What support should hospitals give staff when a patient commits suicide?
This is a sample essay in my Bioethics class. It is hoped that philosophy students, particularly Bioethics students, may find this sample essay helpful in formulating their own.
Suicide has been identified as one of the major and serious health problems globally (World Health Organization [WHO], 2017). In fact, in the US, suicide claimed about 44,000 lives in 2015, and was the second leading cause of death among people with ages 15 to 34 (Leading Causes of Death, 2016), while in the UK, the suicide death toll increased from 6,122 to 6,188 deaths between 2014 and 2015 (Office for National Statistics, 2016).
Although there are a number of factors that increase peoples’ predisposition to suicidal ideation and vulnerability to complete a suicide, a significant link between suicide and mental health disorders has long been established (Harris & Barraclough, 1997). In recognizing this link, the World Health Organization (WHO) gives emphasis on suicide prevention by making it an integral component in the Mental Health Gap Action Programme (mhGAP) that was launched in 2008. The program aims at reducing the global rate of suicide deaths among mental health patients by 10% by 2020 (WHO, 2014).
In this connection, mental health professionals perceive suicide as a hazard in their field of practice (Dransart et al., 2015). It is crucial to understand that death in suicide is a tragic and devastating experience, not only to the significant others, such as the families and friends, but also to the health professionals (Collins, 2003). Thus, the central argument of the essay revolves around the idea that mental health professionals need a holistic support from the organization, inasmuch as death in suicide of a patient brings abysmal distress and pain.
The essay begins with a brief introduction on the meaning, nature, and risk factors of suicide. It then proceeds with a discussion on the different effects of suicide death on mental health professionals, such as hospital staff. In order to understand these effects, the major ethical principles in healthcare are discussed briefly. Finally, the essay concludes with a set of action plans that hospitals and organizations are expected to implement to provide emotional support to and protect the welfare of their staff.
What is suicide and why do people commit this moral act?
The renowned philosopher Tom L. Beauchamp (as cited in Harris, 2009) defined suicide as an act of intentionally killing oneself without being coerced. In relative parlance, the WHO and the Centers for Diseases and Prevention understand suicide as the act of taking away one’s own life without being influenced by other people or by certain situations. There are several important reasons behind people’s suicidal behaviour. The WHO (2014) identified five main categories of risks factors, which increase people’s vulnerability to commit suicide, namely, the health system, societal views, community conditions, interpersonal relationships, and individual conditions. First of all, the health system becomes a risk factor when people experience difficulties in accessing and receiving appropriate health care services. This situation is compounded by societal views, such as the stigma and taboo associated with the suicide phenomenon.
A more striking risk factor that we can observe in the contemporary society is the inappropriate use of social media. A concrete example to this is the very recent Netflix series, ‘13 Reasons Why’, which tells the story of a young woman who committed suicide. One of its episodes portrays in detail the actual act of suicide. The International Association for Suicide Prevention (IASP), through its President, Ella Arensman, expressed concern about the negative effects of the series to the vulnerable young audiences. A briefing was released in May 2017 citing five crucial violations on media reporting, which specifically focused on the detailed documentation or portrayal of the actual suicide process. Moreover, the Association pointed out that the series might lead young people to perceive suicide as an easy escape in difficult situations or in times of depression (Arensman, Niederkrotenthaler & Reidenberg, 2017).
Another risk factor of suicide includes certain conditions in the community, such as disaster or war that brings traumatic experiences to people. We may also add the stress that goes along with the process of acculturation, especially among indigenous people and other minority groups.
Negative feelings or effects associated with interpersonal relationships have also contributed to the commission of suicide. This includes feelings of isolation, lack of support from families and friends, and the painful effect of a relationship break-up. Joiner, Van Orden, Witte and Rudd (2009) explain that some people in a relationship commit suicide not only because they are physically abused but also because they no longer feel a sense of belongingness or they feel as a burden to their significant others. The last category of risk factors that influence suicidal acts includes genetic and biological factors, such as familial history of suicidal ideations, previous suicidal attempts, harmful use of prohibited drugs and alcohol, job loss, financial struggles, feelings of hopelessness, chronic conditions and pain, and mental disorders (WHO, 2014).
