"Make Sure My Daughter Gets My Truck": Suicide Risk on a Surgical Unit
You are the RN caring for a 62-year-old man on postoperative day 3 after a right below-knee amputation for a diabetic foot infection. He has type 2 diabetes, a 40-year history of alcohol use, and chronic pain managed with oxycodone and gabapentin. At 14:00 he is lying with his back to the door, has refused physical therapy for two days, and says, "What's the point? I'm just a one-legged burden now. My wife would be better off." Yesterday he gave his watch to his roommate and asked a nurse to "make sure my daughter gets my truck." He denies a specific plan but says, "I've thought about it." He lives with his wife; his daughter visits daily. Vital signs are stable and the incision is clean and dry.
1. Which findings raise your concern, and which single finding most increases his acute risk?
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Warning signs present:
- Hopelessness and burden language ("What's the point," "better off")
- Withdrawal and anhedonia - two days of refusing physical therapy
- Passive/ambiguous suicidal statement - "I've thought about it"
- Preparatory behavior - giving away a possession and asking for help with distributing his truck
Highest-risk finding: the giving away of belongings combined with the request about the truck. Giving away possessions is preparatory behavior - it indicates the person has moved from thinking to putting affairs in order, which is a stronger predictor of imminent risk than a vague statement of ideation.
Amplifying risk factors: male, older adult, new major loss of function, chronic pain on opioids, 40-year history of alcohol use (access, impulsivity, and a disinhibiting factor), and possible concurrent depression.
Protective factors: involved wife and a daughter who visits daily - but protective factors do not lower the observation level by themselves.
The judgment point: "denies a specific plan" is not reassurance. Preparatory behavior and access to means are what drive the next 24 hours.
2. What will you say and do in the next 30 minutes?
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Ask directly, without euphemism:
- "Are you thinking about killing yourself?"
- "Do you have a plan? Have you thought about how you would do it?"
- "Do you have a gun at home, or medications you've saved?"
- "What has kept you going so far?"
Asking does not plant the idea - it is the assessment.
Do:
- Stay with him - do not leave him alone; call for help rather than leaving the room.
- Initiate 1:1 observation and remove means from the immediate environment per policy (sharps, cords, belts); ask the wife to secure firearms at home before discharge.
- Notify the provider for a psychiatric consult, social work, and a safety-observation order.
- Document verbatim quotes, the questions you asked, his answers, and the actions taken.
- Obtain collateral from the wife with his permission.
Avoid: "You have so much to live for," "Think about your daughter," "That's just the medication talking," or false reassurance. These shut down disclosure.
Do not attribute this to the amputation alone - screen for depression and ask about alcohol withdrawal, which can worsen mood and impulsivity in the first postoperative week.
3. Two nurses disagree about whether he needs 1:1 observation or every-15-minute checks. What determines the answer, and what do you do?
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The level is determined by assessed acute risk plus hospital policy and a provider order - not by who is more senior or by what the unit typically does.
- His profile - preparatory behavior, hopelessness, burden statements, a major loss, chronic pain, and a substance-use history - supports 1:1 continuous observation, which is the more protective level.
- When in doubt, choose the higher level of safety and escalate; the RN can initiate safety measures under standing policy while obtaining the order.
- Notify the provider and the nursing supervisor, request the 1:1 order, and document the rationale for the higher level.
- Do not let staffing pressure drive the decision; if a 1:1 assignment is required, the charge nurse reassigns resources.
Document the disagreement, the risk assessment, who was notified, and the order obtained. The question to answer in the chart is not "what did the other nurse think" but "what did the patient's presentation require, and what did we do about it."