Version: / 1
Author: / Prepared by Eithne Ni Dhomhnaill, Nursing Matters and Associates.
Issue Date: / February 2013
Review date: / February 2015
Authorised by:
1.0 Policy Statement:
It is the policy of The Centre to promote a risk management and person centred approach to caring for residents at risk of or who are identified as at risk of self harm and suicide. Care will be provided within a framework of safeguarding the health, welfare and psychosocial well-being of the resident.
2.0 Purpose:
The purpose of this policy is to outline the process for assessment and care planning to identify residents who are at risk of or present with a history of self harm or suicide attempts.
3.0 Objectives:
3.1 To outline the requirements for identifying residents who may be at risk of self harm and / or suicide.
3.2 To outline the process of assessment and care planning for residents who present with a history of self harm or suicide attempts..
3.3 To safeguard and support resident’s at risk of self harm and suicide.
4.0 Scope:
This policy covers acts of deliberate self harm as apposed to indirect acts of self harm which are not the result of planning and intent. This policy applies to all nursing and healthcare professionals providing care and services to residents in the facility. This policy must be read in conjunction with The Centre’s Policy On Management Of Mood Disorders.
5.0 Definitions:
5.1 Self Harm is defined as ‘self-poisoning or self-injury, irrespective of the apparent purpose of the act’ (National Institute for Health and Clinical Excellence, 2004). However, it has been suggested that deliberate self harm in older people can frequently be regarded as a failed suicide attempt (Dennis et al., 2007). Self harm is the strongest risk factor for suicide, particularly among older adults (Corcoran, P. 2010).
5.2 Passive suicide (also called indirect suicide) includes behavior that occurs over time and can reasonably be expected to result in death. This can include refusing to eat, drink, take medication, or follow other treatment plans, or taking unnecessary risks. Passive suicide is likely to occur among older adults in settings such as nursing homes where they have limited control over their lives and limited access to lethal means. (Reiss & Tishler, Part II, 2008) It is important to note that passive or indirect suicide is different from an end-of-life decision made by a terminally ill older adult, in which a health care team supports a rationally thought-out decision by the individual to have treatment and medication withheld or withdrawn.
Actions
/Responsible Person.
This policy will be disseminated to and read by all nursing and healthcare professionals in the facility.
/Person in Charge
Where a new version of this policy is produced, the previous version will be removed and filed away.
/ Person in ChargeAn explanation of this policy will be given on induction to all nursing and care staff. / Person in Charge
Every resident will be assessed on admission for the risk of or history of self harm or suicide attempts and associated risks factors as part of their initial assessment and every three months or sooner where changes to care or condition indicate.
/ Person in ChargeAssessment and care planning to meet the needs of residents will be carried out as per this policy.
/All registered nurses.
For residents with a risk of or history of self harm or suicide attempts, a documented care plan will be in place and will include specific nursing interventions to meet the resident’s needs as outlined in this policy.
/All registered nurses.
Nurses will maintain their competence in assessment and care planning and communicate any competency / knowledge deficits to their line manager.
/All registered nurses
Care given to meet the needs of residents will be in accordance with the plan of care developed and agreed by the resident and / or representative and other healthcare professionals involved in the resident’s care.
/All healthcare staff providing care to residents.
Changes in a resident’s mood will be reported to the senior nurse on duty or line manager and changes to care will be communicated to all relevant healthcare professionals.
/All nurses, care assistants and other healthcare professionals involved in the resident’s care.
6.0 Responsibilities.
Every staff member has a responsibility to inform the nurse in charge if a resident expresses a wish to die during conversation.
7.0 Self Harm and Suicide Important Facts.
7.1 Older people who harm themselves are more likely to do so in an attempt to end their life (National Collaborating Centre for Mental Health, 2004).
7.2 Following an older person’s self-harm the risk of completed suicide is higher in their first year, (Fox & Hawton, 2004; Hawton et al, 2007a).
