TCPR: Dr. Reid, what are the most common causes of malpractice lawsuits against psychiatrists?
Dr. Reid: Far and away, the most common issue in malpractice lawsuits against psychiatrists is suicide. Matters involving suicide probably make up about 90% of all malpractice lawsuits against psychiatrists.
TCPR: What are the most common issues regarding suicide?
Dr. Reid: There are four issues that tend to come up with the most frequency:
1. A patient comes to a hospital with recognizable suicide risk, is not admitted, and within a few days kills himself.
2. A patient is admitted to a hospital, is discharged after just a few days, and then kills himself.
3. A patient is admitted to a hospital and kills himself while he’s there.
4. A patient who is seeing an outpatient doctor has recognizable suicide risk and kills himself at some point during treatment.
Among those four issues, the most common that I see has to do with patients who’ve been hospitalized and then commit suicide after discharge. However, since far more patients are seen in outpatient settings, there are many lawsuits brought against outpatient psychiatrists as well.
TCPR: How can outpatient psychiatrists decrease the chance that their patients will commit suicide, and how can they properly document their efforts?
Dr. Reid: A friend of mine who is a prominent plaintiff’s psychiatric malpractice lawyer told me something very interesting. He said, “If a family calls me and says that they want to sue a doctor because of a suicide, and I get the records and see that the records reflect adequate assessment and good documentation of that assessment, I will very often tell the family that I see no grounds for that lawsuit.” His point is that judges and juries don’t often second-guess a doctor’s good-faith judgment once he or she has gotten as much information about risk as is feasible.
TCPR: What is an adequate evaluation and how do we go about documenting that?
Dr. Reid: First, you need to document that you’ve done a good evaluation, not a 15 minute checklist, but an evaluation that shows that you covered the most important risk factors, sought collaborating information, and thought carefully about your patient’s suicide risk. Documentation is part of the standard of care, and it is your friend if a tragedy occurs. The magic words in any chart are “suicide risk assessment,” followed by a few sentences that show that you did a detailed assessment. You cannot simply say, “Patient denies suicidal ideation (SI).” Patients lie about suicidality all the time. If someone comes to your office serious about wanting to kill him- or herself, a part of that patient probably wants to keep the suicide option open, and he or she will say the right things, hide certain information, and downplay the risk to prevent you from taking that option away (eg, to avoid hospitalization).
TCPR: Specifically what are some of the things that we, particularly outpatient psychiatrists, should be documenting in our risk assessments?
Dr. Reid: Write down in some detail your good-faith efforts to assess the level of risk and your efforts to prevent suicide. For example, “Explored patient’s thoughts of death.” “Talked at length about his thoughts of killing himself.” “Discussed the fact that his mother killed herself at about his age.” “Talked about the potential consequences of suicide and patient acknowledged that it would be devastating to his family.” If you find that there is a moderate or greater risk of suicide, document that impression and document what measures you took to protect the patient. For example, “The patient is at moderate risk for suicide, but is not at high enough risk to require immediate inpatient hospitalization. I plan to meet with the patient again tomorrow” or, “I discussed my concerns with his wife who will accompany him to his visit tomorrow” or, “This patient needs the protection and detailed evaluation of an inpatient setting.”
TCPR: If we do decide to hospitalize a patient who is actually in the office, how should we approach that, logistically and in terms of documentation?
Dr. Reid: It depends on how imminent you believe the patient’s suicidal ideation is. In many cases, you will want to call the authorities to come directly to your office. Documentation options in that case would include, “Discussed hospitalization with patient and her spouse, and we’ll arrange ambulance transportation to the emergency room.” (Don’t trust high-risk patients to go to the hospital on their own, or to be taken there by family.) Or, “The patient refuses hospital referral even though I’m very concerned about suicide risk. Her mother and nurse Jones will sit with her until officers arrive to execute an emergency health hold.” (Don’t attempt to physically keep the patient in your office; that’s a job for law enforcement.)
TCPR: What do you think about having patients sign “no-suicide ‘contracts’”?
Dr. Reid: I strongly discourage them. From a suicide prevention perspective, and from a malpractice liability perspective, so-called no-suicide or no-harm “contracts” are worthless for at-risk patients. Psychiatrists and other clinicians, nurses, and institutions should not rely on them for patient safety. I’m not criticizing using them in a therapeutic context, when a clinician is working closely with a patient on an ongoing basis, but they absolutely must not be relied upon to protect a patient’s life, and they certainly should not take the place of adequate patient monitoring and physical protection.
TCPR: Which of the major suicide risks should we be most concerned with in our assessments?
Dr. Reid: I recommend that clinicians be aware of a standard list of major risk factors that they can refer to during their interviews. Having said that, it’s very important to note that some risk factors are so critical that once they are present, it should be hard for a patient to convince you that he is not at high risk. I’m speaking of factors such as very recent suicide attempts, threats made by psychotic or severely depressed patients, and dangerous behavior in very unstable, unpredictable patients (including intoxicated ones). But each patient is different, and assessment is not a “cookie-cutter” proposition.
TCPR: Are there any other major risk factors that get left off of common risk factor lists?
Dr. Reid: Patient instability is a huge one. Both doctors and patients may believe that the patient is currently at lower risk (for example, after a few days of monitoring and respite in a hospital), but one must always remember that the patient’s apparent “improvement” may not be reliable and lasting, and may not stand up to whatever environmental challenges might have precipitated the suicidal thoughts in the first place. Be sure to consider whether or not the patient’s apparent improvement is vulnerable to change or breaking down in the days to come.