Suicidal attempt patient. Am I at fault?

[twospadz]

Please no troll comments

Saw a younger patient in the psych ER. Male with no previous psych hx or admissions. Not on psych meds. Got in a fight with family and destroyed the house. Patient denied everything and implied everything was fine. Said the dispute was over money with his parents. Talked with family who said he’s been psychotic for a year. Pt denied SI. Scored low on Safe T assessment. No hx of SI attempts. Family said he made vague SI comments 1 month ago. Admitted pt but on Q15 watch. Evaluated by psych dr in AM on the inpatient unit. Everything fine. The following day pt attempted to choke himself with cloth in the AM. Rapid response was called. Pt is alive. How liable am I in this situation?

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[robellis]

you are not liable at all, why would you be? You admitted the patient it’s not your fault that he tried to choke himself..

 

[twospadz]

you are not liable at all, why would you be? You admitted the patient it’s not your fault that he tried to choke himself..

Because it could argued that I didn’t put him on watch. Despite the attempt happening two days later and me admitting him.

 

[Celexa]

Because it could argued that I didn’t put him on watch. Despite the attempt happening twice days later and me admitting him.

I also am confused why you would think you would be liable once the patient was evaluated by the inpatient doctor. Who also did not necessarily do anything wrong depending on what their eval was--patients sometimes do things on our units and we can only prevent so much. you can't 1:1 everyone.

 

[Old&InTheWay]

You are not responsible for anything your patients do; they are individuals with agency who are responsible for their own behaviors/choices. You are responsible for conducing a thorough risk assessment, and it sounds like you did this (do you agree/could you have done anything differently in your eval?) We cannot and will never be able to predict all suicide attempts. Legally speaking, it also sounds like the patient suffered no harm, so there would be nothing to sue for.

 

[Stagg737]

You are not responsible for anything your patients do; they are individuals with agency who are responsible for their own behaviors/choices. You are responsible for conducing a thorough risk assessment, and it sounds like you did this (do you agree/could you have done anything differently in your eval?) We cannot and will never be able to predict all suicide attempts. Legally speaking, it also sounds like the patient suffered no harm, so there would be nothing to sue for.

Partially agree, though if we deem a patient to lack capacity we are technically responsible for ensuring their safety. Additionally, alive patient and no harm are two very different things, so the potential of a lawsuit could exist.

That being said, I do agree with the point that OP should not be held liable here given that a) it sounds like a thorough risk assessment with collateral was not suggestive of a patient needing CO. B) the patient attempted 2 days after OP admitted him and was seen (likely twice) by another physician who also did not feel CO was necessary. It sounds like standard of care was met, which would be where the lawsuit would fall flat (if there was some form of harm).

 

[calvnandhobbs68]

Partially agree, though if we deem a patient to lack capacity we are technically responsible for ensuring their safety. Additionally, alive patient and no harm are two very different things, so the potential of a lawsuit could exist.

That being said, I do agree with the point that OP should not be held liable here given that a) it sounds like a thorough risk assessment with collateral was not suggestive of a patient needing CO. B) the patient attempted 2 days after OP admitted him and was seen (likely twice) by another physician who also did not feel CO was necessary. It sounds like standard of care was met, which would be where the lawsuit would fall flat (if there was some form of harm).

Yes but there’s no clear standard of care for putting someone on 1:1 vs q15 min checks inpatient. The whole “high” vs “medium” vs “low” risk on the CSSRS is all handwavy bull**** anyway that doesnt predict anything. There’s clear case law that supports this as well...people have killed themselves on inpatient units and the psychiatrist was held not liable since minimum standards of care were met.

In short OP, even if the patient tried to do something on the inpatient unit that night, it’s highly unlikely there would be any sort of successful lawsuit as long as you had a reasonable note and risk assessment.

 

[Old&InTheWay]

Partially agree, though if we deem a patient to lack capacity we are technically responsible for ensuring their safety. Additionally, alive patient and no harm are two very different things, so the potential of a lawsuit could exist.

Agree that we have a duty to do our best to keep people in our care safe. My point was more that we do not have to take personal or professional responsibility for others' actions.

And you are right, I would want to know exactly how alive the patient is.

 

[whopper]

No matter if you are in the right or the wrong, it's very human to undergo tremendous self-doubt and flagellation. It's going to be a DABGR situation.

 

[Stagg737]

Yes but there’s no clear standard of care for putting someone on 1:1 vs q15 min checks inpatient. The whole “high” vs “medium” vs “low” risk on the CSSRS is all handwavy bull**** anyway that doesnt predict anything. There’s clear case law that supports this as well...people have killed themselves on inpatient units and the psychiatrist was held not liable since minimum standards of care were met.