7.3 Contrary to most other European countries, the risk of deliberate self harm and suicide among older adults decreases with advancing age (Corcoron, P. 2010).
7.4 Several studies have shown that suicidal thoughts (ideation) and depression are more common among nursing home residents than among those who are not in nursing homes. This is particularly true for adults recently admitted to a nursing home (Reiss & Tishler, Part I, 2008).
7.5 Overall, among older people, in contrast to younger people, the main factor associated with self-harm and completed suicide is an underlying mental illness, most often depression (Dennis, 2009).
7.6 Specific risk factors for self harm and suicide in older adults include psychiatric disorders (present in 71-95 % of suicides) most commonly depression, chronic and painful illnesses, lack of meaningful activities resulting from functional limitations and social isolation (Jane-Lipois, E. and Gabilondo, A, 2008).
7.7 Suicide prevention in old age has proven to be effective through multi-component programmes addressing different risk factors. Depression is, by far, the most common disorder in older people who commit suicide, with an estimated population attributable risk of 74 % . This means that 74 % of old age suicides could be prevented if mood disorders were eliminated from this population (Jane-Lipois, E. and Gabilondo, A, 2008).
7.8 Several health promotion and preventative measures aimed at delaying the onset of physical illness or reducing its potential adverse outcomes have been found to be useful in improving the mental health and general well-being of old people.
8.0 Prevention of Self Harm in Residents of The Centre.
At organizational level, management and staff in The Centre are committed to providing an environment where residents’ quality of life and wellbeing is maximized through the following approach:
8.1 Person centred assessment and care planning for residents, which commences at the pre admission stage.
8.2 Residents, as far as they are able and / or their representatives as appropriate are actively involved in assessment and care planning
8.3 The Centre provides a range of activities to meet the range of needs of residents.
8.4 The Centre collaborates with psychology and old age psychiatry services to plan care for individual residents who are in need of same.
8.5 Resident Council meetings are held regularly and feedback reviewed by management and at Clinical Governance Meetings as appropriate.
8.6 The Centre Health and Safety Committee meet on a scheduled basis to identify any issues/concerns related to promoting an environment that safeguards the health and wellbeing of residents.
8.7 Person Centred Assessment and Care Planning.
8.7.1 Each resident must be screened for a history or current symptoms of mood problems:
§ At pre admission.
§ On admission.
§ Formally every three months as part of the review of their care plan.
§ Where there is a significant deterioration in the resident’s condition such as deterioration in physical functioning; advance in a progressive illness leading to an increase in symptoms and / or diagnosis of a terminal illness.
§ Following bereavement of a loved one.
8.7.2 Information for initial screening will be obtained from the resident and / or representative as appropriate; referral letters and / or hospital discharge summary.
8.7.3 Where the resident is unable to provide information, the views and observations of the representative will be sought at all stages of assessment.
8.7.4 Where a resident has a history of, or current indicators of low mood, the assessing nurse will complete the Geriatric Depression Scale for residents who are able or the Cornell Depression Scale for residents with cognitive impairment.
8.7.5 Where the depression scale and / or the nursing assessment indicates that a resident has current mood problems, the assessing nurse will arrange for assessment by the resident’s general practitioner.
8.7.6 A person centred approach to caring for any resident who is at risk of self harm must be employed. This includes:
§ Engaging with the resident as far as they are able to identify their feelings and causes of the distress.
§ Identifying interventions with the resident as far as he/she is able to alleviate the causes of distress for example pain management, coping with feelings of loss and so on.
§ Involvement of specialists as appropriate to assess and identify measures to alleviate distress.
§ Involvement of the resident’s representative with the resident’s consent as far as they are able.
8.7.7 A written care plan agreed with the resident as far as they are able and / or the resident’s representative must be documented to meet the individual needs of any resident at risk of suicide.
8.7.8 The care plan must include the involvement of the resident’s general practitioner and other healthcare professionals involved in the resident’s care.
