How an Elder Suicide Almost Happened

On a Sunday, a few years ago a situation unfolded in a Philadelphia suburb that could have ended in a suicide, but fortunately did not. It entailed a chain of events that illustrate that, in at least this one example, there are many opportunities to “do something” to prevent a suicide.

 

Mrs. S, an 80-year old widow, recently moved into a Continuing Care Retirement Community offering independent living, assisted living, and skilled nursing care. A few weeks later she was admitted to a local hospital because of an exacerbation of a chronic illness. In the course of her inpatient stay she manifested depressive symptoms and made statements indicating both suicidal ideation and a plan to take all of her medications when she returned to her residence.

 

The hospital did not have a psychiatric unit but arranged for a psychiatrist to see Mrs. S. The psychiatrist expressed concern about her risk and felt that she should not directly return to her residence. He wrote an order that she be transferred to the skilled nursing facility (SNF) at her retirement community.

 

Mrs. S was discharged the next day at 2:00 PM. For reasons that are not clear the orders were not followed and an ambulance took Mrs. S to her home. At 2:50 PM, Mrs. S called the assisted living facility (AL) in the complex and told them that she was home and that a psychiatrist had told her that she should be on a “suicide watch.” An LPN said that she would try to find out what was going on.

 

The LPN called the SNF, which knew nothing about Mrs. S. She next spoke to a nurse on the floor that had cared for Mrs. S and was told of her suicidality. The LPN relayed what she had learned to the SNF Charge Nurse who requested faxed copies of the orders. The RN called Mrs. S’s unit but there was no answer. It was now about 3:30 PM.

 

Meanwhile Mrs. S went to the AL facility and told an aide what she had been told by the psychiatrist. She said that was going to a concert in the auditorium at 4:00 PM in the hope that it would lift her spirits. The aide alerted the LPN but Mrs. S had left. The LPN contacted the SNF RN who went to the auditorium to try to find Mrs. S. What she found was an overflow crowd of 250 elderly women, many of whom fit Mrs. S’s description.

 

At 3:55 PM, the SNF RN alerted Security, which was changing shifts at 4:00 PM. Neither the outgoing or incoming security staff knew Mrs. S.  One security officer accompanied the SNF RN back to the auditorium to try to find someone on might know Mrs. S. The other security officer called the dining room and other areas where Mrs. S might be present.

 

The concert ended at 5:00 PM and Mrs. S had still not been located. At 5:15 PM, as the concertgoers cleared the lobby one of the security officers saw two women conversing on a sofa.  He inquired if either was Mrs. S. One woman said, “I guess you’re looking for me.” The security officer not wanting to run afoul of confidentiality polices returned to the front desk where he could observe Mrs. S. while the other officer called the SNF RN.

 

The SNF RN arrived five minutes later and told Mrs. S that they were ready to work on her admission. Mrs. S. readily proceeded to the SNF with the RN.

 

The SNF staff was very concerned about its ability to handle this situation. Mrs. S was admitted to a private room. The call button cord was removed and efforts were made to find a bell that Mrs. S, could used to summon help. Maintenance was contacted about securing the windows. By 6:00 PM Mrs. S was settled in and the SNF staff began checking her every hour.

 

Epilogue: When last we heard, Mrs. S was still with us and living independently at the CCCR.

 

Comment: Mrs. S voiced a potentially lethal plan with access to means and a specific timeframe. She should have been strongly encouraged to have a voluntary evaluation at a geripsychiatric facility and, if she declined, a petition for an involuntary psychiatric evaluation (“302”) should have been filed. Hopefully the hospital implemented some precautions during the last day of Mrs. S’s stay (but that is not known). The SNF seems to have taken Mrs. S’s risk seriously but did not seek an assessment. The SNF should have contacted the county crisis center for assistance. The measures taken by the SNF to assure Mrs. S’s safety were minimally adequate. It was suggested that the facility develop a suicide prevention policy for such situations but that has not been done.

