Types of Patients I: Suicidal Ideation/Attempt

My friend Camus once wrote that the fundamental problem of philosophy is whether it is better to live or to die, and that all other philosophical inquiry is based upon one's answer to this question. For if it is better to die, then one should honor that decision and kill oneself. No other philosophical question need be considered.

Of course, in The Myth of Sisyphus, Camus comes down on the other side of the question: regardless of the toil of human life and its miseries and let-downs, it is better to live than die. What one must do in life is find meaning.

Questions remain: why do people attempt to kill themselves; what is the difference between those who succeed and those who don't? The facile answer to the second question is, of course, those who succeed are dead. As for those who don't, these are the one's we often see as patients in the ER.

I divide suicidal patients into two categories: those who I judge have made a serious, truly lethal attempt, and those who have not made a serious attempt. In my ER (and probably ERs nationwide), we see more of the latter than the former. The predominant method of non-serious attempt is overdose. These are patients who ingest large but often unknown quantities of (usually) legal medications, often over-the-counter medicines like cough syrup, acetaminophen, and ibuprofen, but sometimes prescription medicines like anti-depressives or narcotics.

One thing that distinguishes this patient category is that the suicidal individual does not often know what sort of damage the drugs he or she ingested will do. It is not a serious, lethal attempt because the patient hasn't done enough research to know how much to take to kill themselves. Usually the patient has taken enough to harm the liver or the kidneys, but this is damage he or she will more than likely have to deal with later in life.

The smaller category of patients who make truly lethal attempts (some of which become successes), I have found, usually use more violent means. Handguns, hanging, jumping from heights, and machinery are truly lethal mechanisms of self-injury in this patient group. From the patient who laid down on his table saw to the patient who hung himself with a bed sheet, these are the serious attempts. (Incidentally, the former failed whereas the latter succeeded.)

There is often little else that characterizes these groups. Patients are young or old; some have a history of psychological problems, some don't; some have made previous attempts, others not. In fact, the common characteristic of suicide attempts and possible success is the unpredictable nature of the event.

For both categories, however, primary nursing care includes establishing the nature and extent of the patient's self-harm; responding to the patient's injuries with curative and palliative measures; providing a safe environment in the ER; contracting with the patient for no further self-harm (at least, not in the ER); and initiating psychological interventions, whether this be making an appointment with the patient's counselor or admitting the patient to the hospital.

A friend and fellow nurse often says that in order to do ER work a nurse has to "let go of the why." Often we have no idea why our patients do what they do. Suicide attempts are an extreme example of this.

I like to remind patients that self-harm and ultimately self-destruction are long-term solutions to often short-term problems. Whether or not this is helpful to them, I'm not sure. But it probably beats recommending Camus.