Supporting Families and Providers When Suicide Occurs

Death by suicide continues to receive media attention with the recent deaths of Kate Spade and Anthony Bourdain. But suicide does not discriminate and occurs nationally in communities of all socioeconomic classes. In a recent report from the Centers for Disease Control, suicide rates been reported to rise with 45 000 suicides in the United States. ¹ In the national data, many victims have existing mental health problems.

Experts have identified risk factors such as those with major depression and other mental health disorders, substance abuse, violence, and guns in the home. Social isolation may play a role as well. ² Often there is no identifiable precipitant to suicide. In the recent report, almost half of the victims completing suicide had no previous diagnosis of a mental health condition.

Recently our palliative care service was consulted for the case of a young woman who attempted suicide. She was 19 years old and carefully planned to take her life by hanging. Her plan was interrupted as family arrived home and called emergency medical services. She had return of spontaneous circulation and was transported to the hospital. Despite all intensive efforts, she had a catastrophic and profound anoxic brain injury.

During her lengthy inpatient stay, the family was confronted regarding medical decision-making. Early in her stay, the parents were split in what they felt was best. The father could not see his young, beautiful daughter being kept alive on machines. Her mother felt that a miracle would happen.

We learned that that this patient had a struggle with mental health and had been diagnosed with bipolar disorder. Early graduation from high school, acceptance to the top universities, and her other achievements were more of a distraction to what was brewing deep inside her psyche. Despite her accomplishments, she had severe depression for several years requiring intensive psychiatric management. Her world was dark and she would cut herself to release the pain. She was not willing to take her psychiatric medications consistently.

Witnessing the daily suffering of her family impacted all providers. As a parent one hopes that a child will be free to explore and enjoy a happy life. Watching her mother live at the bedside with no regard for herself was challenging. The self-loathing and guilt of the parents was particularly difficult as they bargained for her life and questioned if they could have prevented this attempt.

Our team found ways to provide the important support to the family. We found that in a crises situation, it was important to understand the anger, despair, and vulnerabilities of the families. Calling in backup support from friends in the community, providing clear communication from our colleagues when they shared information, and being willing to hear the life narrative of the patient from the parents daily were only part of our daily support.

When our team was consulted in the intensive care unit, we understood the basic role of providing support and assistance with decision-making. The difference in how we achieved this was quite different compared to our usual practices. We learned that the acute crisis of the situation meant we could not predict what might happen day to day. Would the intense emotions of the situation drive the family toward more or less aggressive care? Each day was different in emotion, mood, openness, and willingness to accept support.

As we worked with the patient, family, and providers, we developed consistent patterns of when we would visit and who would be present and made sure that certain team members were present. Our palliative care chaplain played a central role in sitting with the family and providing prayer and reassurance. The team nurses worked with bedside nurses and the patient’s mother to understand the care around the patient including tracheostomy and feeding tube care. They incorporated the mother into the care as she felt helpless and this gave her a sense of meaning. Social workers participated in the scheduled family meetings outlining options for care including hospice and allowing families to express their grief. As the team physician, I worked with the consultants to ensure that any information shared was consistent and took part in the delivery of changes in the patient’s condition. Each new study including MRI, EEG’s continued to provide the similar information that our patient was not going to regain brain function and would be in a vegetative state.

Outlining goals of care took time, and after a long hospitalization, the family decided to take her home with caregivers. This was accomplished by teamwork between our service and the other specialists.

Our home palliative team and chaplain continued to visit at her home. After several weeks, the families were comfortable with hospice services and ultimately stopped her tube feeds. She died peacefully at home in her bedroom.

In the palliative care population, major depression is highly prevalent. Patients with advanced cancer were observed to have a heightened risk of depression. ³ Many of our patients with advanced chronic illness could benefit from increased identification and treatment for depression since we understand that this is a risk factor for a suicide attempt.

Although much of the training for palliative care providers is based around those with advanced illness, being consulted for incomplete suicide attempts will require additional skills. Providing nonjudgmental support is an important skill in cases of acute trauma such as suicide. Listening to the family’s story over and over again is required. Creating a safe and supportive environment proved to be very important. Grief support can look different in cases of traumatic death. Outbursts and confusion exist as families try to come to terms with this unexpected and tragic experience. Often bedside providers caring for patients and families are highly impacted by cases such as this and need support. Typically, the palliative care service may serve this role.

As the rate of suicide rises, it is important to understand how improved screening can be implemented in our palliative care population. Aside from improving screening practices, palliative care providers may be consulted on suicidal patients. Reasons for consultation may include providing much-needed support to families and caregivers of unsuccessful attempts or working with patients for support.

The general practice of palliative care requires excellent self-care. Cases such as this require open communication within the team to support one another. Providing an intervention can be as simple as asking a question and referring to help.