A Patient Contemplates Suicide: Protect the Patient and Yourself

Carolyn Buppert, MSN, JD

Disclosures

January 08, 2019

To submit a legal/professional healthcare question for future consideration, write to the editor at lstokowski@medscape.net (include "Ask the Expert" in subject line).

Question

Suicide has become a global health epidemic. Many healthcare providers are unclear about their role in suicide prevention. So the question is, what is the standard of care for clinicians in office practice and hospitals?

When someone dies by suicide, his or her family may blame the patient's clinician or hospital for not identifying or preventing the problem. A lawsuit for malpractice may follow. Claims have included failure to diagnose risk for suicide and failure to provide sufficient treatment, monitoring, safety, or follow-up.

Response from Carolyn Buppert, MSN, JD
Healthcare attorney

 

Three Suicides

These three real cases illustrate the potential consequences of failure of healthcare clinicians to assess for suicide and take steps to prevent this tragic outcome.

Failure to Screen and Treat

A middle-aged man having thoughts of suicide sought help at a local hospital. After being admitted, he was tapered off a long-term benzodiazepine he had been taking, and discharged to the care of a psychiatric nurse practitioner (NP). She saw him once, and instructed him to return in 3 months. Nine days later, he killed himself.

The man's family sued, alleging that that the NP failed to properly diagnose, treat, and monitor him and did not get him into an intensive outpatient program. A jury awarded his family $12 million, holding the hospital 65% responsible and the NP 35% responsible.[1]

Failure to Monitor and Follow Up

A man in his 50s was a long-time patient of a primary care provider (PCP), who had prescribed paroxetine. The physician had neither seen nor examined the man in about 10 years, during which time the patient's prescriptions were routinely renewed. After a telephone call during which the patient reported an anxiety attack, the physician prescribed olanzapine and doubled the dose of paroxetine. Soon after the telephone order, the man went to a hospital, thinking he was having a heart attack. Myocardial infarction was ruled out, and the paroxetine dose was lowered.

After the hospital visit, the primary care physician saw the patient for the first time in 10 years. According to the patient's family, the physician, furious that the patient had gone to the hospital and "exposed his treatment," dismissed the patient from his office, without action or planned follow-up.

A few days later, the patient presented at another hospital and a physician there changed his medication regimen, but did not arrange for follow-up. The patient's symptoms got worse, and shortly thereafter he killed himself. The state licensing board held that the primary care physician was negligent for refilling the prescription without evaluating the patient for 10 years. His license was put on probation. A jury awarded the patient's family a total of $1.5 million for the physician's malpractice.[2]

Failure to Protect

A 16-year-old boy was admitted to a children's hospital for treatment of depression and suicidal ideation. He was placed on high suicide precautions. The precautions included orders that staff members keep the teen in sight at all times except when he was using the bathroom. When he was in the bathroom, staff were to communicate with him every 30 seconds.

The boy was allowed to use the bathroom at 9:55 PM. At 10:15 PM, he was found, having hung himself with his scrub pants. He had a permanent brain injury. His father sued the hospital for negligence. Both the trial and appellate courts held that the hospital had a duty to protect him.[3]

The Standard of Care for Preventing Suicide

Given the dire consequences of suicide and the likelihood of a lawsuit, clinicians should be clear about what is expected of them. Practices and facilities should have policies and protocols directing clinicians regarding when and how to screen for suicidal thoughts, and when and how to treat and follow up those who screen positive. Policies should reflect the current standard of care—that is, what experts would testify should have been done, if there is a bad outcome and a case is filed.

If sued, hospitals and practices will want to defend by showing that they have researched the current thoughts on risk assessment and subsequent activities and have directed clinicians and other staff, through policies and training. If healthcare providers follow the steps that a reasonably prudent clinician would follow under similar circumstances—the "standard of care"—then clinicians may save a life. If a patient does die by suicide, despite best efforts to prevent it, and the family sues, the clinician, hospital, or practice will have a solid defense.

This article summarizes the current recommendations for screening for and dealing with suicide risk for three settings: primary care office, emergency department, and hospital.

