TCPR: If you can’t predict suicide, what can you do?
Dr. Reid: One thing is sure: Unpredictability doesn’t mean we don’t have to take responsibility for assessing and managing suicide risk. The heart attack analogy is one that juries frequently can identify with. If I have chest pain, the cardiologist cannot predict whether or not I’m going to have a heart attack. However, the standard of care requires that my cardiologist assess me and not let me leave the hospital or clinic until he or she reasonably believes it’s safe for me to leave. If there are things the cardiologist, hospital, or clinic reasonably can do to decrease my risk of a heart attack, they should show that those things have been done. And when I leave the emergency room, they should make sure that I know that I can call them any time, that I can come back in a few days if my symptoms return, etc. That’s how a jury thinks about these things. Analogously, you may not be able to predict whether or not a patient is going to commit suicide, but you can show that you’ve done all that is reasonably within your power to assess that risk and manage serious risk.
TCPR: You’ve talked a lot about the negative risk factors, but there are also potentially protective factors, such as a patient having children or a supportive home. Should we document those as well?
Dr. Reid: Document them, sure, but unfortunately, those so-called “positive” factors, such as having a supportive family or having a good job, are pretty much worthless when it comes to calculating serious suicide risk. One or two major risk factors, such as severe depression, overwhelm so-called “positive” factors very quickly. Positive factors may be statistically significant when you’re studying large groups of people, but people who are truly in danger of dying by their own hand usually don’t care that they have three children, or that they have a job, or that they have a religion that frowns upon suicide. It’s as if they have blinders on: the pain is so great, and the anguish is so all-consuming that they just don’t pay much attention to anything else. When you talk to people who came close to death by suicide, they routinely tell you something such as, “I don’t know what came over me, I wasn’t even thinking of the effect on my kids.” On the other hand, being aware of “positive factors” can be very helpful when you’re doing suicide counseling with people at lower risk. Saying things such as, “Do you really want to give your family pain for the next two generations,” (which is often how long a family’s response to suicide lasts), can be quite helpful in a counseling context.
TCPR: One of the most difficult dilemmas for any outpatient psychiatrist is whether or not to commit a patient against his or her will when you think there may be a substantial risk of suicide. These are really the patients that keep us up at night. Can you help us think that issue through?
Dr. Reid: First, let me say that the psychiatrists who stay up at night worrying are the ones who are least likely to be sued. They are caring about their patients and working hard to do the right thing. I want them to document their caring. In terms of committing patients, I’m not suggesting that psychiatrists hospitalize—voluntarily or involuntarily—every person who talks about hurting himself. On the other hand, every psychiatrist needs to have access to some kind of protective resource, such as an emergency room or a psychiatric hospital. Once you come to a conclusion that there is a higher than moderate risk, you need to talk about hospitalization. If you choose not to hospitalize, you need to document why you came to that decision.
TCPR: In practical terms, sometimes we will bring up the issue of hospitalization and patients may be very reluctant to be hospitalized. We may believe that there is some degree of risk but it is always a judgment call, and we may choose not to hospitalize in order to maintain the therapeutic alliance.
Dr. Reid: It’s reasonably seen as a judgment call only if the assessment has been adequate and the clinician is trying to do the right thing. It can be a difficult decision. But there are several bad reasons that we sometimes use to decide not to admit patients that you should keep in mind. For example, if the patient doesn’t want to go into a hospital—he thinks he’ll lose his job, or do damage to a relationship, or that he can’t afford it—that’s not a good reason to take a chance on his survival. Think about the potential heart attack analogy: Once you make the decision that a person needs around-the-clock protection, don’t be swayed by these kinds of arguments. Another potential pitfall is relying on the family to do the job of a hospital. A family might say, “We’ll keep an eye on him, doctor,” or you might feel tempted to ask the family to do that. But that’s just not reasonable when the risk is high, and that decision is unlikely to assuage your guilt or hold up in court if a tragedy happens. There are two reasons that families can’t take the place of hospitals. First, hospitals have trained staff to monitor and treat patients. Second, in a hospital, a patient can be monitored 24-7, but at home, as vigilant as families might be, they are not going to be following patients everywhere they go (such as to the bathroom). Asking them to take over a hospital’s and nursing staff’s role is unfair, and it doesn’t work to protect the patient adequately.
TCPR: You said several times that we need to assess whether the patient is at moderate or greater risk of suicide. Is there an agreed-upon definition of what constitutes more than moderate risk?
Dr. Reid: There really are no agreed-upon definitions. There are various checklists of risk factors that provide a numerical “score” representing moderate or high risk. Being aware of such checklists, or the factors on them, is helpful, provided they are used as a “jumping off place” for a complete, personalized assessment. What I really want to see in my reviews for lawyers and malpractice carriers is some narrative in the chart that indicates personal assessment and judgment on the part of the doctor.
TCPR: Are there any particular examples of poor documentation that you frequently see that you would recommend that we avoid?
Dr. Reid: Sure. One of the worst is a simple “No S/I” without even a few sentences indicating that suicide risk was adequately explored. Such brief shorthand implies—whether it’s true or not—that the clinician didn’t spend much time and the assessment may have been superficial. I also hate the phrase “suicide gesture.” If somebody took six Valium, or superficially cut herself, it is tempting to say that was not a serious event, but just a “gesture.” That’s dangerous. If that happened to your wife or husband, or son or daughter, you would take it very seriously; doctors should as well. In fact, so-called “gestures” often escalate to serious attempts without adequate psychiatric or psychological attention. Another phrase that I don’t like to see downplayed in risk assessments is “cry for help.” If a particular patient’s version of a cry for help is to open up a vein, that should be taken very seriously.
Let me say that the psychiatrists who stay up at night worrying are the ones who are least likely to be sued. . . I want them to document their caring.
~ William H. Reid, MD, PhD
TCPR: I think we all know that talking to family members is good practice in psychiatry, particularly in situations where there is a possibility of suicide. However, in this age of HIPAA privacy regulations it sometimes gets confusing as to who we can and cannot talk to. Do you have any words of wisdom about that?
Dr. Reid: Stop worrying about HIPAA or confidentiality when a patient’s life might be in danger and you’re acting in good faith. Talking with relatives who know the patient well, if they can be reached, is often crucial. Juries understand that all bets on confidentiality are off when you’re trying to figure out whether or not a patient’s life is in danger. Lawsuits related to suicide are common, but the number of lawsuits related to breaches of confidentiality in situations such as this is so low that I’ve seen only one in over 40 years of clinical work and forensic consultations, and that one was dismissed by the judge. Which do you want to worry about, the patient’s life or whether or not he’ll sue you for talking to his wife?
TCPR: Thank you, Dr. Reid.