The reactions to suicidal or homicidal thoughts in homecare depend on the level of threat
Upon hire and annually, direct care staff of At Home Nursing Care are trained as mandated reporters about threats to oneself or others, abuse, neglect or safety concerns. Suicidal or homicidal thoughts in homecare are important topics to cover.
As an agency that works with clients who have dementia, depression, psychosis or difficult family or health situations, we have numerous experiences with suicidal thoughts, and more limited experience with homicidal thoughts, usually verbal threats directed at family members during especially stressful transition periods.
Statistics show that older adults make up 12% of the US population, but account for 18% of all suicide deaths. Men over age 75 are particularly at risk.
The Cleveland Clinic describes suicidal ideation or thoughts as “thoughts or ideas centered around death or suicide. Experiencing suicidal ideation doesn’t mean you’re going to kill yourself, but it can be a warning sign. Treatment is available.”
Wikipedia describes homicidal ideation as “a common medical term for thoughts about homicide. There is a range of homicidal thoughts which span from vague ideas of revenge to detailed and fully formulated plans without the act itself. Most people who have homicidal ideation do not commit homicide.”
Most homecare and home health agencies train caregivers and nurses that any imminent danger or threat is a 911 call and report to the supervisor. In California, the situation must also be reported to Adult Protective Services (APS). This is the 1st way to react to suicidal or homicidal thoughts in homecare, especially if the threats are specific and the client is acting violent or incoherent.
For a more nuanced situation, such as a client making general troubling comments, the caregivers are trained to alert the nursing supervisor or manager, who will assess the situation, discuss an APS report and relay concerns to the client’s family, physician, care manager or other involved party. This is the 2nd way to react to suicidal or homicidal thoughts in homecare.
When people are in pain or depressed at losing independence due to age, mental or physical health-related factors, it’s not uncommon for them to make statements such as “I’d be better off dead,” or “Why won’t God just take me?” We advise our direct care staff to have empathy when hearing those words. One of the best statements a person can make when others are suffering is to simply say, “I hear you and I want to help.” Or, “You are not alone in how you feel, let’s talk to someone about it.”
Caregivers are not clinicians nor therapists, they don’t diagnose, prescribe medications or give medical advice. That’s why we ask that they report these comments to a nursing supervisor or case manager so that a full range of professional support can be considered and provided. A home health agency might provide a medical social worker to assess the client and make recommendations. The client’s physician may contemplate changing or adding medications such as anti-depressants or anti-anxiety drugs. The RN supervisor might suggest a support group.
Each client’s situation in homecare is different, and each client deserves an individualized plan of care to meet their changing needs, strengths and wants. Our agency has a skilled nurse visit the client every 60 days who will inquire about their state of mind or any feelings of pain, depression or sadness. Some clients who need extra support may elect to also add some care management.
In hospice, someone who is mentally competent may express interest in California’s End of Life Option Act (EOLA). This allows terminally ill adults to request and self-administer aid-in-dying drugs. This is different than suicidal or homicidal thoughts and should be relayed to the hospice nurse and physician.
Our experience working with hundreds of clients since 2010 has also taught us something about firearms in the home. Those experiences led to our own policy on firearms for clients who have dementia or psychosis, including the disarming or removal of those firearms. A question about firearms is now part of our initial homecare assessment.
In conclusion, the 2 ways to react to suicidal or homicidal thoughts in homecare depend on whether the threat is imminent or whether the situation is more complex, but not likely to produce violence. In each case, the client should be treated with dignity, respect and empathy. And in each case, the caregiver or nurse should feel supported by supervisors and management.