Standards for Primary Care

What is the standard of care for screening for suicide in primary care? The US Preventive Health Services Task Force has held that data are insufficient to support a recommendation that PCPs screen their general population for suicide risk.[4] However, in 2016 the Task Force said that PCPs should screen all patients for depression.[5]

In February 2016, the Joint Commission recommended that primary, emergency, and behavioral health clinicians look for suicidal ideation in all patients in both acute and nonacute healthcare settings.[6] The Joint Commission advised the following:

  • Review each patient's personal and family history for suicide risk factors;

  • Screen all patients for suicide risk factors using a brief, standardized, evidence-based screening tool; and

  • Review screening questionnaires before the patient leaves the appointment or is discharged.

The Suicide Prevention Resource Center (SPRC), an organization supported in part by the Substance Abuse and Mental Health Services Administration but not officially endorsed by the government agency, says, "In a zero suicide organization, all patients are screened for suicide risk on their first contact with the organization and at every subsequent contact. All staff members use the same tool and procedures to ensure that clients at suicide risk are identified."[7]

So, if a lawsuit is filed, experts are likely to testify that the standard of care, as of the end of 2018, is to screen the general patient population for depression. There is some support for screening the general population for suicide risk. This puts the PCP in this position: If a patient was not screened for suicide risk, the patient died by suicide, and the family sued, experts might disagree on whether the current standard of care requires screening everyone for suicide risk. However, experts probably would agree that all PCPs should be screening all patients for depression. Therefore, the PCP should screen all patients for depression, and should consider screening all patients for suicide risk.

Research suggests that several brief screening tools are reliable at identifying patients at risk for depression and suicide. These tools include:

Screening should be repeated periodically, depending on the circumstances; there is no generally accepted schedule for repeat screening.

If a patient screens positive, these additional actions are called for:

  • Obtain past medical records and gather information from family or friends.

  • Take action to improve the safety of suicidal individuals through "safety planning." Safety planning might involve speaking with family members and/or friends, preferably with the patient's consent. If the clinician believes the patient is an imminent danger to himself, the patient's consent to speak with family or other close associates is not needed.[8] Safety planning often includes removal of lethal means in the home.

  • Make follow-up contact with the at-risk person in the next 48 hours.

  • Engage the individual in writing up an agreement that states goals of treatment, such as reducing stressors; developing coping strategies; and developing multiple sources of support, which may include group therapy. Communication, referral, and treatment should be commensurate with the severity of symptoms and risk for future harm.

  • Refer the individual to a mental health specialist.

  • Have an alternative provider accessible to the individual if and when the primary clinician is unavailable.

  • Have the means to admit the person to inpatient care, if necessary.

  • Provide the number for the National Suicide Prevention Hotline (1-800-273- TALK [8255]).

Documentation should include the results of assessments, plans for safety, decisions made, communications with family and other providers, and referrals made. Documentation of follow-up visits or contacts should address improvement on the PHQ-9 score or other screening tool.

Standards for Emergency Departments

Malpractice cases against emergency departments (EDs) have focused on the failure to provide a safe place. Specific incidents involved patients who used ECG machine cords or a patient gown to hang themselves or overdosed while in the ED on medication hidden among the patient's personal belongings.

In "Managing Suicidal Patients in the Emergency Department," Betz and Boudreaux[9] provide an evaluation algorithm, recommend the use of the SAFE-T tool if a mental health consultation is not obtained, and discuss decision support on whether a patient needs admission.

The Emergency Nurses Association (ENA) clinical practice guideline "Suicide Risk Assessment" identifies five useful tools for the initial assessment:

For information on these tools, review the ENA's Clinical Practice Guideline: Suicide Risk Assessment The ENA guideline also offers tools to use to evaluate lethality for discharge.

Guidance for EDs is also found in the SPRC report "Caring for Adult Patients with Suicide Risk: A Consensus-Based Guide for Emergency Departments." SPRC also offers a training course, "Preventing Suicide in ED Patients", for healthcare professionals.

The SPRC report indicates that patients who screen positive for depression and suicidal thoughts should be offered a mental health evaluation at that visit. These patients should not be allowed to leave the ED until the evaluation is complete, and should be protected from self-harm while in the ED.

