Beyond BLS: Suicidality and postvention
What EMS needs to know about treating suicide attempts
Suicide is always preventable. If you are having thoughts of suicide or feeling suicidal, please call the National Suicide Prevention Hotline immediately at 988. Counselors are also available to chat at www.suicidepreventionlifeline.org. Remember: You deserve to be supported, and it is never too late to seek help. Speak with someone today.
EMS providers all too often respond to calls where the patient’s injuries resulted from a suicide attempt. As necessary, they provide pre-hospital treatment, site safety and transport of the patient to the emergency department. However, unlike other patient needs they address, EMS training supplies little understanding on the causes and consequences of suicide attempts.
Most people have little idea how often EMS providers have contact with patients who have severely, intentionally injured themselves (or, sadly, patients who have died by suicide). EMS practice covers the skills and knowledge to deal with such injuries, but most emergency responders know little about the emotional and psychological wounds a suicide attempt may produce.
Recovery from a suicide attempt that is medically serious and imminently life threatening can be long and frustrating. Early support can help the patient come to terms with the aftereffects of lethal self-harm. EMS providers can help lower ongoing suicide risk with a better understanding of suicide attempts and a better attitude toward these patients.
Knowledge of suicidal ideation and behavior is also important for EMS providers because many of their peers have attempted suicide or contemplated doing so. In a 2015 survey, almost 7% of EMS providers reported making a suicide attempt. By comparison, in 2019, the National Survey on Drug Use and Health found that 0.6% of U.S. adults reported an attempt in the past year.
The nature of suicide attempts
The CDC define a suicide attempt as, “a non-fatal, self-directed, potentially injurious behavior with intent to die as a result of the behavior.” Making a suicide attempt is a very traumatic event. Protective factors have failed, risk factors are strong, intent to die is severe, lethal means are on hand and a plan is underway.
When a patient survives a suicide attempt, many of these prerequisites remain. Only intent to die may subside. Suicide risk stays very high. Protective factors do not rebound. Suicide plans may remain in the patient’s thoughts and the means to die may still be available. Coming to the brink of ending one’s life weakens resistance to do so again.
An analysis of U.S. suicide attempt related ED visits found:
- Females accounted for more attempts than males (who use lethal means, such as firearms, and have a lower survival rate)
- About one-third of the attempts involved violent means (e.g., cutting, hanging, firearms, jumping, crashing a vehicle, burns or electrocution)
- Overdoses of prescription medications, primarily psychotropic drugs, were the most frequent means and played a role in about two-thirds of the attempts
- Cutting or piercing were the second most common means
Other research found that approximately 7% of those who attempted suicide died by suicide later in life, 23% made another nonfatal attempt and 70% made no further attempts. The first suicide attempt creates high risk for dying by suicide, and the majority of completed suicides occur within a year of the first attempt.
The American Foundation for Suicide Prevention reports that 25%-50% people who die by suicide have made a previous attempt. Of suicide attempt survivors who required hospital treatment, about 5% to 11% go on to die by suicide. These individuals are likely to have had EMS contact, with most in need of help beyond basic life support.
Suicide attempt survivors
A suicide attempt survivor is an individual who had intent to die, had a plan for bringing about their death at a specific time and place, and had the means to do so, but did not die as intended. The appropriate terminology for a suicide attempt that did not result in death is a nonfatal suicide attempt. “Unsuccessful suicide attempt” is inappropriate.
We know little of the long-term medical outcomes of nonfatal suicide attempts. Nonviolent means, such as poisoning, may have less impact on future health than violent means, such as jumping from an elevation. As the majority of attempts employ nonviolent means, most who survive nonfatal attempts probably do not have significant ongoing physical disability.
Nonetheless, attempt survivors must contend with many challenges, some with post-traumatic stress. Life problems that precipitated their suicidality may persist or return. Loss, abuse, chronic illness or pain, disability, substance use, mental illness, financial or housing insecurity, interpersonal conflict, social isolation and criminal justice involvement do not subside after a suicide attempt. Feelings of hopelessness, guilt and shame make things worse.