Relationship between mental disorders and suicide
Although there are several risks factors that act cumulatively in increasing people’s tendency to commit suicide, the essay intends to focus only on the relationship between mental health disorders and suicide.
It is a common belief that most suicide attempts are committed by people who are not mentally stable. In fact, a study conducted in 2003 shows that an estimated 90 percent of those who commit suicide in high-income countries has one or more diagnosable mental health conditions, such as severe depression, bipolar disorder, border-line personality disorder, and schizophrenia (Mental Health Reporting, 2017; WHO, 2014). Severe depression brought about by difficult life situations, such as being diagnosed of terminal illness or death of a loved one, can lead people to have very low mood or loss of interest in many things. It could also make them feel tired, desperate, and hopeless. As a result, people who suffered severe depression are prone to entertain suicidal thoughts (WHO, 2014).
Additionally, bipolar disorder is another risk factor. People with bipolar disorder experience very erratic mood swings any time of the day. Thus, during moments of either feeling very high, hyperactive, and happy, or feeling very low, inactive, and depressed, they are prone to suicidal ideation. According to the Mental Health Reporting (2017), based on annual estimates worldwide, people who are diagnosed with bipolar disorder are 20 times more likely to have suicidal attempts, and 3-20 percent of them die by suicide, while about 6-15 percent of people with schizophrenia die due to suicide. As is well-known, these mental disorder linger for so long and as the condition progresses, the mental state deteriorates causing changes in the patients’ behaviour. These conditions may also cause hallucinations and delusions, which highly trigger suicidal thoughts.
Mental health professionals as suicide survivors
Now that the meaning and nature of suicide, and the risk factors contributing to people’s vulnerability to commit suicide have been thoroughly discussed, this section intends to explore the impacts of suicide death on health professionals as suicide survivors.
Suicide survivors generally refer to individuals who are affected with feelings of pain and profound loss as a result of death in suicide (Farberow, 2015). Traditionally, suicide survivors refer to the victim’s significant others, such as the family members, relatives, loved ones, and close friends. Hence, according to Plakun and Tillman (2005), the topic on suicide survivors in healthcare is replete with researches and literatures that focus on the impact of death in suicide on these individuals, as well as the kind of support that needs to be extended to them.
However, the healthcare team of professionals directly involved in the care of the suicide victim has to be recognized as suicide survivor as well (Farberow, 2005). This is precisely because of the likelihood that these professionals encounter patient suicide, increasing their risk to experience the feeling of loss and bereavement in the same way as the primary significant others. In connection to this reasoning, Robert Simon (as cited in Plakun & Tillman, 2005) categorized mental health professionals into two: (1) those who experienced their patients committing completed suicide, and (2) those who are yet to experience it. This simply means that all mental health professionals are very likely to encounter patients committing suicide, at least once in the entire span of their career. Now, it can be inferred that the likelihood of encountering patient death in suicide predisposes these professionals to emotional stress. As Farberow (2005) argued, the concept of death of a patient unconsciously triggers intense emotions on health professionals, regardless of their competence in the field of practice, or prior experience of patient death due to suicide.
In what follows, the intense negative emotions felt by the healthcare professionals in facing the death of patient in suicide are described, regardless of the healthcare setting in which the patient is being cared for, may it be in the office, hospital, or community. First off, health care professionals express that death by suicide has a long-term emotional effect (Darden & Rutter, 2011). In fact, 38 percent of psychiatrists whose patients’ mental health condition resulted in completed suicide, experience ‘severe distress’ (Plakun & Tillman, 2016). This has led healthcare professionals to doubt their skills and competence, experience low self-esteem, and impaired interpersonal relationships with colleagues and other patients under care (Farberow, 2005; Plakun & Tillman, 2005).