8.7.9 The resident’s care plan must be updated in accordance with their changing needs.
8.7.10 A daily record of the resident’s care and condition must be kept for any resident who is at risk of suicide.
8.8 Risk Assessment.
8.8.1 Any resident who has a history of deliberate self harm or suicide attempts must have a risk assessment completed.
8.8.2 The purpose of the risk assessment in a residential care setting is not to predict if or when a resident will deliberately self harm. The purpose of the risk assessment is to identify risk factors that can be mitigated and protective factors that can be strengthened and in doing so promote the safety of the resident. Focusing care and treatment on these factors may make it possible to decrease a resident’s suicide risk (APA, 2003; Mann, Apter, Bertolote, Beautraise, Currier, Haas, et al., 2005 cited in Registered Nurses Association of Ontario, 2009).
8.8.3 Assessing risk factors also includes identification of opportunities for self harm, which can also be addressed to promote the resident’s safety.
8.8.4 Risk factors for deliberate self harm in older people include (see also Appendix 1).
§ Previous episodes of self harm.
§ Depression.
§ Deterioration in health leading to decreasing functional ability.
§ Chronic pain.
§ Recent bereavement.
§ Loneliness and isolation.
§ Substance Abuse.
§ Availability of Opportunities:
F Are they ambulatory?
F Can they readily leave the facility?
F Elopement risk
F Is a method of suicide available to them, such as overdose, hanging suffocation, fall, cutting wrists?
F Do they have the cognitive ability to formulate a plan for suicide?
8.8.5 Where risk factors are present, the admitting/assessing nurse will develop a care plan to address the risk factors. This may include, for example liaison with the resident regarding activities to prevent loneliness or isolation; liaison with family members and liaison with other health care professionals involved in the resident’s care. For example the nurse would liaise with the resident’s general practitioner to develop a care plan to address the management of pain or low mood. It may also include looking at how the resident would have greater access to social activities to address loneliness and / or isolation.
8.8.6 Nurses must be aware of their scope of practice and acknowledge any competency limitations when care planning for a resident at risk of deliberate self harm and seek the advice and guidance of the resident’s general practitioner and specialist services as needed.
8.8.7 As each resident is unique, the approach to addressing risk factors will be individual to the resident.
8.8.8 If the resident is at risk of self harm and not under the care of specialist psychiatric services, or has not recently been reviewed, the admitting nurse will liaise with the resident’s general practitioner regarding the need for same.
8.9 Suicidal Wishes/Ideation.
8.10 Any expression, whether direct or indirect of suicidal intention from a resident must be taken seriously.
8.11 A resident may express suicidal thoughts in a direct way, such as by stating a desire to die or indirectly through behaviours such as self neglect. Furthermore, the indicators that people give may be somatic in nature, particularly with elderly people (RNAO, 2009)
8.12 “Taking seriously” means to conduct a suicide risk assessment, to document the assessment, to discuss the assessment with other members of the client’s health care team and create a plan for safety and care as determined by the outcome of the assessment. If there is any uncertainty about suicidal intent and risk, the nurse should discuss the resident immediately with the resident’s GP and / or specialist mental health professionals involved in the resident’s care. The resident’s status should be considered a potential emergency until assessed otherwise by clinicians (NZGG,2003).
8.13 In performing the risk assessment where a resident has expressed suicidal intent either directly or indirectly, the nurse should also find out whether or not the resident has thought of ways to self harm and has developed a plan.
8.14 While awaiting the outcome of discussions with other healthcare professionals, the nurse on duty must ensure that the resident is not left alone and that a member of nursing staff remains with them.
8.14.1 Nursing staff should also identify the need to take the following precautions:
§ Removing items such as
F Cords
F Belts
F Shoestrings
F Plastic utensils
F Plastic bags
F Razors or sharp objects.
§ Being extra vigilant about ensuring that the resident takes medicines administered.