Suicide liability

whopper

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    Any Psychiatry residents out there? If so (and I'm sure you're here), what sources of info can you give me on suicide liability?

    What exactly is the standard of care in evaluation & decision of admission of someone who is showing suicidal behavior or claming suicidal ideation?

    Don't tell me its common sense or your gutt feeling. If you believe that, you don't understand medicine and the law. This standard probably exists based on past legal cases or by standards dictated by evidenced based medicine. (sorry, a little rant there because a lot of people I've been asking say just go with your gutt. You go with your gutt and you get sued, I'm sure the judge & jury won't care too much for that explanation.... :cool: ) I don't know the exact standard.

    I have been hearing from some attendings that you have to hold the patient for 24 hours. Maybe they're right, however I see a lot of attendings kicking out patients after evaluation who are claiming suicidal ideation who are known malingerers wanting 3 hots & a cot. If the standard of care truly is to take in ANYONE claming suicidal ideation, then these doctors are breaking the standard of care (Even though I might think they are right...)

    So can anyone help me? Are these docs breaking the standard of care?
     

    mdblue

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      whopper said:
      Any Psychiatry residents out there? If so (and I'm sure you're here), what sources of info can you give me on suicide liability?

      What exactly is the standard of care in evaluation & decision of admission of someone who is showing suicidal behavior or claming suicidal ideation?

      Don't tell me its common sense or your gutt feeling. If you believe that, you don't understand medicine and the law. This standard probably exists based on past legal cases or by standards dictated by evidenced based medicine. (sorry, a little rant there because a lot of people I've been asking say just go with your gutt. You go with your gutt and you get sued, I'm sure the judge & jury won't care too much for that explanation.... :cool: ) I don't know the exact standard.

      I have been hearing from some attendings that you have to hold the patient for 24 hours. Maybe they're right, however I see a lot of attendings kicking out patients after evaluation who are claiming suicidal ideation who are known malingerers wanting 3 hots & a cot. If the standard of care truly is to take in ANYONE claming suicidal ideation, then these doctors are breaking the standard of care (Even though I might think they are right...)

      So can anyone help me? Are these docs breaking the standard of care?
      This is a good starting point http://www.psych.org/psych_pract/treatg/pg/Practice Guidelines8904/SuicidalBehaviors.pdf
      Suicidal assessment is supposed to be unique for every pt. You can't really extrapolate your experiences w/ a certain pt to others. Also you can not prevent every suicide. But good documentation explaining your decision will certainly CYA in any legal situation.
      Hope this helps.
       

      Anasazi23

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        Great link, MD Blue...exactly the link I was prepped to give as well.

        You are in no way obligated to admit every patient that says they are suicidal, and as the link above indicates, there are ways to assess and make the best informed decision as to suicidality. If I admitted every patient that said they were "suicidal," including those already admitted on the detox unit, the hospital would be overflowing with them, and for no good particular reason.

        There are suicide assessment absolute risk questions to ask. Just a few include, "Did you call anyone to tell them goodbye? Did you arrange for care of your dog/cat/pet? Recent stressors/deaths? Previous legitimate attempt? Employed? Married? Live alone? Suicide history in the family? Housed? etc., etc."

        Of large importance are the lab results and especially the etoh level and utox. There's usually a drastic change in heart when the etoh comes down from 180 to <5 :)
         
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        Milo

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          Phillip Resnick, a forensic psychiatrist, at Case Western recently recorded a decent lecture on suicide risk assessment for audio digest (audiodigest.com)

          On the tape he said he testifies or works on about a dozen psychiatric malpractice cases a year (the vast majority from suicide).

          I loved the little nugget he adds; 1/12 psychiatrists are sued annually, so the average psychiatrist will have 3 law suits in a 36 year career. <gulp>

          There is a decent synopsis of the talk on the website or you can shell out a few bucks to buy the recording. As it turns out I'm glad I used a bit o' my book fund to get a subscription.


          Cheers
           

          whopper

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            My fellow shrinks, Thank you!

            (meant in a self deprecating manner, if any of you took offense tell me. I'm serious.)

            Anyways I'm in a strange situation.

            I've read in various situations that "IF YOU DON'T RECORD IT IN THE CHART, FOR ALL INTENTS & PURPOSES IN THE EYES OF THE LAW, YOU DIDN'T DO IT".