In short OP, even if the patient tried to do something on the inpatient unit that night, it’s highly unlikely there would be any sort of successful lawsuit as long as you had a reasonable note and risk assessment.

My point was just that OP seemed to have done their due diligence in meeting standard of care and shouldn't be held liable. Do you have links to the case law? Would be interested in reading it if I'm able to.

 

[calvnandhobbs68]

My point was just that OP seemed to have done their due diligence in meeting standard of care and shouldn't be held liable. Do you have links to the case law? Would be interested in reading it if I'm able to.

So I don’t have the specific cases because this article doesn’t cite the specific cases...maybe if I looked harder I’d find the cases they’re referencing (but I’m sure it’d take forever...)

https://www.mdedge.com/psychiatry/article/59845/depression/liability-patient-suicide?sso=true

 

[Mass Effect]

Please no troll comments

Saw a younger patient in the psych ER. Male with no previous psych hx or admissions. Not on psych meds. Got in a fight with family and destroyed the house. Patient denied everything and implied everything was fine. Said the dispute was over money with his parents. Talked with family who said he’s been psychotic for a year. Pt denied SI. Scored low on Safe T assessment. No hx of SI attempts. Family said he made vague SI comments 1 month ago. Admitted pt but on Q15 watch. Evaluated by psych dr in AM on the inpatient unit. Everything fine. The following day pt attempted to choke himself with cloth in the AM. Rapid response was called. Pt is alive. How liable am I in this situation?

What you did is you saved his life by admitting him. Someone else may have discharged him or failed to get collateral (believe it or not, that happens) and he goes home and attempts to kill himself (or actually does it). You did nothing wrong. You made a risk assessment, spoke to family, and despite the patient telling you everything was fine, your gut told you something different and you admitted him. And (this is the important part), you were right. You did the right thing here. The inpatient doc didn't put him on CO either, so give yourself a break on that one.

 

[J ROD]

There is no pill for free will. Do the best you can.

 

[Old&InTheWay]

What you did is you saved his life by admitting him. Someone else may have discharged him or failed to get collateral (believe it or not, that happens) and he goes home and attempts to kill himself (or actually does it). You did nothing wrong. You made a risk assessment, spoke to family, and despite the patient telling you everything was fine, your gut told you something different and you admitted him. And (this is the important part), you were right. You did the right thing here. The inpatient doc didn't put him on CO either, so give yourself a break on that one.

Perhaps, but it's hard to say with the info we have. The seriousness of the attempt is unclear: ie trying to "choke yourself with a cloth" could range from a secretive hanging attempt with bed sheets, to someone manually choking themselves with a hand towel in front of a nurse. Obviously we don't have a complete history, but it wouldn't shock me with a few more details if this patient had more of a BPD picture and hospitalization may ultimately be counter productive. Perhaps the hospitalization itself provoked the suicide attempt and is doing more harm than good.

We can never really know whether we made the right decision, only whether we made the decision in the right way with the information that was available to us.

 

[Mass Effect]

Perhaps, but it's hard to say with the info we have. The seriousness of the attempt is unclear: ie trying to "choke yourself with a cloth" could range from a secretive hanging attempt with bed sheets, to someone manually choking themselves with a hand towel in front of a nurse. Obviously we don't have a complete history, but it wouldn't shock me with a few more details if this patient had more of a BPD picture and hospitalization may ultimately be counter productive. Perhaps the hospitalization itself provoked the suicide attempt and is doing more harm than good.

We can never really know whether we made the right decision, only whether we made the decision in the right way with the information that was available to us.

I disagree. Hospitalization is not always counter-productive in BPD. The point of hospitalization in most patients is for safety. If a BPD is spiraling out of control and making suicidal threats/gestures and something happens, a point can easily be made that you'd be negligent in not hospitalizing for immediate safety. Don't forget that BPD's do actually commit suicide. It's not like it's for show. So I fail to see how, evem if this patient is a BPD, this would mean the OP didn't do the right thing.

I also disagree that the OP could in any way be responsible for a case of the hospitalization provoking the suicide attempt. That's an illogical way of thinking for me. If someone is unstable enough that they'd attempt suicide - regardless of hospitalization - they should be hospitalized and if they then attempt suicide inpatient, it's just more evidence to me that hospitalization was warranted.

 

[d2305]

It sounds like a suicide gesture to me.

 

[Old&InTheWay]

I disagree. Hospitalization is not always counter-productive in BPD. The point of hospitalization in most patients is for safety. If a BPD is spiraling out of control and making suicidal threats/gestures and something happens, a point can easily be made that you'd be negligent in not hospitalizing for immediate safety. Don't forget that BPD's do actually commit suicide. It's not like it's for show. So I fail to see how, evem if this patient is a BPD, this would mean the OP didn't do the right thing.

