Suicide potential (suicidal ideation, gesture)
Also Consider: Behavioral Disturbance, Delirium, Mental Status Change, Mood Change
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Causes
Common: Adjustment disorder, major depression, dementia, psychiatric illness, normal grief reaction, stress
Uncommon: pain/discomfort, medication side-effect (steroid, amphetamine, beta blocker, clonidine), substance abuse
1. Take Vital Signs
Temperature:
Blood Pressure:
Heart Rate:
Respiratory Rate:
Oxygen Saturation:
2. Evaluate Symptoms and Signs
Injury from any suicidal gesture or attempt (ask patient if an attempt has already been made)
Negative Expressions: Tearful, crying, irritable, scared, frowning
Positive Expressions: Laughing, smiling
Behaviors
Interactions with others
Statements made
Specific plans for committing suicide, details of plan, access to lethal materials
Prior attempts at suicide or other self-injury
Unrelieved pain
Alcohol intoxication, drug use, or potential overdose (for opioids, evaluate for need for naloxone)
Hoarding of medications
Events leading up to the suicide potential (for example, death of family member)
3. Take Action using SBAR Report:
Presence of other, significant symptoms or signs of illness
Refer to appropriate Situation-Specific Evaluation for the identified symptoms and signs.
Immediately notify the medical staff & resident representative
Makes a suicidal gesture, OR discusses a detailed plan for carrying out suicide
Notify medical staff on the next business day
New onset of talking about wanting to die, but not making any specific suicidal threats
Notify medical staff at the next regular rounds
Increase in frequency or extent of discussions of wanting to die
SBAR Report
Situation: "Suicidal” (ideation) (gesture) “in a patient with” (a detailed plan) (history of suicide attempts) (psychiatric illness)
Background:
Reason the patient is in the nursing home (rehab for___, long term care for __).
When the suicide potential started, how severe it is, getting worse or staying the same, what treatments have been tried, events leading up the suicide potential=
Abnormal Vital Signs
MOLST / Advance Directives
Recent illness (medical or psychiatric), medication changes
General observation of patient condition
Evidence of intoxication or drug use
Uncontrolled pain
Assessment from last psychiatry evaluation, PHQ-9 result on last MDS
Assessment: I am concerned about: __________
Recommendations/Requests:
Labs: Drug levels, toxicology screen
Psychiatric consultation
Urgent psychiatric evaluation
Medication change
Pain Medication
Counseling / psychologist referral
Chaplain referral
Other:
Clarify expectations for care, interventions, and illness course/prognosis. Repeat any telephone orders back to the provider to ensure that they are correct and complete
4. Implement Management Plan
Increase monitoring/supervision (15 minute checks, 1:1 observation, etc), inviting assistance from patient’s family and friends
Assess risk for injury
Remove items that may be used as weapons or otherwise cause harm to the patient or others
If at risk for opioid overdose, assure naloxone is available.
Place on 24-hour report for 2-3 days
Document symptoms and response to interventions each shift
Update care plan regarding supervision for safety
Review status and plan of care with designated representative daily until suicidal ideation / gestures are managed.
Update advance directives, if appropriate.
2025-04-27
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