Stigma impedes recovery from a suicide attempt. Stigma often incorrectly characterizes attempt survivors as selfish, attention seeking, manipulative, weak or mentally ill. Stigma may have a greater effect on those with histories of multiple attempts. Anticipated stigma deters some from seeking help for suicidal feelings and makes it more likely they will persist and worsen.
Emergency responders are especially unlikely to disclose a suicide attempt or talk about whatever precipitated their suicidality. EMS culture can view suicidal behavior of any type with antipathy more so than empathy. Emergency responders may not disclose a suicide attempt least they be seen as unstable and unreliable. Aversion to peer stigma by emergency responders who have made suicide attempts increases the odds that they will do so again.
How suicide attempts happen
The prevailing theoretical model of suicide holds that a lethal suicide attempt may occur when an individual has both an intense desire to die and the ability to take their life. Intent may arise from a sense that one is socially disconnected from significant others, feeling one is a burden to them, and believing that they will be better off if one were dead. The capability for a suicide attempt results when one does not fear dying and has overcome the inborn resistance to self-directed death.
A suicide attempt is the outcome of a process. The factors driving the process do not necessarily abate with the attempt, even when the intent to die lessens. One of the most dangerous myths of suicide is the belief that surviving a suicide attempt indicates a lack of intent to die. The reality is that intent may be rekindled by subsequent life circumstances and/or misperceptions of one’s value to others and restart the process towards an attempt.
A suicide attempt that did not end in a suicide is the strongest risk factor for a subsequent attempt and suicide. Resistance weakens with each suicide attempt.
Suicide attempt postvention
Postvention is helping someone after a suicide attempt. It addresses the challenges faced by someone contending with the aftermath of trying to die by suicide and surviving a deliberate suicide attempt. EMS providers can perform basic postvention at the scene or in transport when a patient is alert. It may include:
- Listening, without judging, if the patient wants to share
- Answering questions about what to expect at the ED and afterwards (i.e., a suicide risk assessment, psychiatric evaluation and determination of the need for inpatient or outpatient care)
- Encouraging the patient to engage with providers at the ED and accept any care referrals offered
Postvention is ongoing. During and after medical treatment, suicide attempt postvention includes:
- Information and education about suicide risk and suicide attempts
- Suggesting self-help and self-care measures to deter the onset of suicidal thoughts
- Recommending a personal safety plan that outlines what to do or who to reach out to in case suicidality recurs
- Promoting participation in a suicide attempt support group (e.g., Alternatives to Suicide)
Persons who have made a suicide attempt may find information countering stigma, addressing negative community attitudes towards suicide, and promoting hope helpful. Personal stories of recovery by attempt survivors are very useful.
Having at least minimal suicide prevention training can be helpful in postvention. More important is having a positive attitude about suicide prevention and being open-minded and unbiased toward people who die by suicide or who have engaged in suicidal behavior.
Suicide prevention in EMS
Given the incidence of suicides in the ranks, it is likely that many EMS providers know an EMT or paramedic who has survived a suicide attempt or come close to making an attempt. Promote attitudes that are supportive of attempt survivors and a work environment free of stigma towards those who have made suicide attempts.
Every EMS station needs a suicide prevention plan. It must acknowledge suicide risk as an EMS reality and give guidance on sources of help. Jokes about suicide and disrespectful references to suicidal patients should be actively discouraged. Suicide prevention education should be mandatory and required at least as often as CPR recertification.
EMS must see suicide attempts as a public health problem having lasting harmful effects on individuals, families and communities. Helping or at least relating in a positive manner to patients who survive suicide attempts falls within their scope of practice. Supporting suicidal patients may encourage EMS providers contending with suicidality to seek help.
More suicide attempt survivor resources
Following are resources for suicide attempt survivors:
- Sarah Klein, Explore Health. What suicide attempt survivors want you to know
- After an Attempt – US DHHS, Substance Abuse and Mental Health Services Administration
- How to Support Survivors of Suicide Attempts – Michigan State University Extension
- A Journey toward Health and Hope: Your Handbook for Recovery After a Suicide Attempt - US DHHS, Substance Abuse and Mental Health Services Administration
What EMS needs to know about suicide loss
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