Protection means placing the patient in a private room without access to potentially dangerous objects (belts, shoelaces, sharp medical instruments, cords, weapons, or pills in the patient's belongings). Before using mechanical or chemical restraints, try to verbally calm agitated patients. That may be accomplished by having extra staff step out and by engaging in collaborative, respectful conversation.

Therefore, EDs should have written policies to guide clinicians in the care of suicidal patients. Policies should include how to assess for suicide risk; what to do if a patient screens positive; how to protect the patient's safety while in the ED; and criteria for observation, the use of restraints, personal searches, and admission or discharge. A tool can be used in deciding whether a mental health consultation is warranted. The Annals of Emergency Medicine article[9] includes a tool for deciding whether a mental health consultation is warranted.

Before discharge from the ED, the patient must be assessed as being safe to leave. More information on making the decision can be found in the SPRC guide, Caring for Adult Patients With Suicide Risk: A Consensus Guide for Emergency Departments.

Documentation should include assessment findings, safety precautions taken, communications, decisions and plans made, the rationale for decisions and plans, and patient responses to the decision and plans.

Standards for Hospitals

Cases against hospitals include those involving patients who jumped out of a window; were not monitored according to orders; were not staffed one-to-one when so ordered; drank cleaning supplies; or used bell cords, bandages, sheets, restraint belts, plastic bags, elastic tubing, or oxygen tubing to hang themselves in their hospital rooms. One patient removed a lighter from the pocket of her jeans and ignited the curtains.

Screening tools commonly cited for use in hospital include the PSS-3, C-SSRS, and ASQ. The Joint Commission's 2016 Sentinel Event Alert, "Detecting and Treating Suicide Ideation in all Settings," included the following recommendations:

  • Keep patients in acute suicidal crisis in a safe healthcare environment under one-to-one observation. If in a locked unit, obtain a psychiatric evaluation to determine whether the patient is sufficiently free from impulsive inclinations before allowing the patient out of a locked unit.

  • Follow physician orders regarding observation.

  • Do not leave these patients by themselves.

  • Check these patients and their visitors for items that could be used to make a suicide attempt or harm others.

  • Keep these patients away from anchor points for hanging and material that can be used for self-injury.

A 2018 Agency for Healthcare Research and Quality analysis states that hospitals should focus on mitigating the risk for hanging.[13] This means removing the patient's clothing and having them dress in a hospital gown—not just a regular gown, but one of special design or color. The color of gown can be used to identify the patient as high risk for suicide, serving as visible notice to staff that the patient is under suicide precautions and cannot be allowed to leave.

Documentation by inpatient clinicians should include assessment results and, if the assessment was positive, that reasonable next steps were taken to ensure the patient's safety while admitted. Documentation on discharge should include an assessment that the patient was evaluated by a qualified provider and deemed safe to go home. The patient should be set up with follow-up appointments and numbers to call if suicidal feelings recur.

A hospital policy on suicide prevention should include direction to staff about screening tools, protocols for one-to-one observation, and environmental rounds. Environmental precautions include removal of anchor points in rooms where patients at risk for suicide are placed. For guidance on conducting environmental rounds, visit the Joint Commission report Suicide Prevention in Health Care Settings.

Some states now mandate suicide-related training for clinicians. A summary of state requirements is found at State Laws: Training for Health Professionals in Suicide Assessment, Treatment, and Management. Hospital policies should include provisions for training new hires as well as refreshers for long-term staff.

The organization Zero Suicide advises that hospital policies specify not only when to physically check on a patient but also when to complete a full reassessment.

In a study[14] of suicide events at mental health units of Veterans Administration hospitals, the following root causes were identified:

  • Poor communication of patient risk;

  • Problems with observation protocols;

  • Need for more standardized assessment and treatment protocols; and

  • Need for staff training.

Organizations may want to review Intermountain Healthcare's Process Model, which guides clinicians in the choice of suicide risk screening tool, treatment, referral, and follow-up. It also provides direction on patient safety plans and guidance on admission and discharge.

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