The first twelve months in aged care is the highest risk time for suicide. The following case study provides poignant lessons for those who work in Residential Aged Care.
Case No: GLTCRC 2016-23
Précis author: Carmel Young RNCCM, Department of Forensic Medicine, Monash University
Mr Z was a 95-year-old male admitted to a long term facility (LTF) in June 2013.
Past medical history included hyperlipidemia, hypertension, angina, atherosclerotic heart disease, atrial fibrillation, heart failure, glaucoma, cataracts, a previous fracture of the neck of his femur, osteoporosis, and benign neoplasm of the anus.
In November 2015, he went on an outing and on his return injured his back when he twisted to get out of the car. The back pain was initially treated with ‘Panadol’ and two days later this was changed to the stronger analgesic ‘Panadeine’. As the pain was not improving, a portable X-Ray of the lumbar spine was organised and the images indicated a compression fracture of L1. In December, the analgesia was adjusted to Oxycodone 5mg three times a day and then to hydromorphine 0.5 mg three times a day along with dimenhydrinate (antiemetic) 25mg.
A few days later Mr Z developed urinary retention and required a urinary catheter. An acute hospital review followed, which confirmed the diagnosis of compression fracture at L1 and he was prescribed an increased dose of hydromorphine. He requested “pills and poison” and stated that he just wanted to die.
Around this time his daughter became concerned that her father was increasingly sedated, with nausea and decreased appetite.
As his power-of attorney, she requested the analgesia be withheld. This led to the pain returning, which became so severe he was screaming. Two days later he had a fall, sustaining a haematoma to the right side of his face. He requested “pills and poison” and stated that he just wanted to die. Staff contacted his daughter and placed him on “suicide watch” that required observations every 15 minutes. One hour later he was found dead lying on his bed with his head towards the wall.
Autopsy gave the cause of death as Plastic Bag Asphyxia. The possibility of intracranial pathology due to the fall was excluded. That inadequate management of pain often results in sleep abnormalities and may lead to depression.
The coronial investigation revealed Mr Z had no mental health diagnoses and no cognitive impairment.
The investigation found a number of gaps in the care provided. These included: his care plan was not reviewed and, it was not revised after he complained of sudden back pain or when he developed urinary retention; that the pain assessment instrument was not used; that his medical practitioner was not informed the pain medications were withheld.
Comments and Findings
The impression was that Mr Z had become depressed and lost the will to live due to the circumstances. That inadequate management of pain often results in sleep abnormalities and may lead to depression.
The Geriatric and Long Term Care Review Committee in Canada made a number of recommendations, including the following:
- Ensure treatment plans are developed and implemented in consultation with all members of the clinical team and that any changes are communicated and discussed with other team members.
- All medical, nursing and care staff should receive appropriate training and education on the principles of recognition of pain, as well as, the complications associated with poorly managed pain.
If you or anyone you know needs help these telephone support services are available to individuals: • Lifeline Australia telephone counselling at 131 114 (24 hours)
- Suicide Call Back Service on 1300 659 467 (24 hours)
- SANE Helpline – Talk to a mental health professional at 1800 187 263 (10am-10pm AEST)
- Guide to staying alive: https:// www.sane.org/mental-health-andillness/facts-and-guides/guide-tostaying-alive
- Beyond Blue on 1300 22 46 36
- Perinatal Anxiety & Depression Australia on 1300 726 306
- Kids Helpline on 1800 551 800
- MensLine Australia on 1300 789 978
- Headspace on 1800 650 890
- Resources for discussing suicide: http://www.conversationsmatter. com.au/
Did you know that you can sign up for free to receive the Communiqué? For more information and to register Click here to go to the site.
The thoughts of this blog are of the individual writer and not necessarily those of the Nurses for Nurses Network. To read our full disclaimer click here >>