Moreover, in a qualitative study on the experiences of nurses of inpatient suicides in general hospital, overarching themes on emotional reactions were identified (Matandela & Matlakala, 2016). Primarily, severe emotional reactions were observed, which include profound feelings of grief, sadness, stress, emotional trauma, and depression. Then, feelings of disbelief and helplessness were verbalized. The nurses were in utter disbelief when they found out that the facility’s units served as a medium for the patient to complete a suicide. For example, one nurse described her disbelief of the horrible scenario of a patient jumping out of the window on the third floor. After the incident, she experienced visual hallucinations of the crushed body of the patient. The feelings of disbelief are often accompanied by feelings of helplessness as the nurses deem the facility’s failure to ensure strict implementation on safety standards. In addition, the nurses expressed feelings of blame and condemnation from the victim’s family members and significant others. Consequently, this may lead to another stressful feeling of guilt and inadequacy. Oftentimes, nurses feel guilty that they failed to identify the patient’s suicidal behaviour, and have not prevented the death. Lastly, nurses, as with all other members of the healthcare team (Plakun & Tillman, 2005), experience the fear of losing their jobs should their employer decide to remove them from service, or as an outcome of medical malpractice lawsuit.
Now, in order to better understand the effects of suicide on mental health professionals as discussed in the previous section, it is important to dig into the ethical and moral principles that govern the practice of medical professionals.
The Ethics of Care
The ethics of care is rooted in the concept that care is essential for human relationships to thrive. As Beauchamp and Walters (1999) argued, people deeply value certain personal traits, such as compassion, sympathy, friendship, love, and the likes, which nurture interpersonal relationships. Moreover, Dr. Jean Watson (as quoted in Lachman, 2012) who developed the theory of care in nursing believed that nurses must establish a ‘deep connection to the spirit within the self and to the spirit within the patient’. So, in connection to the issue on suicide, the centrality of ‘care’ in the healthcare delivery system is primarily the reason that healthcare professionals feel abysmal pain and distress when a patient under their care dies, especially when the death is caused by circumstances that could have been prevented, such as suicide.
Duty of Confidentiality
Confidentiality entails upholding the ‘sanctity of information’ that the patient imparts to physicians, nurses, and other members of the healthcare team (Barrett, 1997). The importance of this principle has long been stressed in the patient-healthcare professional relationship. In fact, the Health Insurance Portability and Accountability Act (HIPAA) is strictly imposed in the US. This act prohibits the disclosure of protected health information (PHI) to individuals who do not have authority to obtain those (Health Information Policy, 2017). In the UK, there is also the Data Protection Act mandating ‘all those handling personal information to do so fairly and lawfully’ (Gray, 2010). Moreover, in 2003, the Department of Health issued a Code of Practice on Confidentiality to strengthen the law and encompass the healthcare sector in the UK (NHS Code of Practice, 2003). As we can see in the example that follows, mental health professionals are often confronted with an ethical dilemma in the issue of suicide in the light of the strict principle of confidentiality. For example, a patient diagnosed with severe depression confides his/her suicidal thoughts to the nurse, but demands that such information should be kept confidential for whatever reason. The nurse should be able to decide reasonably whether to uphold or breach the principle of confidentiality. If the nurse decides not to share information to the team due to the principle of confidentiality, and the patient actually commits suicide, the patient’s death would definitely result in feelings of guilt and depression.
Respect to Patient Autonomy
Beauchamp and Walters (1999) define autonomy as ‘freedom from external constraints and the presence of critical mental capacities, such as understanding, intending, and voluntary decision-making capacity’. This definition may seem inapplicable to the mental health sector as most patients are mentally unstable. However, it is important to note that the goal of mental health professionals is to bring back the normal functions of the patient. Thus, healthcare professionals have to balance the care in a manner that both consider dependent actions (those that require assistance to improve health, such as the use of medication), and independent actions (those that the patient can freely do without much need of assistance, such as mobilization). Allowing the patient to carry out independent actions implies a respect to autonomy. However, this can possibly lead to suicide death. For instance, to improve the patient’s physical health, the nurse allows the patient to do walking. Unfortunately, the patient jumps out of the window and dies. This situation brings feelings of blame, condemnation, and fear of lawsuit.
Responding to the impact of suicide
With all the foregoing discussion on the negative emotional reactions that stem from the death in suicide of a patient, it is crucial to understand that the experience is indeed devastating and traumatic for healthcare professionals. This is because healthcare professionals are not just emotionally attached to their patients but also because they are easily affected by the condition of the environment that they are in. Human beings as they are, they cannot be indifferent to what is happening around them. Thus, when patients die, it is natural for healthcare professionals to experience some kind of a feeling of loss, not to mention the feeling of guilt that goes along with the failure to perform their duty well.