I also disagree that the OP could in any way be responsible for a case of the hospitalization provoking the suicide attempt. That's an illogical way of thinking for me. If someone is unstable enough that they'd attempt suicide - regardless of hospitalization - they should be hospitalized and if they then attempt suicide inpatient, it's just more evidence to me that hospitalization was warranted.

I didn't say that hospitalization is "always counter productive" but rather that it "may be counter productive" which is not really disputable.

I also didn't say the OP was responsible for the attempt. In fact, I was arguing that the OP was NOT responsible for outcome, but rather for the decision-making process. I was pointing out that there is no way to know whether the decision to hospitalize the patient saved his life (as you implied) or whether it had some other effect (e.g. my hypotheticals above). I also didn't claim the OP "didn't to the right thing," rather, I pointed out that the "right thing" in this instance is HOW the decision whether to hospitalize is made, rather than the decision itself.

Logically, you cannot both claim that the OP saved the patient's life while denying that IF the hospitalization provoked the suicide attempt, the OP would not be responsible. If we want to take credit for outcomes, we would have to take credit regardless of whether the outcome is positive or negative. But I would argue that the OP would not be responsible for the outcome in either case.

Also, as an aside, post facto justification of a decision to hospitalize based upon behavior while in the hospital is circular reasoning. If I stab a peaceful patient in the arm with an injection of haldol, then they turn and punch me in the face, does that justify my decision to give the haldol?

 

[Mass Effect]

I didn't say that hospitalization is "always counter productive" but rather that it "may be counter productive" which is not really disputable.

I also didn't say the OP was responsible for the attempt. In fact, I was arguing that the OP was NOT responsible for outcome, but rather for the decision-making process. I was pointing out that there is no way to know whether the decision to hospitalize the patient saved his life (as you implied) or whether it had some other effect (e.g. my hypotheticals above). I also didn't claim the OP "didn't to the right thing," rather, I pointed out that the "right thing" in this instance is HOW the decision whether to hospitalize is made, rather than the decision itself.

Logically, you cannot both claim that the OP saved the patient's life while denying that IF the hospitalization provoked the suicide attempt, the OP would not be responsible. If we want to take credit for outcomes, we would have to take credit regardless of whether the outcome is positive or negative. But I would argue that the OP would not be responsible for the outcome in either case.

Also, as an aside, post facto justification of a decision to hospitalize based upon behavior while in the hospital is circular reasoning. If I stab a peaceful patient in the arm with an injection of haldol, then they turn and punch me in the face, does that justify my decision to give the haldol?

You stated: "but it wouldn't shock me with a few more details if this patient had more of a BPD picture and hospitalization may ultimately be counter productive. Perhaps the hospitalization itself provoked the suicide attempt and is doing more harm than good."

And I'm saying that even if the patient is a BPD patient, given the collateral information, I think the OP made the right choice and that based on what we do know, hospitalization seemed an appropriate choice. Do we know everything? No, of course not. But based on the information we have, hospitalization was appropriate and the suicide attempt/gesture on the unit reaffirms my opinion for this thread.

You also said: "Logically, you cannot both claim that the OP saved the patient's life while denying that IF the hospitalization provoked the suicide attempt, the OP would not be responsible"

Of course you can. If the patient is at risk of suicide and you hospitalize and a subsequent attempt is aborted, how can you not argue that being in a hospital likely saved their life regardless of whether or not it was the hospitalization that triggered it? What you're neglecting is that the patient was at risk of suicide in the first place, hence the hospitalization. If the patient wasn't at risk of suicide, he likely wouldn't have been hospitalized (unless severe impairment was detected).

Also, as an aside, post facto justification of a decision to hospitalize based upon behavior while in the hospital is circular reasoning. If I stab a peaceful patient in the arm with an injection of haldol, then they turn and punch me in the face, does that justify my decision to give the haldol?

Except that the OP is looking for opinions on whether the right assessment/decision was made and having information about the hospitalization informs our opinions on his assessment.

 

[Merovinge]

Also, as an aside, post facto justification of a decision to hospitalize based upon behavior while in the hospital is circular reasoning. If I stab a peaceful patient in the arm with an injection of haldol, then they turn and punch me in the face, does that justify my decision to give the haldol?

