PRMS | Psychca

10 THINGS ABOUT: SUICIDE

From Professional Risk Management Services (PRMS)

An impression shared by many psychiatrists is that to avoid liability related to patients with suicidal behaviors, they must be able to predict whether a particular patient will attempt suicide and prevent all suicide attempts however unforeseeable. Fortunately, courts recognize that psychiatrists are only human and do not expect impossible powers of prediction.
If a patient reports a history of suicide attempts or ideation, make certain that you obtain past treatment records if possible. If you are unable to obtain records, document your efforts to do so. Plaintiff attorneys often cite a psychiatrist’s failure to obtain past treatment records in post-suicide lawsuits.
A formal suicide risk assessment tool should be utilized for consistency and thoroughness. Two excellent tools are the Columbia Suicide Severity Rating Scale and SAFE-T (Suicide Assessment Five Step Evaluation and Triage).
Address the need for a safe environment for patients with suicidal behaviors. The accessibility of firearms or other weapons should be assessed and an appropriate plan for safety should be instituted, including getting information from and instructing family/significant others about this issue.
Make certain that your records reflect what treatment options/actions were considered, what options/actions were chosen and why, and what options/actions were rejected and why. In the event of litigation, it is important to your defense that your record reflects your clinical judgment and choices, the knowledge and skill you exercised during treatment, a contemporaneous assessment of the patient's needs and behaviors, revisions to the treatment plan, and explanations of your decisions.
Reassess suicide potential whenever there is an incidence of suicidal or self-destructive ideation or behavior; when significant clinical changes occur; when any modification in supervision or observation level is ordered; and at the time of discharge or transfer from one level of care to another.
Never agree to treat a suicidal patient in a split treatment relationship if you are uncomfortable working with the other treater. When managing a suicidal patient, it is imperative that psychiatrist and therapist are able to work as a team. In the best case scenario, split-treatment can enhance care and patient safety as it allows for closer patient monitoring using the separate expertise of two skilled clinicians; however, when clinicians do not work well together, both patient and clinicians are put at risk.
Remember, patient safety always trumps confidentiality. Accordingly, even without patient consent, consider alerting family members and significant others to the risk of outpatient suicide when: the risk is significant, the family members do not seem to be aware of the risk, and the family might contribute to the patient’s safety. Likewise, a psychiatrist should never ignore offers of information from family members or close friends that might be relevant to a patient’s safety. It is not a HIPAA violation to listen. You do not want to be in a courtroom listening to a plaintiff attorney argue that a patient’s suicide could have been prevented had you only bothered to return a call.
Do not rely solely on “no-harm” contracts as a guarantee of patient safety. These “contracts” have no legal force and cannot take the place of an adequate suicide risk assessment. It may be appropriate for a “no-harm” contract to be one part of a comprehensive treatment plan but it is the clinician’s responsibility to evaluate the patient’s overall suicide risk and ability to participate in the overall treatment plan.
As a psychiatrist, you are expected to know the standards and procedures for civil commitment in your state. When contemplating commitment, document that you have considered this option and the clinical basis for rejecting or proceeding with it. Even if you think it is unlikely that police will take your patient to the hospital, if you believe that he/she is at eminent risk of suicide, you should still make the effort of calling 911. Make certain that you document your efforts including what information was given to the police.

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