Chapter 8. Deliberate self-harm, alcohol and substance abuse
Care of the unconscious patient: ABCDE282
The patient who refuses treatment287
Cocaine303
Ecstasy303
Heroin abuse305
Needle stick injuries308
Hospital-acquired methicillin-resistant Staphylococcus aureus infections309
Violent incidents309
Deliberate Self-Harm
General Principles
Principles of treatment
• Appropriate emergency management to ensure the safety of the patient
• Granting the same care, respect and privacy as any other patient
• Proper psychosocial assessment
• Identification of patients at risk from further self-harm
• Where possible, the patient should be given the choice of a male or female member of staff to assess them and provide the care
Who Commits Suicide?
There are 5000 suicides per year in England and Wales: 45% by violent methods, mainly jumping from heights, strangulation and drowning; and 35% by drug overdose, predominantly antidepressants and paracetamol. Interestingly, the rates in both sexes are falling throughout the age range. Numerous factors are said to contribute to this: higher employment rates, recent initiatives to counteract self-harm, and reduction in carbon monoxide levels in exhausts. There is still concern, however, over rates in young males, which, compared with two decades ago, are particularly high.
Who is at a particularly high risk of suicide?
It is important to be aware of the vulnerable groups, because they will be encountered on the acute medical wards as a result of self-harm or because of their high rates of poor overall physical health.
• Schizophrenia, especially in patients who are poorly compliant or lost to follow-up
• History of drug and alcohol abuse
• Any patient who says that they are feeling suicidal, especially if accompanied by feelings of hopelessness
• Patients living in social isolation with no family support
• Several previous episodes of deliberate self-harm (25% of successful suicides have tried before within the past year)
• Asingle episode of deliberate self-harm carries 1 in 20 rate of suicide within 10 years
Which Type of Patients are Admitted With Deliberate Self-Harm?
The admission rate for deliberate self-harm is 300 per 100 000 of the population per year and is increasing, particularly among males aged 15–24 years.
• The average age is 30 years
• 40% will have taken a previous overdose
• 20% will take a further overdose within a year, particularly those
— who have a history of alcohol and substance abuse
— who discharge themselves before the initial assessment has been completed
— who have had several previous episodes
• Social deprivation and social isolation are common
• Up to 10% will have a serious psychiatric disorder, commonly depression
• There is a strong link with a history of epilepsy, particularly in males
• There is often a history of early parental death or separation
• Aquarter will have been in contact with the psychiatric services
• Common triggers are major domestic arguments or a recent separation
The embarrassed and impulsive
• The spur of the moment
• Often triggered by a row and alcohol
• Not necessarily a trivial amount, often paracetamol
• Low risk of recurrence or future suicide
The serious attempt
• A planned event
• Carried out alone and in secret
• No attempt to get help
• Suicide note
• Admits to the intended outcome
• Even ‘trivial’ overdoses may represent a determined attempt at suicide
The high-risk self-harm
• Older
• Male
• Isolated
• Unemployed/retired
• Alcohol dependence
• Poor general health
• Violent method used
• Repeated attempts
• Suicide note
Why do Patients Deliberately Harm Themselves?
• To gain temporary respite – ‘I just wanted to get some sleep/escape/to get away for a while’
• As a cry for help – ‘I didn’t know what to do next/where to go/who to turn to’
• As a signal of distress – ‘Nobody listened/I just couldn’t explain what was happening to me’
• Communicating anger/eliciting guilt/influencing others
— ‘I did it on the spur of the moment in front of them all’
— ‘This will show her/him what it’s been like for me’
• To end their lives – ‘There’s no point in any of it any more’
Two high-risk patients
Case Studies 8.1 and 8.2 illustrate different types of self-harm cases.
Case Study 8.1
A 40-year-old man was admitted with an overdose of one of the newer less toxic antidepressants.
He complained of feeling generally upset and lonely, but denied significant past illnesses. He was single and lived alone, visiting his father at weekends. He presented as an outwardly cheerful, middle-class articulate man who could not really account for the overdose. Nothing else was noted in the medical or nursing notes.
On subsequent very close questioning, he admitted to previous problems with depression and recalled having ECT in his 20s after a period when he thought he was going mad. He had been treated with antipsychotics at that time.There was a history of progressive social isolation, with only occasional visits away from his bedsit to visit his father.
Case Study 8.2
A 75-year-old man with severe ischaemic heart disease, cardiac failure and persistent hypotension was admitted because of self-harm.
