torn bath towel, torn bed sheets etc.[9],[11],[12]
  14. Nurses have to be alert to the possibility of the patient saving up his/her medications and always should keep the drugs in locked cupboards.[11]
  15. Nurses can use documented checklist of regular safety inspections which may minimize the occurrence of most unfortunate inpatient suicide.[10]
  16. Nurses should avoid over reliance on screening for common risk factors which may lead to decreased vigilance regarding those who do not match the typical profile. Hence only regular, repeated psychiatric evaluations are useful in identifying the most relevant risk factors in individual patients.[10]
  17. Patients in seclusion require very high levels of monitoring by nurses, they have to do regular checks about internal protuberances which may provide access for patient commit suicide.[11],[12]
  18. Nurses and clinician should negotiate a “no-suicide contract” during periods of high risk to determine if the intensity of observation can be reduced. Ongoing assessment of suicide risk is warranted whether or not a patient has agreed to a no suicide contract. There are many variables that can affect patient’s adherence to no suicide contract including the length of time the patient has known to the clinician and nurses, the quality of therapeutic relationship, the presence of varying degree of internal and external stress, and rapidly evolving clinical status. A patient may be able to agree in good faith to refrain from self harm at a specific moment in time, but be unable to adhere to this agreement during the next nursing shift, or some other time in the immediate future.[6],[8],[10]
  19. Monitoring of compliance with medication should be ascertained on regular intervals.[11]
  20. Hanging is the most common method of suicide in hospital and hence the minimization of environmental risk factors begins with elimination of structure that are capable of supporting a hang object such as exposed utility pipes, rods, low end windows n bathrooms and toilets.[7],[8],[12]
  21. A change of case manager a written report should draw the successor’s attention to important specifics in the management of suicidal patient.[10]
  22. Family members of the suicidal patient should be educated about management of suicidal patient and need for continuous monitoring should be ensured.[11],[12]
  23. Encourage and support the client’s expression of anger/emotions. Teach problem solving approach, social skills and self care activities.[6]
  24. If suicide occurs in ward or unit other client to be reassured and taken away from the scene of the attempt as quickly as possible and visit all the patient in ward at regular intervals and see that they appear to be calm.[9],[11]
  25. At some stage after an inpatient suicide it is advisable to hold a postmortem meeting with all staff who has been involved in the patient care. This allows a review of management, event leading up to suicide and various clinical decisions which were made. It enables those who feel guilty about their part in the patient care to express their guilt in a supportive milieu

  Conclusion Top

The suicide in psychiatric hospital inpatient is a rare but important event. As well as the grief caused to family and friends, and the significant effect it can have on other patients, it also raises question of responsibility and guilt for the professionals involved in caring for the patient. The utilization of knowledge in recognizing the patient at risk for suicide and intelligent use of self in intervening such cases will save the life and upholds the institute moral and respect.

  References Top

Gururaj and Isaac. Suicide prevention information for health professionals. NIMHANS, Bangalore 2003, 1. (www.nimhans.kar.nic.in)  Back to cited text no. 1
Sims Andrew. Mortality statistics in psychiatry. The British Journal of Psychiatry 2001; 179: 477-478.  Back to cited text no. 2
Retterstol Nils. Suicide: a European Perspective. First edition. Cambridge University Press: Cambridge, 1993, 1-2, 106, 114, 118.  Back to cited text no. 3
Shah AK and Ganesvaran T. Inpatient suicides in an Australian mental hospital. Australia New Zealand Jl of Psychiatry 1997 Apr; 31(2):291-298.  Back to cited text no. 4
LeMoyne Charles, Proulx F, Lesage AD and Grunberg F. One hundred inpatient suicides. British Jl of Psychiatry 1997 Sep; 171: 247-250.  Back to cited text no. 5
Elizabeth A, et al. The Wessex recent in-patient suicide study, 2 cases—control study of 59 in-patient suicides. The British Journal of Psychiatry 2001; 178: 537-542.  Back to cited text no. 6
JY Dong, Ho TP, and CK Kan. A case-control study of 92 cases of in-patient suicides. Journal of Affective Disorder 2005 Jul; 87(1):91-99.  Back to cited text no. 7
Li J, Ran MS, Hao Y, Zhao Z, Guo Y, Su J and Lu H. Inpatient suicide in a Chinese psychiatric hospital. Suicide Life Threat Behavior 2008 Aug; 38(4):449-455.  Back to cited text no. 8
Combs Heidi and Romm Sharon. Psychiatric inpatient suicide:a literature review. Primary psychiatry 2007 Dec; 14 (12): 67-74.  Back to cited text no. 9
Lynch MA, Howard PB, El-Mallakh P and Matthews JM. Assessment and management of hospitalized suicidal patients. Jl of Psychosocial Nursing and Mental Health Services. 2008 Jul; 46(7):45-52.  Back to cited text no. 10
Lalitha. K. Mental Health and Psychiatric Nursing an Indian Perspective. First edition, V.M.G Book House: Bangalore, 2007, 18-20  Back to cited text no. 11
Daniel Z. Lieberman, Harvey L.P. Resnik and Vicenzio Holder- Perkins Environmental Risk Factors in Hospital Suicide. Suicide and Life-Threatening Behavior 34(4) Winter 2004, 448-453  Back to cited text no. 12


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