Suicide Risk

A positive suicide screen is not a diagnosis and does not, by itself, establish imminent danger. It is a signal that the RN must move from screening to a fuller, structured assessment. An adult presenting with suicidal ideation or suicidal behaviour should be assessed with a standardized instrument approved by the organization. The Columbia-Suicide Severity Rating Scale (C-SSRS) is one example. PHQ-9 item 9 can identify the need for further assessment, but a positive response should not be treated as a disposition decision. Other tools, including SAD PERSONS where adopted by local policy, must be used according to their intended purpose. The nurse’s language affects the quality of the information obtained. Ask plainly: “Are you having thoughts of killing yourself?” or “Are you thinking about ending your life?” Direct questions do not create suicidal thoughts. They make it safer for a person to disclose thoughts that may already be present. Avoid leading questions such as, “You’re not thinking of suicide, are you?” because they invite denial rather than assessment. Suicidal ideation exists on a spectrum. A passive wish not to...