This is a more interesting point than you are letting on and is certainly not circular reasoning. I can reasonably ascertain that most individuals even given an injection against their will would not punch someone in the face and thus if this is their reaction, it does point towards a certainly pathology. Now certainly no one is ever sitting peacefully and given an IM for absolutely no reason, some nurse or physician had to initiate that and malevolence is maybe the reason 0.0001% of the time. Certainly for someone intoxicated/psychotic it can feel like it came out of the blue but again this reaction is meaningful then.

 

[nexus73]

This hypothetical that IF the patient is borderline, that somehow psychiatric admission caused the suicide attempt and the psychiatrist was negligent for admitting them, seems like such an irrational stretch. This scenario has way too many unpredictable and unknowable variables I don't see how any honest assessment could confidently say the decision of admission is the direct cause of the suicide attempt.

Of course anything is possible, but is this a probable scenario that could predicted? I say absolutely not.

Is there any data linking psych admission of patients with BPD with increased risk of suicide attempt while admitted -vs- not admitting and suicide attempts in the outpatient setting? I can't imagine this is something even possible to study in an ethical way.

 

[Crayola227]

Not to mentions, gesture or no, even just "gestures" can prove as fatal as a more determined attempt. Sometimes people that fully intend to die don't manage to complete their suicide, and others with no real intention of completing do indeed complete.

 

[hallowmann]

I mean, depending on what the family defined as "psychotic", I might have discharged that patient. If we are talking clinical psychosis, then sure, yeah, I probably would have done the same thing for FEP and treatment. I think OP is fine, and sure sounds like they did the right thing.

I also do want to push back though at this idea that since the patient attempted while inpatient, then it was the "right" decision and OP saved their life. By the same logic, if a patient with a similar assessment, but collateral said they were fine were discharged, and 2 days later they committed suicide, can we truly say that discharge at the time was the "wrong" decision or that we failed to save their life? I mean I don't think we truly have that level of power.

I think we should be hesitant to make those type of statements, or we'll set ourselves up for turmoil for the inevitable time where a patient seemed fine, we let them go, and they killed themself.

Also, sometimes inpatient is harmful to people. I know we know this, but it doesn't hurt reminding everyone that involuntarily admitting someone that doesn't need to be admitted, which might result in them say losing their job or losing their car or losing their child, is certainly something that can result in a suicide attempt as a result of a psychosocial stressor that we created. I mean, I hope no one is involuntarily admitting people who clearly don't need it, but we also need to be able to recognize when admission might be harmful and admitting people "just in case" they will harm themselves is not what we are tasked with.

 

[AD04]

A lot of us are young physicians with potentially long careers. Thus, initial reaction to critical events such as suicidal attempts is to worry if you did the right thing. You are judging this based on outcome. But that is a recipe of burnout because patients will do bad things to themselves under your care, especially if you work with very mentally sick people who need to be in psychiatric hospitals. Not only will you have bad outcomes, people will threaten to sue or even actually sue.

You have to start thinking in terms of your actions, not patients' outcome. Focus on what you can control. Did you do the right thing given the information you had at the time? Did you meet standard of care? Did you document well?

To give an analogy, if you are driving a car, are you driving at the speed limit or less? Do you stop at stop signs? Do you use your turn signals? If yes, you are a good driver based on your actions. But even as a good driver, you can get into an accident through no fault of your own: icy roads, drunk drivers, whatever.

I take care of really sick people. I sometimes run the whole psychiatric department myself, especially now during the holidays. I take care of inpatient, C&L, outpatient, and ECT. I've had multiple critical events -- many overdoses, several self-mutilation, one guy jumped off a bridge and shattered his legs, one of my patients' died of unknown reasons and his estate asked for his medical records. And yet I sleep like a baby because I know my actions meet standards of care and my notes back up why I did what I did. That is all I care about -- did I meet standard of care and how will it look in court. I don't worry if my patients will harm themselves or not. Because if I start worrying about poor outcomes, I will burn out and if I am gone due to burn out, more people will harm themselves. It's easy to see the bad outcomes that transpired but it is hard to see the bad outcomes that were prevented.

One of my patient's family member threatened to sue because I took him off his medications too quickly. Asking for compensation. Asking if I had insurance. What she forgot was the patient was delirious to the point that he was sexually harassing and sexually assaulting female staff members. I told her that his sexual harassment and assault were in the notes in details. And what was also in the note was that I saw him the next day after I took him off the medications and he was no longer sexually inappropriate and that he didn't complain of any withdrawal symptoms. And I know if I had to go to court (which is unlikely as the case would have likely been thrown out by a group of reviewing physicians as I met standard of care), I can confidently say I did the best I could given the situation and any physician who cared about his staff members and about his patient would have done the same.

P.S. OP, I think you met standard of care. When in doubt, admit. How can that be held against you?

