The Suicidal Patient

Questions

• 1.

  Has a suicide attempt been made, and if so, is the patient medically stable?

If you are being called by staff from an inpatient psychiatry unit, you are probably the first physician who is being notified about the case. Determine if there is active bleeding, if there has been a toxic ingestion, if there are vital sign abnormalities or changes in mental status, or if there is any other cause for immediate medical attention. If so, you will want to contact the medical or surgical consult teams as quickly as possible.

• 2.

  What brought the patient to the hospital?

Once you have established medical stability, you will want to obtain more detailed information about the case on the phone. For patients in a medical unit or in the emergency department, acute medical issues have probably been addressed, and you may be told “patient has been cleared for admission (or transfer) to psychiatry” before the consult has even begun. It is crucial to be vigilant of medical issues that may not have been considered by the medical teams, to rule out the possibility of an illicit ingestion, and to confirm that there have been no recent mental status changes. Remember that suicidality in the context of new onset confusion in a medically hospitalized patient is delirium until proven otherwise.

• 3.

  What does the patient look like right now?

Always make sure to begin assessing the physical safety of the patient during this phone call. A disorganized, psychotic patient reporting suicidality in the context of psychosis, or an agitated, impulsive, intoxicated patient, may warrant social or chemical restraints urgently. It may be prudent to ask that the patient be placed on one-to-one observation immediately (see “Orders”), and you can ask that the primary team institute this monitoring even before you reach the patient to begin your clinical assessment.

Orders

With a suicidal patient, your first decision is determining whether or not the patient needs a higher level of observation than is standard. Though you are the psychiatrist, you will likely be working in tandem with other physicians and hospital staff who may be able to give you important input. Discuss with the nurse or primary physician whether the patient has a specific plan for suicide and active intent or has expressed passive suicidal ideation. If the former is true, consider starting one-to-one observation prior to your assessment and asking the nurse to remove any potentially dangerous objects from the patient’s room. If the latter is true, you can probably defer the decision about one-to-one observation until you meet the patient. If unsure, err on the side of caution and recommend a one-to-one. Though close monitoring is a limited hospital resource, it is certainly better to be cautious and recommend a high level of observation, particularly as this can be easily discontinued after your assessment. Regardless of your decision, make sure to communicate the rationale for your recommendation to the nurse or primary physician, particularly your assessment of the safety risk.

While you are on the phone getting the initial consult, consider if the immediate administration of as-needed (or PRN) medications might be necessary. If the patient appears acutely psychotic—particularly if he or she is reporting command auditory hallucinations or exhibiting other gross impairments in reality testing—the patient may benefit from an immediate dose of antipsychotic medication. Antipsychotics should be offered in oral form; however, they can be given via intramuscular injection or intravenous push if oral is refused and there is an acute risk of danger towards the patient or staff. If the patient is complaining of intolerable anxiety (e.g., a patient who informs a nurse that he or she is having a panic attack and sees suicide as the only way out), a benzodiazepine such as low-dose lorazepam (orally or intramuscular/intravascular if needed) may be highly effective. The expeditious and judicious use of medication can sometimes relieve a patient’s suffering so a more effective interview can be performed. If the patient becomes too sedated to be interviewed, it will be necessary to frequently reassess the patient until an interview can be performed.