THE SUICIDE OF A PATIENT is a tragedy for any physician. Patients with suicidal thoughts or ideation appear occasionally in physician encounters. The Joint Commission recently noted that the rate of suicide is increasing, and suicide is now the 10th-leading cause of death in the United States. (1) Most people who commit suicide received healthcare services in the year prior to death, usually for reasons other than mental health issues or suicidal thoughts. It’s a strong reminder that any patient — no matter what issue is being treated and in any setting — could be at risk for suicide.
The patient’s well-being should be the primary concern, but physicians also must consider the potential legal liability that can come from failing to adequately screen patients for suicide risk and taking the proper steps when needed. The remorse a physician may face over missing signs can be compounded by legal action claiming the physician is accountable for the patient’s demise. A consistent and formal screening process, plus a response plan, will protect both the patient and the physician.
CASE STUDY: REVIEWING PATIENT’S FULL HISTORY IS KEY
A recent case illustrates how even if the patient denies suicidal ideation when asked, the physician could be held liable for the suicide if there were other risk factors to consider. The case involved a 60-year-old woman with chronic back pain from an auto accident 10 years earlier, treated by her family practitioner over several years for pain, depression, and hypertension. Prior to her death, the woman had three appointments with the doctor over nine months for insomnia, pain medication adjustment, antidepressant medication monitoring, and blood pressure checks.
The notes from the last encounter state: “No energy; insomnia; denied suicidal thoughts; and denied feeling depressed.” Six days later, the patient overdosed on a combination of sleeping medication and anti-anxiolytics. Notes in the medical record from the next-to-last appointment said the patient “complained of insomnia; increased depression and increased anxiety; referral to psychologist.” However, she did not see the psychologist and the family practitioner’s office did not follow up. The defense experts said that the doctor should have considered the entire history instead of just the last visit and concluded the patient was at risk of suicide.
HOW TO HELP PREVENT TRAGEDIES
These are some key strategies for ensuring that a physician practice or hospital is sufficiently addressing suicide risk in patients:
• Establish a formal policy on screening and responding to suicide risk. Establish a policy that stipulates what screening will be done and how to respond to suspected risk. All employees should be trained. The policy should include front desk staff and other non-clinicians, who may pick up on signs that the patient could be suicidal.
• Implement an effective screening process. The questions typically asked on intake can be more of a formality than a true screening. Ask specific questions that can reveal situations that might put the patient at risk for depression and suicide. Examples include asking whether the patient has recently experienced the loss of a family member, a change in marital status, a change in jobs, sleeping difficulty, or loss of appetite.
• Connect with the patient. If in the screening process, the patient demonstrates suicidal tendencies or it’s suspected that the patient may be suicidal, refer the patient immediately to a mental health professional or ask the patient’s permission to contact family members or outpatient treatment providers.
• Do not be deterred by HIPAA. The patient privacy law can leave clinicians thinking that they may not discuss their concerns about suicide with the patient’s family. The patient can give permission for the physician to talk to others about his or her healthcare, and refusal to grant that permission might be considered another sign of suicidal risk.
• Establish a relationship with mental health professionals for referral. In a hospital setting, the physician should always know who is on call for patients with psychiatric risks. In other settings, the physician should establish a referral relationship with at least one or two professionals who can be called as needed. Be sure to document when and how the contact was made and any follow-up. Remember that simply advising the patient to seek help is insufficient. Contact the mental health professional directly and arrange for the patient to be seen quickly. Be sure to follow up to confirm that the patient has seen the mental health professional.
• Establish safety procedures for the patient who may be suicidal. Once this risk is established, the clinician is responsible for protecting the patient from self-harm. That means keeping the patient away from sharp objects, medications, and bed sheets. Having the patient wait in a typical exam room may not be safe because the patient would have access to scissors, scalpels, needles, and other such items. When appropriate, ask the patient to put on a hospital gown and remove from the room the patient’s shoelaces, belt, and any other items that could be used for harm.
• Monitor the patient closely. If feasible, have staff or the patient’s family monitor the patient continuously, in person or on video, until the next step of care. If continuous monitoring is not possible, check on the patient frequently. Carefully document the monitoring procedure, including frequency and type as well as observed patient behaviors.
• Call for help if needed. Call for additional help if the facility has no ability to isolate the patient from dangerous items or provide adequate monitoring, and also if the patient has already left against medical advice. State laws vary regarding how and when a patient may be held against their will.
REFERENCE: (1) Detecting and treating suicide ideation in all settings. The Joint Commission. https://www.jointcommission. org/assets/1/18/SEA_56_Suicide.pdf. Accessed November 14, 2016.
article by ROBIN DIAMOND
Robin Diamond, MSN, JD, RN, is Senior Vice President of Patient Safety and Risk Management, The Doctors Company. In addition to her legal experience, Diamond has a master’s degree in psychiatric nursing from Vanderbilt University. For more information, visit thedoctors.com/patientsafety.