Homicidal and Suicidal Ideation:

Definition/Etiology:

We all know the definitions here. Homicidal ideation is the thought of killing another person and suicidal ideation is the thought of killing oneself.

The causes for either of these conditions are too numerous to mention here. While the numbers of homicidal ideation are kind of tough to find, the numbers for suicidal ideation are not. Data shows that in the United States, someone takes their own life about every 15 minutes. Think about that. In the time you are given for this exam, 12 people will kill themselves. Ok I’m sorry, that was kind of morbid…let’s move on.

Pathophysiology:

While there is no specific cause identified for either of these situations, there are some red flags that can identify the potential.

• Females 3x more than males
• Males are 4x more likely to succeed at an attempt
• About 70% of all suicide deaths are white men
  Elderly patients represent about 16% of all suicides
• Increased risk for suicide in families with history of attempts
• Family history of mental disorder is a risk factor for both suicide and homicide, so is childhood abuse
• Substance abuse increased the risk for both
  The risk of lethality is always greater if the person has access to a weapon and has a plan.
  And just so you know, more suicides occur in the spring

Clinical Presentation:

The clinical presentation of these patients runs the gamut from somnolent and depressed to hyperactive and violent. The most important thing in presentation, is to listen to the patient. If a patient says they are going to kill themselves, then believe them. If they say they are going to kill someone, believe them.

• Side note…it’s much more concerning if a homicidal patient actually has a target. “I’m going to kill my father”, or “I’m going to kill that ass, Chad at work”.
• Another side note. When we ask a patient about suicidal ideation, do not ask if they are thinking of “hurting themselves”. Ask them if they are thinking of killing themself or ending their life. Some nurses feel like they will embarrass or offend the patient if they are so blunt. Get over it, be blunt, you can actually save the person’s life here. One of the best things that can delay a person’s suicidal ideation until it passes is just that…time passing!

Collaborative Management:

It’s important to provide safety for these patients. Removing all items from the room and all belongings. Do not provide anything to them that can allow them to carry out any plan they may have.

• 1:1 observation is a must. These patients must be watched closely for their own safety and the safety of others
• Get a psych consult ASAP. I know many of us are dealing with long term psych holds in our ERs, but we have to do the best we can with what we have.
• All of these patients need basic blood work and tox screens to rule out other medical possibilities for their mental state.

Evaluation | Patient Monitoring | Education:

When we evaluate these patients there are a few important details.

• Has there been a prior attempt or act
• Do they have a plan
• Have they spoken to anyone else about these feelings
• How long have these feelings been present
• Are they having any auditory hallucinations (is anyone or anything telling them what to do)

We want to evaluate the effectiveness of any medications we give them. This includes any sedatives.

• We need to know what meds they are on. Are any of them causing these feelings?
  Encourage the patient to talk about the problem that led to their current situation.
• Prepare the patient for admission to the hospital

Linchpins: (Key Points)

• Safety First
• Be Direct
• Set Limits
• Check the Plan