He had become increasingly frustrated and angry with an unexplained pain in his lower abdomen, which had been thoroughly investigated. He was feeling low and had been sleeping badly. He went into the kitchen, took the scissors, and made multiple superficial incisions across his upper abdomen to ‘relieve the blood congestion’. On admission, he was tearful and frustrated, but embarrassed to have caused so much trouble.
From Case Study 8.1 it is clear that:
• the history needed unearthing
• this patient had a long unrecognised history involving a major psychosis: probably schizophrenia
The man in Case Study 8.2 is at very high risk:
• elderly male
• violent method of self-harm
• features of depression
• failing physical health
In this age group, deliberate self-harm is commonly triggered by disability, social isolation, chronic pain and untreated depression. It is important to recognise symptoms of depression in the elderly:
• anorexia and weight loss
• constipation
• change in sleep
• pattern of mood swings, especially early morning depression
• physical and mental slowing
• suicidal ideas
Because the highest rates of suicide are seen in elderly men, it is generally routine to refer for psychiatric assessment any patient older than 65 years who is admitted with self-harm. Such an act, in the over-65s, signifies significant suicidal intent.
Nursing the Patient in Self-Harm
Acute Medical Assessment Units should have internet access to TOXBASE the UK database of the National Poisons Information Service. This provides detailed descriptions of the management of individual clinical problems.
Critical nursing tasks in deliberate self-harm
Take appropriate blood and urine tests
Assuming, after the initial assessment, that the patient does not need to be transferred to the HDU, steps should be taken to decontaminate the gut.
Decontamination of the gut
Gastric lavage. Gastric lavage is no longer indicated as routine in self-poisoning. Occasionally it is used:
• within the first hour of ingestion (particularly with iron tablets or lithium)
• if the airway is secure
• if a potentially life-threatening overdose has been taken
Activated charcoal
Single dose. A single oral dose of 50g activated charcoal enhances the elimination of several drugs and is used when anything more than a trivial amount has been taken (accepting the unreliability of the history in this group of patients). It is most effective when given within an hour of the overdose.
It is most useful in:
• paracetamol
• tricyclics
• aspirin
• theophylline
• phenytoin
• carbamazepine
• digoxin
It is of no value in poisoning with:
• iron tablets
• lithium
• methanol
• antifreeze
To avoid the risk of aspiration, the airway must be secure before charcoal is used: it may be necessary to administer MDAC via a nasogastric tube.
Repeated vomiting reduces the effectiveness of charcoal treatment, so antiemetics such as i.v. cyclizine 50mg 4-hourly or i.v. ondansetron may be indicated.
Experimental and new treatments. Recent advances in the treatment of self-poisoning include a new antidote for methanol and antifreeze poisoning: 4-methylpyrazole. Whole-bowel irrigation with polyethylene glycol is used for serious overdoses of enteric-coated drugs, iron-containing compounds or sustained-release preparations.
Important nursing tasks in deliberate self-harm
Ensure that all the relevant information is available
If the patient is unable to give a reliable history but there is a strong suspicion of self-harm:
• What is available to the patient?
— the patient’s usual medication, including insulin
— other tablets and medications at home
— illicit and recreational drugs
• Is there evidence of self-poisoning
— empty bottles, blister packs, foil wrappers
— has alcohol been involved?
• Is there a suicide note?
Other information from the patient or relatives. The key pieces of information needed in the patient’s history are listed in Box 8.1.
Box 8.1
The history must include:
• Mental state
• Past psychiatric history
• Previous self-harm
• Alcohol use
• An assessment of suicidal intent
Confidentiality. When dealing with the patient’s family, the clinical need to know the nature and timing of the overdose must be balanced against the patient’s right to confidentiality. There may be sensitive matters that the patient would not want to disclose to a third party. Common issues in this area include extramarital relationships, serious difficulties at work, unwanted pregnancy and conflict over child custody.
Relevant medical history
• Heart disease (tricyclics trigger arrhythmias)
• Liver disease (increases the risk of liver damage with paracetamol)
• Alcohol abuse (liver damage and a marker for high suicidal intent)
• Chronic disability (increases the likelihood of significant depression)
Psychosocial history
• The sequence of events that triggered the overdose
• Psychiatric history, especially of depressive illness
• Domestic situation and family support:
— marital status
— who else lives in the home
— names and ages of children and who is caring for them
— recent bereavements, anniversaries of deaths
— has the patient a social worker/community psychiatric nurse?
• Previous self-harm
• Are there any vulnerable children/possible abuse? This requires urgent attention
• Job and financial worries
• Alcohol or drug abuse
• Evidence of domestic violence – it is acceptable to ask directly about possible abuse by a partner
• Recent childbirth
• Is there still suicidal intent?
