Suicide risk in LTC: Effective protocols may not be what you think

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Eleanor Feldman Barbera, Ph.D.
Eleanor Feldman Barbera, Ph.D.

According to researchers, 11% to 43% of LTC residents have thoughts of suicide1-3, with higher rates in larger facilities and in those with more staff turnover4. Other stressors include medical illness, the presence of a mood disorder such as depression, social isolation, and recent life stressors5 – factors that frequently affect our residents.

The MDS 3.0 requires that facilities ask residents questions regarding their risk of suicide. If a risk is identified, then effective protocols should be employed. In a June 2013 Annals of Long-Term Care review article, Challenges Associated with Managing Suicide Risk in Long-Term Care Facilities6, authors O'Riley, Nadorff, Conwell, and Edelstein offer alternatives to the procedures frequently in place in LTC settings – close observation or transfer to a psychiatric facility. These methods are often used unnecessarily, the authors note, due to staff fear of legal liability, concerns regarding their perceived competence in handling suicide risk, and the personal fear of losing a resident to suicide.

Essential for immediate risk

The authors argue that while close observation and hospitalization are essential when residents have the means, intent, and ability to end their lives at any moment (high risk situation), they're ineffective in situations where there is a minimal or low risk of imminent death by suicide. For example, a resident may express thoughts of suicide but have no access to a means to do so or no ability to make use of an available means, making suicide very unlikely or virtually impossible. Other times a resident may have thoughts of suicide but no plans to do it any time soon. “If things get worse down the road,” they'll sometimes say, “then I'm going to end it all.”

Ineffective for minimal risk

While a low or minimal risk should still be taken seriously, there is no evidence that it's effective to put a resident on 15-minute checks or to send him or her to the psychiatric hospital. In fact, residents may find close observation makes them feel “uncomfortable, frustrated, and ashamed.” Unnecessary psychiatric hospitalizations can create a stigma for residents in their communities and be disruptive to care. For the facility, it can be a financial challenge to provide extra staff for close observation or to have an empty bed while the resident is away. Additionally, once a resident is put on observation, it can be difficult to determine when it's safe to discontinue the measure. Clearly, alternatives to these typical protocols are needed in low and minimal risk situations.

How do you know when the risk is minimal?

O'Riley et al recommend asking the four questions in the P4 Screener which assess the person's past history, plan, probability, and preventive factors in order to determine whether the risk is high, low, or minimal. Additional tools are the PQH-9 or the Geriatric Suicidal Ideation Scale (GSIS). Once the risk level is determined, staff can use the very helpful flow chart in the research article to guide their planning. 

High-risk protocol

If an individual is found to be at high risk of suicide, one-to-one supervision is necessary until they can be transferred to a safer environment.

Low-risk protocol

If a resident is at low risk of suicide, the authors suggest, among other things, providing one-to-one supervision and removing any potentially dangerous items until an emergency care plan meeting can be arranged. 

Minimal-risk protocol

A resident expressing suicidal ideation but with a minimal risk of imminent danger should be referred to a mental health professional. If it's difficult to consult with a mental health professional, facilities might consider training select staff to assess and handle residents with suicidal ideation.

In all situations, it's critical to document appropriately in order to improve communication between staff members and reduce risk of suicide. 

Facilities looking to revamp their suicide risk policies will find the O'Riley et al review article and its flow chart essential reading.


1.Haight B K. Suicide risk in frail elderly people relocated to nursing homes. Geriatr Nurs.1995;16(3):104-107.
2. Malfent D, Wondrak T, Kapusta ND, Sonneck G. Suicidal ideation and its correlates among elderly in residential care homes. Int J Geriatr Psychiatry. 2009;25(8):843-849.
3. Ron P. Depression, hopelessness, and suicidal ideation among the elderly: a comparison between men and women living in nursing homes and in the community. J Gerontol Soc Work. 2004;43(2-3):97-116.
4. Osgood NJ. Environmental factors in suicide in long-term care facilities. Suicide Life Threat Behav. 1992;22(1):98-106.
5. Conwell Y, Van Orden K, Caine ED. Suicide in older adults. Psychiatr Clin North Am. 2011;34(2):451-468.

6. O'Riley A, Nadorff MR, Conwell Y, Edelstein B. Challenges associated with managing suicide risk in long-term care facilities. Annals of Long-Term Care. 2013;21(6):28-34.


Eleanor Feldman Barbera, PhD, the author of The Savvy Resident's Guide, is an accomplished speaker and consultant with over 16 years of experience as a psychologist in long-term care. A long-time contributor to McKnight's publications, this blog complements her award-winning website, MyBetterNursingHome.com, which has more on how to create long-term care where EVERYBODY thrives.