            OK fine, we all know that.

            Problem is, in the residency program I'm in, often times while on call, I get calls from screeners from other hospitals where they give me a report of a potentially suicidal patient. I ask specific questions: example, is the patient sober? IS the UDS negative, okay fine, are there any past suicide attempts? No--

            Ok all good and done, no pertinent positives, the patient now denies suicidal ideation, has a plan, has a good support system, is informed and acknowledges to call 911 or come back if there's any problems. NO PROBLEM...

            Except that this patient is in the other hospital about 1 hour away. There's no way I can get my report into that patient's chart. So now for all intents & purposes should I get into any legal tangles, there's no report in the chart and all the questions I asked? In the eyes of the law I NEVER ASKED THEM!

            Should I go as far as to demand the program change the entire way they are handling this? The way the program in structured, both attendings & residents are handling this in the manner I mentioned. Is there some thing about this that is "kosher" that I don't know about? It seems to me its not yet there's a heck of a lot of attendings that seem comfortable with this system.

            Or should I just friekin admit everyone that is reported to me over the phone in an effort to play "cover your ass" medicine-which will greatly PO the staff and adminstration of the hospital?
             

            Milo

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              Yikes, that is pretty scary, and I thought my program allowing residents to okay S&Rs over the phone was risky.

              I do know that a few attendings in my program coordinate and supervise a 'rapid response' team in town, but I'm not sure how they manage risk. Thanks for raising this point, it's definitely going to be something to look into.

              Unfortunately, for now, I can only commiserate with your dilemma.
               

              PsychMD

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                Although this method of "phone triage/decisionmaking" is widely used in the "real world", I really don't think it is quite appropriate in a formal training program. It does create undue burden and anxiety on the resident, and possible problems with supervision and "who's in charge re. decisionmaking", etc. Plus...it really sounds more of a service requirement than "true" training, unless one defines "training" very broadly...I do think it may be useful to bring up your concerns with your program director, in a non-threatening/non-demanding way of course. I doubt there will be anything that can be immediately done to resolve the situation...there are longstanding service requirements at play here...but, if your program director is worth their salt, they should be able to "hear" you, and, maybe, down the road, this may lead to certain improvements to the quality of your training program.
                 

                lazure

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                  Do you really not learn this in school?? Scarey...

                  Yes, I did learn suicide assessment - but I feel that it was not covered in sufficient detail. So I am looking for more information. I liked the comrehensiveness of the adult reference above and I would like to find out more about references for child and adolescents. Your comment didn't help me very much.....
                   

                  whopper

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                    Thanks for all the responses.

                    I had a frustrating experience on Tuesday. I sat with all the residents at my program and brought up this matter, because the topic of the lecture was suicide.

                    Now bear in mind that about 2/3ds of the residents don't work in the hospital I work at. The program is divided into 2 locations and most residents stay in their respective location throughout the entire program. 2/3ds of those residents aren't in the situation I'm in, where you have to make a decision from the phone with a patient you can't see, and not have the ability to document the event in the patient's chart.

                    Anyways, I brought this up and some residents in my program were under some erroneous notion that simply because they are the psychiatrist they are the standard of care. One said, "psychiatry is more of an art than a science, that's what separates us from medicine, you just use common sense". Implying that Psychiatry doesn't use evidenced based medicine.

                    Well aside from the fact that this guy was justifying pretty much every other MD's opinion that psychiatrists are lesser doctors with that comment, I just kept wondering what the heck this guy's training was with the medical-legal standard.

                    That's why my first post was a little stern in tone (if you remember it).

                    I'm going to talk with my program director on Monday about this. The guy has a Forenic fellowship under his belt so I'm sure he can offer some type of insight. I did ask my attending today that I'm assigned to in the ward, and he didn't know. He told me "honestly James, that's a good question. I don't know."
                     

                    mdblue

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                      whopper said:
                      Thanks for all the responses.

                      I had a frustrating experience on Tuesday. I sat with all the residents at my program and brought up this matter, because the topic of the lecture was suicide.