 

[Mass Effect]

I also do want to push back though at this idea that since the patient attempted while inpatient, then it was the "right" decision and OP saved their life. By the same logic, if a patient with a similar assessment, but collateral said they were fine were discharged, and 2 days later they committed suicide, can we truly say that discharge at the time was the "wrong" decision or that we failed to save their life? I mean I don't think we truly have that level of power.

I'll agree with that to an extent, but I think that someone emotionally/psychologically vulnerable in which (a) family is worried, (b) family says made suicidal statements, (c) was "psychotic" (and I agree, I'd want to know if this was clinical criteria that was met, then (d) attempted suicide on the unit, it's hard to say they shouldn't have been admitted in retrospect. It isn't just the suicide attempt. It's the suicide attempt in addition to everything that came before it.

In most states, there's very clear criteria for involuntary admission. So if someone is discharged and then commits suicide 2 days later, you can't really go back to determine if the criteria was met 2 days earlier because a lot can happen in 2 days out in the world. They may not have met criteria on Tuesday, but did meet criteria on Thursday. In this patient's case, I'm making the assumption that he's getting care in those 2 days and was able to stay safe in that time, but that he still attempted suicide, not to mention an attending saw him on the unit and didn't discharge him either so that also suggests the OP was on to something in thinking this person was at risk and met criteria for involuntary admission.

I also agree that involuntary admission can have repercussions, not to mention be significantly traumatizing to a patient. But if this is cause for suicide, I don't think the person admitting him can be held responsible so long as the patient met criteria.

Involuntary commitment is a controversial thing and I've had colleagues tell me they'll never put someone in the hospital against their will, which I think is also a dangerous way of thinking. It definitely can cause harm which is why it always has to be examined with an excruciatingly thorough lens.

 

[Candidate2017]

Based purely on OP's report, I'm surprised the patient got admitted, notwithstanding any subjective "psychotic" reports from the family. Even if the patient killed himself after DC from the ED, it would still be difficult to hold OP liable.

 

[FN9]

Based purely on OP's report, I'm surprised the patient got admitted, notwithstanding any subjective "psychotic" reports from the family. Even if the patient killed himself after DC from the ED, it would still be difficult to hold OP liable.

 

[Heathcliff]

Is there any data linking psych admission of patients with BPD with increased risk of suicide attempt while admitted -vs- not admitting and suicide attempts in the outpatient setting? I can't imagine this is something even possible to study in an ethical way.

You may find this article helpful.

"Is Hospitalization Useful for Suicidal Patients with Borderline Personality Disorder?" by Joel Paris, MD.

 

[futureapppsy2]

Suicidality does not equal BPD. The majority of people who are suicidal have other psychiatric disorders, especially mood disorders and PTSD, and there’s been an over correction in terms of clinicians assuming that suicidality equals BPD, especially without first thoroughly assessing for and treating any Axis I disorders.

 

[birchswing]

I know this is irrelevant to your question (I'm more curious why you asked the question because while I am a layperson I don't see how you could rationally assume responsibility): Given that he was medication naive, was he placed on any before this suicide attempt and if so which ones? It wouldn't change the answer to your question. I'm just curious.

 

[clausewitz2]

Suicidality does not equal BPD. The majority of people who are suicidal have other psychiatric disorders, especially mood disorders and PTSD, and there’s been an over correction in terms of clinicians assuming that suicidality equals BPD, especially without first thoroughly assessing for and treating any Axis I disorders.

'it must be BPD and not bipolar, look how many times they have attempted suicide" - something I heard way too often during training.

 

[twospadz]

I know this is irrelevant to your question (I'm more curious why you asked the question because while I am a layperson I don't see how you could rationally assume responsibility): Given that he was medication naive, was he placed on any before this suicide attempt and if so which ones? It wouldn't change the answer to your question. I'm just curious.

Yes. He was started on Risperidone.

 

[twospadz]

Based purely on OP's report, I'm surprised the patient got admitted, notwithstanding any subjective "psychotic" reports from the family. Even if the patient killed himself after DC from the ED, it would still be difficult to hold OP liable.

The family collateral was very convincing. Basically he believed he was writing the bible, he believed a radio station was talking about him and was arragning people to come after him. He has been talking to himself. Had episodes of self harm in the home including banging his head. Patient denied all of this but I was very concerned about what the family said so I admitted him.

 

[michaelrack]

Now certainly no one is ever sitting peacefully and given an IM for absolutely no reason, some nurse or physician had to initiate that and malevolence is maybe the reason 0.0001% of the time.

some patients ask for an IM injection of haldol... sometimes because they feel it will help their psychosis, sometimes because it usually comes with ativan