For this reason, it is essential that hospitals and other healthcare institutions extend support to mental health professionals. Laying out action plans to support and protect hospital staff in the event of death in suicide minimizes the hazardous effect of suicide. Since the issue on suicide has been a priority by the WHO, it is likely that hospitals and other organizations are currently putting in place support systems such as risk management program, critical incident stress management (e.g., staff debriefing), and employee assistance programs.
Working closely with the organization’s risk management officer, legal counsel, and malpractice carrier is one of the wise actions that a hospital administrator could take to protect the healthcare team’s legal rights, as well as to address the concerns associated with public humiliation, litigation, or loss of employment. This gives the healthcare team the confidence that the case will be taken care off without prejudice or blaming. For instance, by assigning a legal counsel, healthcare professionals who are directly involved in the care of suicide victim will have an opportunity to speak truthfully about the experience. Although there is always the possibility of lawsuits, the expression of empathy and clear and honest communication reduce the risk of litigation (Ballard et al., 2010). Moreover, implementing a critical incident stress management (CISM) or staff debriefing greatly help hospital staff in recovering from trauma.
What follows is an example of a CISM, adopted from the Ontario Centre of Excellence (2013), which categorizes the chain of emotional reactions into three phases, and appropriate activities to support the staff are provided. The first phase is called the immediate aftermath (the first week after the suicide). During this phase, the feelings of disbelief and helplessness are evident; thus, the goal of debriefing is to make the health care professionals understand that despite extending reasonable and good care to the patient, at times it is really unavoidable that the suicidal behaviours cannot be identified (Powell et al., 2000). Actions that can be taken during this phase includes conducting staff meeting that promotes an open-line communication to provide facts, express disturbing feelings, and reinforce feeling of safety. Informal peer support network shall also be started. Moreover, involvement in bereavement rituals such as attending funeral, if possible, can be done at this phase to facilitate emotional healing and closure.
The end of the first week marks the second phase, which is characterized by overwhelming and mixed feelings of turmoil, anger, blame, guilt, self-doubt, and the like. These emotions are destructive, which can cause the staff to feel exhausted or demoralized, and eventually lead to high absenteeism. Actions plans during this phase are targeted at finding meaning and managing staff’s affect through informal peer support group discussions, and even involving the help of a therapist. Finally, the third phase (between the second to sixth months) aims at restoring personal and professional integrity, and relationships. As the intensity of negative feelings decreases within this phase, it is an appropriate timing for the administration to conduct suicide autopsy to understand what really happened, and then identify areas of improvement. It is imperative that such meetings be conducted to learn more about the suicide as basis for improvement and not for the purpose of throwing blames.
While it is noteworthy that some hospitals and institutions are currently implementing staff support systems, many mental health professionals expressed sentiments that they have not received ample support from their peers and supervisors, or even from the hospital administrators (DeAngelis, 2001). According to reports, some staff are hesitant to reach out to support groups and employee assistance programs due to confidentiality and job security issues (Ontario Centre of Excellence, 2013). Thus, it can be suggested that studies must be conducted that aim at assessing the availability of support programs, as well as evaluating the effectiveness of these programs in managing the hazardous effect of patient suicide to healthcare professionals.
This essay began with a discussion on the meaning, nature, and risk factors of suicide and then proceeds with a discussion on the different effects of suicide death on mental health professionals Finally, the essay has presented with a set of action plans that hospitals and organizations are expected to implement to provide emotional support to and protect the welfare of their staff.
Suicide is indeed an occupational hazard in the healthcare sector as it negatively impacts the wellbeing of the healthcare professionals and threatens their dignity. Thus, it is imperative that hospitals and other healthcare institutions put in place certain policies, systems, and programs that aim at holistically supporting healthcare staff in the event of patient suicide. This may include, but are not limited to, risk management program, critical incident stress management (e.g., staff debriefing), and employee assistance programs. However, it is not enough that programs or policies are in place. Effective implementation, which is free of early reassurance, blaming, or prejudice is paramount.
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For students who are new to philosophy, this article may help: http://philonotes.com/index.php/2017/12/16/what-is-philosophy/.