Provide a suitable and safe environment in which to recover consciousness
• Physical safety is ensured from the use of the recovery position combined with appropriate monitoring of the consciousness level and the vital signs
• It is important to maintain a calm, competent and non-judgemental approach. You are dealing with a very vulnerable group with low self-esteem, high stress levels, guilt about ‘wasting everybody’s time’ and perhaps just extreme embarrassment
• Organise appropriate communication with the mental health liaison nurse or social services, who can provide effective help
• Listen to the patient. Try and understand why the patient took the overdose at that particular time and with what intent
Case Study 8.3 illustrates the importance of reacting appropriately to the results of nursing observations:
• the combination of carbamazepine and diazepam produced a prolonged period of sedation
• the patient’s initial aggression overshadowed the later fall in the consciousness level
• the nursing observations were not acted on with sufficient urgency
• the falling GCS and the increasing respiratory rate should have alerted the doctors of the impending need for ventilation. These patients are better nursed on the HDU
Case Study 8.3
A 20-year-old man with financial problems lost his job and on an impulse, took 30 of his father’s carbamazepine tablets (a total of 12g), without any alcohol.
On arrival in AED at 01.30h, he was agitated and very aggressive and refused oral charcoal. He was given 15mg of rectal diazepam and admitted.
At 03.00h his GCS was noted to be 3/15. He remained on the medical ward.
By 04.30h he became aggressive again and was given a further dose of 10mg diazepam.
He had improved by 09.30h, but deteriorated again by 21.15h the following evening:
• oxygen saturations 80%
• low pO2 (8.0kPa)
• pulse 120 beats/min
He was given high-flow oxygen and observed.
By 05.00h, his GCS had fallen to 7/15. Oxygen saturations were 86% on high-flow oxygen. His respiratory rate was 20 breaths/min.
Over the next 3h, his GCS dropped to 6/15. His respiratory rate increased to 50 breaths/min and his pulse to 120 beats/min. He was deemed unable to protect his airway and transferred to ITU for ventilation. X-ray showed aspiration pneumonia.
After 4 days on a ventilator he made a full recovery.
Case Study 8.4 shows that assessment has to be performed with care, if necessary by conforming to a checklist of high-risk factors. However, a checklist cannot replace sympathetic listening. Furthermore, simply asking if the patient ‘feels suicidal’ is often enough to identify risk. When time is at a premium, there are two key questions that are known to be an accurate prediction of genuine depression:
Case Study 8.4
A 49-year-old woman was admitted to hospital with a significant overdose of amitriptyline. She had left a suicide note to her son and had only been found at home by luck. She made a good recovery and did not appear depressed on the ward. However, on further questioning she admitted that, 2 weeks before admission, she had taken 30 nitrazepam tablets but had not told anyone about it and her husband had not been aware of her depression.
She was considered at high suicidal risk and admitted as an informal patient for further psychiatric assessment.
During the past month, have you often been bothered by:
1. Feeling down/depressed or hopeless?
2. Having little interest or pleasure in doing things?
The Patient Who Refuses Treatment
This is one of the most difficult areas of clinical practice, even for the most experienced medical and nursing staff. There are a number of common scenarios:
• a patient is admitted from casualty, but refuses to stay on the ward
• a recovering patient refuses to wait to see a psychiatrist
• a patient absconds from the ward
• a patient is intoxicated and abusive and refuses to cooperate
• a patient is cooperative, but will not see a psychiatrist
• a patient refuses specific medical treatment for the overdose
• a patient with acute alcohol withdrawal discharges himself
In all such cases, a balance must be struck between the duty of care that we owe to our patients, and a respect for their autonomy, which is based on their competence at the time to make a decision.
Within the decision-making process, there are two components to this competency:
• understanding and retaining the details of proposed treatment – its benefits, its risks and the consequences of turning it down
• having the ability to weigh up the alternatives in coming to a decision
It is important to understand that it is the ability of the patient to participate in the decision-making process, and not the quality of the decision, that is important. A competent patient can refuse treatment even if the decision seems irrational or abnormal or lacking common sense and perhaps may even result in his death.
An assessment of competency (or ‘capacity’, as it is termed legally) will, in difficult cases, require the expertise of senior medical staff, although it is clear that in most acute situations the combination of emotional distress and the effects of drugs or alcohol makes it fairly obvious when a patient is not competent to make such important decisions. The patient’s capacity must be carefully documented in the records.
If the patient is not competent to make a decision about treatment and the treatment would ‘save life and limb’ (e.g. i.v. N-acetylcysteine [Parvolex®] in severe paracetamol poisoning), then such measures can be given against the patient’s wishes under what is termed, in England and Wales, Common Law.
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