Responsible Reporting of Suicides

NB: While the commentary below originally appeared in The Philadelphia Inquirer in 2004, the issues discussed are, sadly, just as relevant today.  There have been some changes in the manner in which suicide is reported in the media, however there are still glaring misconceptions about the appropriate way to cover a suicide, if it is appropriate in the first place, terms to use and terms to avoid, and a lack of knowledge about facts, risk factors, and warning signs.  The hope is that this article will serve as a reminder about the importance of responsible reporting of suicides and the responsibility of media outlets to provide relevant facts and information.  

Report Suicides Responsibly

by Tony Salvatore, MA

Like many, I was saddened to read of the deaths of David Wallace and his wife, Joan, particularly of the means by which they died (“Eminent architect dies in double suicide,” July 20).

Given David Wallace’s stature, and the comparative rarity of double suicides, I understand why this tragic situation would receive significant media attention. However, from my suicide-prevention perspective, the nature of The Inquirer’s coverage raises a number of concerns.

First, the article appeared on the front page. Second, it included a fairly detailed description of the method by which the couple ended their lives. Third, it made no effort to put the deaths into the context of suicides among elders. Sadly, these are increasing in what is often called a silent epidemic.

A number of organizations have offered guidelines for coverage of suicide. They seek to raise awareness that some vulnerable, high-risk individuals may carry out their own suicides by reading detailed news accounts of how others took their own lives. One such set came in 2001 from the Annenberg Public Policy Center of the University of Pennsylvania, acting in concert with national suicide-prevention organizations.

The report, “Reporting on Suicide: Recommendations for the Media,” explicitly discourages the placement of such stories on the front page or at the top of a broadcast. It is understood that suicides involving prominent persons, public circumstances, multiple deaths, or the very young are generally considered newsworthy. The Wallaces’ deaths fell into two of these categories and merited coverage. However, front-page treatment was not necessary.

Of greater concern was the detailed description of the lethal means that the Wallaces employed – another practice that the Annenberg report discourages.

These details, which I obviously choose not to get into here, were not essential to reporting this loss. Moreover, given that some may see these deaths as rational suicides – Joan Wallace was in hospice care; David Wallace had cancer – some circumspection was in order.

So-called copycat suicides are not limited to youths. It is to be hoped that The Inquirer would not have described the means used in reporting a high-profile teen suicide. The same judgment should have applied here.

Lastly, the Wallaces, David Wallace in particular, were in an age group at high risk of suicide, a fact not well known. According to data from the Centers for Disease Control and Prevention, there is a suicide by someone over 65 every 90 minutes, which amounts to 16 such deaths daily in the United States. Elders account for 20 percent of all suicides but represent only about 12 percent of the population. White men over 85 have a suicide rate six times higher than the national average.

Statewide, says the Pennsylvania Department of Health, there were more than 1,200 suicides among people 65 and over from 1997 through 2001 and fewer than 400 among those 19 or younger.

This same pattern prevails in Southeastern Pennsylvania, where elders accounted for more than 18 percent of all suicides in the same period and youths represented less than 6 percent of the losses.

The point is not that greater numbers make elder suicides more distressing than those at the opposite end of the age spectrum. Rather the point is that The Inquirer, having chosen to highlight the deaths of David and Joan Wallace, could have used this opportunity to inform its readers about the little-known incidence of suicide in the “golden years.”

Depression and hopelessness play a prominent role in elder suicide. Neither condition is normal at any age. Caregivers and health-care providers could have been alerted to these possible precursors to suicide in elders.

The Inquirer could also have noted that frailty makes the elderly less likely to survive suicide attempts. And it could have mentioned that greater social isolation makes it less likely that elders attempting suicide will be discovered in time to save their lives.

With the accelerated aging of our society, we must pay more attention to elder suicide and how the media should treat it. Suicide prevention is obviously not the media’s primary job. Nonetheless, it can play a powerful role in educating the community about this preventable problem.

