Challenges Associated With Managing Suicide Risk in Long-Term Care Facilities : Page 2 of 2

June 17, 2013

Few data exist about how to best conduct a suicide risk assessment with LTC residents; however, one assessment tool, the P4 screener, has recently been shown to be useful in assessing potential suicide risk in medically ill patients with depression.40 The P4 screener consists of four questions that should be asked after a resident expresses suicidal ideation. The questions assess past suicide attempts, plans for suicide attempts, probability of completing suicide, and preventive factors. The screener assists clinicians in determining a person’s level of suicide risk (minimal, low, or high) based on the way individuals respond to these four questions. Some evidence suggests that death ideation is normal at the end of life; however, other research indicates that expressing thoughts of death may be a risk factor for suicide.25 Given the fact that we do not yet have a strong evidence base distinguishing normative death ideation from death ideation associated with suicide risk, we recommend conducting the P4 screener whenever a resident expresses thoughts of death or suicidal ideation. Staff should also consider administering measures of depressive symptoms, such as the PHQ-9,3 and a measure of self-reported suicidal ideation, such as the Geriatric Suicide Ideation Scale (GSIS).41 The GSIS is a 66-item multidimensional tool that assesses degree of suicide ideation, death ideation, loss of personal and social worth, and perceived meaning of life.

Once a resident’s level of suicide risk (minimal, low, or high) has been determined, LTC staff need to take action to manage the resident’s risk. The actions taken should be dictated by the resident’s level of risk. The Figure serves as an example of a decision tree that might be used by LTC facility staff to manage different levels of suicide risk. Staff can also use the SAMHSA toolkit, which specifies how facilities might develop plans based on residents’ level of risk.4 

decision tree; suicide risk

Our decision tree emphasizes thorough documentation. This is an important aspect of its use, as appropriate documentation increases the likelihood of preventing death by suicide at LTC facilities by improving communication between staff members. Our decision tree also assumes that LTC facilities have access to either psychological or psychiatric consultation; however, we acknowledge that many facilities do not have such resources available. We believe that, in the case of managing the care of residents at risk of suicide, it is essential that facilities have the capability to consult with a mental healthcare professional. Given its importance, when psychological or psychiatric consultation is not available, facilities might consider contracting with a mental healthcare professional for the sole purpose of securing specialized mental healthcare for residents at low or minimal risk of suicide. The SAMHSA toolkit includes more information about how to develop relationships with mental healthcare professionals.4 Alternatively, such facilities might consider designating certain staff members (eg, social workers and nursing staff) who are willing to seek additional training on how to effectively assess and manage individuals with suicidal ideation.

In addition, the decision tree includes an emergency care plan meeting for all residents at risk of suicide. Several issues should be discussed at this care plan meeting. First, any mental health issues of the resident should be addressed. Effectively treating depressive symptoms, in particular, often results in marked reductions in risk of death by suicide.38 The SAMHSA toolkit provides detailed information on addressing the mental health needs of LTC residents.4 In some cases, it may be feasible to enlist family members to bring residents to mental healthcare specialists outside of the LTC facility. A safety plan should also be developed during this care plan meeting. If this plan includes close observation for an extended period of time, we recommend that a point in time be set for the reevaluation of the resident’s risk of suicide using instruments such as the P4 screener,40 the PHQ-9,3 and the GSIS.41 It is important that close observation not ensue indefinitely; unfortunately, however, there is not enough research examining the use of close observation for LTC residents at risk for suicide to explicitly recommend how it should be used and when it should stop. We recommend that staff at individual facilities consult with local mental healthcare professionals to develop explicit plans about when close observation should be utilized and the criteria that will be used to determine when close observation of an at-risk resident is no longer necessary. Finally, for some residents at both minimal and low risk, it may be necessary to spend some time determining the function (ie, purpose) of the suicidal ideation. For example, while all expressions of suicidal ideation indicate that residents are in some kind of distress, in some cases the behavior may be serving additional functions. For example, it is possible that a resident might express suicidal ideation out of extreme frustration or anger with staff. If after thorough analysis the staff believes this to be the case, we recommend spending time identifying the intended purposes of the behavior so that they can be addressed appropriately in a positive, structured behavior plan. For example, staff could, in some cases, offer the resident more adaptive ways to get his or her needs met. Staff might also actively work to meet the needs of residents in other ways, such as engaging the resident in one-on-one activities and involving family members to help meet the interpersonal needs of the resident.


The effective management of suicide risk in residents of LTC facilities is complicated; however, it is imperative that every LTC facility and nursing home have an effective protocol in place for managing suicide risk, especially with the advent of the MDS 3.0 and the potential suicide risks that the new MDS questions may reveal. Implementing a standardized protocol will not only reduce anxiety among staff members, but also improve the overall quality of LTC residents’ care and reduce the morbidity and mortality from suicide.


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Disclosures: The authors report no relevant financial relationships.

Acknowledgments: Dr. O¹Riley received grant support from a National Institute of Mental Health T32 National Research Service Award training grant (2T32MH020061-11; PI: Conwell) during the preparation of this manuscript. All of the authors would also like to acknowledge the nursing and social work staff at Hopemont Hospital in Terra Alta, WV, for their input on the decision tree presented here.

Address correspondence to: Alisa O’Riley, PhD, University of Rochester School of Medicine and Dentistry, Box Psych, 300 Crittenden Blvd, Rochester, NY 14642;