“It is important to look not just at what the person took, but what the person was thinking to do,” Dr. Levenson said.
He recommended considering one-to-one care for suicidal patients and assessing environmental safety, which refers not only to exits and stairwells, but also to “all kinds of dangerous things coming in and out of the room.” Before moving patients to psychiatric units, he said, psychiatrists should do their own “medical clearance” to be sure patients are medically stable.
Finally, he said that a suicidal patient who is being discharged should always be asked, “Do you have a gun at home?”
A Lexicon for Suicidality
Consultation-liaison psychiatrists need more than one word for suicidality, according to Dr. James L. Levenson, who offered a brief lexicon at the meeting.
Dr. Levenson defined the following terms in a talk on the varieties of suicidality that are encountered in the general hospital. All are difficult situations, he warned, “and they require judgment calls at the end of the day.”
▸ Occult suicidality. (This is also referred to as the “shot-in-the-dark” patient.) Dr. Levenson described a 74-year-old, widowed, white man who was weak, losing weight, and suffering from nausea. The man was diagnosed with “failure to thrive.” Nonmedical staff should be educated in how and when to ask patients about suicide, said Dr. Levenson.
▸ Suicide in perpetuity. The patient has made one attempt after another, and psychiatric hospitalizations did not help. The medical/surgical staff wants the patient transferred to the psychiatric service, but Dr. Levenson wonders whether that would make the patient worse.
▸ “Boy who cried wolf.” Dr. Levenson told of a chronically ill woman who had threatened suicide for years, and then jumped off a roof while hospitalized for transverse myelitis. “Why was this threat different from all other threats?” he asked, warning against becoming inured.
▸ Pseudosuicidality. The patient who threatens suicide is about to be discharged and/or be cut off from opiates. Is the patient trying to manipulate hospital staff? Again, Dr. Levenson emphasized the need to document the reason for not taking a threat seriously.
▸ Suicidality in the future conditional tense. The patient “reserves the right to kill myself someday.” Don't overreact, advised Dr. Levenson. “Explore what this means to the patient.”
▸ Suicidal figures of speech. The patient says he feels like jumping out the window. He means it as a figure of speech, but family members and staff take him seriously. Dr. Levenson said to be sure to thank everyone for calling. Otherwise, nurses will think they wasted the psychiatric staff's time, and may not call the next time when a patient really means it.
▸ Unintentional suicidality. The patient is delirious and tries to jump out a window or poke himself with needles. “Delirious patients who are suicidal are impossible to predict. Nonpsychiatric personnel need to know the delirious patient is the one you need to be most concerned about,” said Dr. Levenson.
▸ Quasisuicidality. The patient wishes to end dialysis. Does the patient want to die, or is his quality of life too poor? Recognize that this is not a simple decision to make, and that the assessment of the patient's capacity is not simple either.
▸ De facto suicidality. The patient is a nonstop drinker or an asthmatic who continues to smoke. Dr. Levenson said psychiatrists need to accept their limits when attempting to treat such patients, but also to guard against nihilism.
▸ Medical Russian roulette. The patient will not permit replacement of the battery in her pacemaker. Don't underreact or overreact, advised Dr. Levenson. “Explore what this means to the patient.”