Tony Salvatore is director of development of Montgomery County Emergency Services Inc., a nonprofit emergency psychiatric agency in Norristown.

Suicide Attempt Survivor Support: A Critical Unmet Need

Montgomery County has a serious problem with suicide, losing over one-hundred residents yearly.  It is probably less well-known that the county has a much bigger problem with non-fatal suicide attempts, all of which raise the individual’s life time suicide risk, and many of which subsequently become fatal attempts.

There is little data on the incidence of suicide attempts, an act in which a person with intent to die acts on a plan using potentially lethal means.  Many attempts occur without coming to anyone’s attention. Those that do usually are as a result of a need for medical treatment, self-reporting by the individual in seeking help, or when there has been an intervention.

Depending on age and gender, the ratio of suicide attempts to fatalities varies widely. Youths make more attempts than adults, men make considerably fewer attempts then women, elders tend to die on their first attempt.  Lethality of means, particularly firearms, accounts for these disparities.

Individuals with serious mental illness, especially schizophrenia, bipolar disorder, and major depression, attempt suicide more frequently than those without these conditions.  Alcohol abuse and dependence figure highly in suicide attempts. Imminent and actual suicide attempts account for a significant number of voluntary and involuntary psychiatric hospitalizations.

We could go on, but suffice it to say that focusing suicide prevention on individuals who have made a suicide attempt would likely save a lot of lives, enhance the recovery prospects and duration of those who may re-traumatize themselves when beset by even passing suicidal thoughts, and free up ERs and psychiatric hospitals to address other needs.

In 2012, the Action Alliance, a national suicide prevention coalition, identified support for attempt survivors as a priority for focus in the revised National Strategy for Suicide Prevention (NSSP).  This led to a national Suicide Attempt Survivors Task Force to help forge a path for stopping suicide attempts and deaths by engaging and supporting people with lived experience of a suicidal crisis.

In 2014, the Pennsylvania Adult Suicide Prevention Plan included an objective (9.1) to “identify all suicide strategies and services that respond to and care for individuals affected in the aftermath of a suicide attempt…and promote awareness of these resources.”  This state plan will presumably motivate the implementation of aftercare resources for suicide attempt survivors at the county level.

 

There are few suicide attempt support groups anywhere.  A 12-step based “Suicide Anonymous” group met for several years in Norristown, but ceased when its leader moved out-of-state.  At present, the only such support resource that we know of anywhere near Montgomery County is a “Suicide Anonymous” group in Burlington County, NJ:

Rise Above/R.I.T.E. Center

Twin Oaks Community Services

693 Main Street Building C

Lumberton, NJ 08048

1st Floor, Center Door

Group and Skype: 7:00pm 2nd and 4th Thursdays

Skype Only: 1st, 3rd, and 5th Thursdays

 

So why such a paucity of support groups in a major metropolitan area that probably has support groups for every other malady known to humanity?  Liability for self-injury or fatalities among group participants is often cited.  This probably would not apply to a peer-led group and has not proved insurmountable in the few provider-based groups around the country.  Bigger problems are stigma and finding peer facilitators.  (It is likely that there are a number of Certified Peer Specialists who have “lived experienced” of a suicide attempt as well as group facilitation skills.[i])  Indifference toward the needs of attempt survivors is an issue.  Perhaps those affected by recurrent episodes of acute suicidality will at some point step up.

 

Repeatedly hospitalizing those who make or almost make suicide attempts may be more part of the problem than part of the solution.  Clearly inpatient care may be indicated for stabilization and safety but there is no evidence of any long-term preventive value.  Moreover, the first 30 days after discharge from a psychiatric facility are a very high risk period for suicide.  Many readmissions within 30 days of discharge involve suicidal behavior.

 

Here are some on-line information resources on this topic:

 

 

 

[i] See “Peer Specialists can Prevent Suicide” Behavioral Healthcare, September 30, 2010 at http://www.behavioral.net/article/peer-specialists-can-prevent-suicides