Robert Roca, M.D., M.P.H. easily recalls being called to an emergency in another facility many years ago, and coming upon a psychiatric patient hanging by a rope. This patient had committed suicide on the very unit where she was placed to prevent such a tragedy. Intrahospital suicides continue to occur. In fact, some 500 have been reported to JCAHO in the past 12 years. Suicides constitute the most commonly reported sentinel event for JCAHO. Dr. Roca, Vice President and Medical Director at Sheppard Pratt Hospital, finds this puzzling. The Institute of Medicine, he relates, found some 98,000 medication-related intrahospital deaths a year when they surveyed the problem in 2000.
Why, then, do hospital suicides cause more alarm? Is it the belief that all of them should have been detected and stopped? Dr. Roca has been studying the problem and believes that suicidal risk can be assessed, but actual suicides cannot be predicted with precision. A percentage of patients–including a majority of those who kill themselves in the hospital–deny their suicidality. Some are intent upon death, even if placed on suicidal precautions. And their lives are not static; outside events can negate a will to live made tenuous due to depression. Furthermore, psychiatric hospitals are not prisons. Physical movement is possible. Privacy exists. There are places and spaces to hang or suffocate oneself. A patient can cheek medication and save it up for a lethal dose.
Nonetheless, in concert with a new JCAHO regulation requiring hospitals to make a formal risk assessment of suicide on newly admitted patients, Dr. Roca has led the development of a Suicide Assessment Instrument. This is used by clinical staff to ascertain not only open suicidal intent, but other factors such as despair and self hatred. The instrument asks clinicians to rate as “yes” or “no” three dimensions of risk: expressed intentions, mental status elements, and historical items. In the first dimension are questions regarding attempts and plans. The second category is more difficult, and involves probing the patient’s thinking for indications of psychological pain, anguish, or agitation. Many of these signs and symptoms are elicited only by more extensive talking, and may not be easily observable at first glance. The third category seeks to gather information about relatives who might have attempted or completed suicide, and other family-related parameters. Included here are risk factors such as substance abuse and recent stressors. Dr. Roca points out that his assessment tool is subject to modifications and is a work in progress. For example, there are protective factors such as religion that need to be counted upon as deterring someone from suicide. Also, the social support system is complex. Some families can be a distinctly positive force for a patient to remain alive. The matter is not simple.
On the basis of positive answers given to questions, patients are to be considered at various high levels of observation (even if they deny open suicidal intent). It is not enough, Dr. Roca points out, to simply ask a patient whether he is suicidal. Dr. Roca acknowledges that using his instrument is not a casual undertaking. His instrument is not a check-list; indeed, no satisfactory suicidal check-list exists. Instead, the clinician will need to explore in greater depth those values and beliefs that keep a patient alive or cause him to believe that he or she is better off dead. Dr. Roca cautions that the use of so-called “safety contracts” contributes little to the matter of risk assessment, particularly in patients who have no relationship with staff. Such contracts are superficial. They deal only with expressed intent and not with underlying feelings which can fuel suicidal actions.
Surprisingly little is known for sure about why patients actually do commit suicide while hospitalized. Sometimes, an external loss occurs such as a romantic breakup. A family visit may kindle a lethal distress. Or a patient may feel (rightly or delusionally) that he or she is being ostracized by others on the unit. Some patients chronicle their increasing hopelessness in journals, but why at a particular moment they decide to kill themselves remains a mystery. Dr. Roca points out, patients in other disciplines of medicine “go bad” for unexplained reasons as well. For example, a cardiac patient may be released from the ICU only to collapse days later. Yet somehow, in psychiatry, the purposeful act of suicide appears more predictable than in the patient with atrial fibrillation who develops a massive embolism. It is known, incidentally, that a certain small percentage of patients commit suicide even when placed on suicidal watch. Determined to die, a patient can use ingenious methods. While improvements have been made in the architecture of ward design with break-away shower bars, it remains virtually impossible to suicide-proof any facility as complex as a hospital unit.
Because of changing criteria for admission in this era of managed care, more patients enter the hospital with suicidal ideation. They are allotted few days for assessment, so the burden of detecting lethality is high. At the same time, suicidal patients may keep things to themselves or may fool even experienced clinicians. Evaluating who may kill themselves at any one point in time is a lesson in humility.
Dr. Roca has carried out his work with the Health System’s Division of Quality and Evaluation Services. He can be reached at 410-938-4320.