Recently, I caught up with a friend of mine who shared a story with me about his practice, in particular about a patient who had been suicidal. The situation with this patient had caused him great distress. Suicidal patients are never easy to treat. Not only must the practitioner be concerned for the physical well-being of the patient, but also for his/her professional safety.
The Patient
The patient is a woman in her late 30s. She is financially secure, though she has been out of work for over a year and is having no luck finding employment. She indicated that she felt "useless" because she did not have a job, though she has enough savings that she can provide for herself for many years, even without employment. The patient has no partner or children, about which she also expressed great disappointment. She also despairs that because of her age, she has lost the opportunity to have a family. She is relatively new to town, having moved a year earlier. Although she has made some friends and is active in a local religious group, she told her practitioner that she felt disconnected and missed the established relationships she had in the state from which she relocated.
The patient had spoken with the practitioner on occasion over several months about suicidal ideation. During that period, she indicated no intent to act or plan to act upon. She was not abusing alcohol or drugs and does not own or have access to a firearm. The practitioner had suggested that she see a psychotherapist and had provided acupuncture treatments to lift her spirit. He continued to monitor her thoughts/feelings about suicide during their sessions.
Without indicating to him that her situation had deteriorated, the patient called the acupuncturist and left a message telling him "goodbye." She indicated in her message clear intention to act. She did not state that she had a plan, but the tone of the message was such that the practitioner believed that she intended to act immediately. As soon as he received the message, he tried to call the patient; she did not respond. Desperate, the practitioner called the patient's friend (whom he also treats) and her religious advisor. The friend called the police. The police believed the message indicated high risk of suicidal action. They went to the patient's home with EMS (emergency medical services). They entered the house and searched, but the patient was not present. Eventually, the patient made contact with her acupuncturist to say that the crisis had passed. She was outraged that the practitioner had involved her friends and the authorities, though she accepted that she had "brought that on [herself]." The practitioner suggested again that she see a psychotherapist and psychiatrist in addition to her acupuncture treatment, to which the patient agreed.
Identifying Potentially Suicidal Patients
I work with recovering addicts, very often these individuals express suicidal thoughts. I am not a psychotherapist and always refer these clients to mental health professionals, as the acupuncturist did with his patient. One must always consider scope of practice and the laws of your state when deciding what kind of support to provide for a potentially suicidal patient.
Suicide is consistently one of the top 10 leading causes of death in individuals over the age of 10. Suicidal ideation runs a gamut between fleeting fantasy and completed suicide. Suicidal individuals may not offer up information about suicidal ideation, but often will discuss such thoughts if asked directly. It is important to be able to assess a patient's immediate risk of acting on suicidal thoughts and to be knowledgeable about community resources to provide appropriate referrals.
Please note that this article is in no way to be considered a substitute for training and referral. If assessing suicidal tendencies is beyond your scope of practice (as it is for the majority of acupuncturists) and/or if you are uncomfortable working with such patients, it is important both to refer these patients to appropriate clinicians and to receive training to increase your comfort level when addressing patients with suicidal ideation.
Assessing Immediate Risk for Suicide
Unless you happen to be a physician, social worker, psychologist or other trained mental health professional who is also an acupuncturist, it is likely beyond your scope of practice to assess suicide risk. However, if you are in a room with a patient who expresses suicidal ideation or whom you think is at risk of suicide, as a health care provider, it is expected that you will act. The American Acupuncture Council can assist you with understanding precisely what your obligations as an acupuncturist are in these situations.
There is a lengthy list of indicators that professionals use to assess the risk of a patient completing a suicide in the short term. For the purposes of the acupuncturist, these can be addressed by asking questions about intent and plan.
Suicidal ideation may indicate a vague desire to die. "I'd rather not wake up in the morning," is an example of a statement that indicates a low degree of suicidal ideation. If upon questioning, the patient indicates no intent to kill himself or plan to do so, the immediate risk to his life is low. If a patient says, "Yes, I'd rather not wake up in the morning, but I could never kill myself because it would devastate my children," the patient is likely not in imminent danger. The suggestion can be made (and documented) for the patient to see a psychotherapist.
At the other end of the spectrum, patients may express clear intent to act. "I can't go on and I just want to say goodbye," signifies intent. "I've put my affairs in order and need to cancel my appointment next week," also shows intent. If, upon further questioning, the patient indicates that he has the means to commit suicide along with intent, "Yes, I own a gun," or "I have the pills I need to do the deed," this constitutes a medical emergency. How you respond will depend on many factors including but not limited to: your relationship with the patient and how quickly you believe the patient might act. It might be appropriate to call the patient's spouse and ask her to remove all weapons from the home or you may feel the need to get the patient immediate in-patient treatment. No matter how you act, it is important to document these actions in the patient's medical chart.
Outrage Over "Meddling"
Suicide is illegal. Those who show a clear intention to harm themselves are subject to involuntary hospitalization. If your actions cause a patient's temporary loss of freedom or embarrassment in front of friends or family, he or she may express anger toward you. However, laws allowing medical professionals to breach patient/practitioner confidentiality privileges are standard if the practitioner truly believes that the patient's life is in immediate danger. According to the law,"In an emergency, consent is not required to release information to family/significant other(s), although it is a courtesy to inform the patient of disclosure of information. Consent is also not required to obtain information from family/significant other(s)." Though the patient may be outraged or otherwise upset that you called emergency services or their family or friends, you are within your rights to break patient/practitioner confidentiality to do so.
Instilling Hope
In the case of the patient whose story begins this article, she is alive. Not only has she not attempted to kill herself, but she remains in the care of the same acupuncturist. He reports that she speaks with him openly now about how she feels and that she is beginning to see some hope for a better future for herself.
The dangerously suicidal patient will feel a profound sense of hopelessness. He will believe that the future is bleak and that there is no possibility for it to improve. The pain (physical or emotional) he is experiencing is more than he can bear. What is important to remember as an acupuncturist is that most patients who express suicidal thoughts have mixed feelings about carrying out their plan. What they want is an end to their suffering. You can provide a voice of reason and hope that there is treatment and support available for the patient that does not include ending his life. Difficult feelings or moments may persist, but the prognosis for recovery from suicidal thoughts is good with proper treatment and support.
Perhaps most important, take the patient's situation seriously, but not personally. If your patient has openly discussed suicidal thoughts with you, know you are in a position of trust. Your patient will be conflicted about his/her feelings and options. Whether or not a patient chooses to end their life is beyond your ability to control. You can only serve as an appropriate support and resource. Your patient's journey is their own.
References
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