                      Now bear in mind that about 2/3ds of the residents don't work in the hospital I work at. The program is divided into 2 locations and most residents stay in their respective location throughout the entire program. 2/3ds of those residents aren't in the situation I'm in, where you have to make a decision from the phone with a patient you can't see, and not have the ability to document the event in the patient's chart.

                      Anyways, I brought this up and some residents in my program were under some erroneous notion that simply because they are the psychiatrist they are the standard of care. One said, "psychiatry is more of an art than a science, that's what separates us from medicine, you just use common sense". Implying that Psychiatry doesn't use evidenced based medicine.

                      Well aside from the fact that this guy was justifying pretty much every other MD's opinion that psychiatrists are lesser doctors with that comment, I just kept wondering what the heck this guy's training was with the medical-legal standard.

                      That's why my first post was a little stern in tone (if you remember it).

                      I'm going to talk with my program director on Monday about this. The guy has a Forenic fellowship under his belt so I'm sure he can offer some type of insight. I did ask my attending today that I'm assigned to in the ward, and he didn't know. He told me "honestly James, that's a good question. I don't know."
                      you can use a standard tel eval form and fax it to the clinic where it becomes a part of the pt chart.
                       

                      whopper

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                        mdblue said:
                        you can use a standard tel eval form and fax it to the clinic where it becomes a part of the pt chart.


                        Well that's a very good suggestion, but its something my program currently isn't doing, we were never given the fax numbers of this place, I don't have a fax machine at my place (many of these calls are given to me while I'm sleeping). It is a good suggestion though.

                        Here's a copy of an email I'm thinking of giving my program director, but I'm playing by the rules and going up the chain of command to my chief resident first. Here it is....


                        "After looking into various medical legal sources, after a heated discussion on Tuesday on suicide liability, I come across some issues I felt I need to discuss with you.
                        In medicine, as far as I've been told in medical school, from a practicing lawyer, from various sources I've seen on the web, from a good friend of mine who is a lawyer, and from Dr. Salam, the director of the residency program of Internal Medicine at ACMC, you have to document everything.
                        In a medical legal sense, should the case reach a legal forum, if you didn't document the event, for all intents & purposes for legal purposes, it didn't happen.
                        I believe I'm telling you information you already knew. I thought I already knew it.
                        Here's the point. For some reason, it just clicked in my head...
                        During the on call at ACMC for Psychiatry residents, often times, we are asked if we should discharge a patient based simply on a screener's report over the phone. Sure, we can ask the questions..
                        Is the patient still expressing suicidal ideation?
                        Is their concentration & memory intact?
                        Is their UDS negative?
                        Is their BAL negative?, if not is it under 100?
                        Do they have a support system that can tell if they are in danger?
                        Do they know they can call emergency services if need be?
                        Etc.....
                        But the bottom line is when they call us, and if we discharge the patient, we have not documented what happened.
                        Some of it is because we're not at PIP. We've gone home. Some of it is because the patient is at Mainland. Some of it its because they're at another institution that falls under the service of ACMC which serves the county.
                        We cannot document our report. Even if the residents were somehow able to document that night, and if the charts were held until we could put our reports in the next morning, many of these patients are at other institutions that are some distance from ACMC. I.E. if we were to put our reports in the charts, we would probably lose some hours getting to the corresponding institutions, finding the charts, & putting our reports into those charts.
                        So now, and I hope I'm wrong about this, I'm interpreting the situation to be that we are not following the standard of care because we are not documenting our assessment of patients who are potentially suicidal, who were brought to a facility for evaluation.
                        It is true that screeners also do assess, the patients, but as you know from your experience from the PIP, psychiatrists are still asked to discharge the patient. From the Captain of the Ship Policy precedent that was brought up in various legal cases such as McConnell v Williams, 361 Pa. 355 (1949)., the physician is to held responsible for the actions of everyone in the team working to the treatment of the patient, i.e. the resident and/or the attending physician is held liable.
                        I brought up this issue with Dr. Zwil who is very on top of many issues in Psychiatry and has been an excellent teacher. Dr. Zwil scratched his head and said something to the effect of, "I don't know, that's a good question". He acknowledged that good documentation is necessary, but it is not being done in this case. Dr. Zwil did suggest something to the effect that perhaps by not admitting the patient, the physician is not held liable because he/she is not taking up the patient under his/her care.
                        Now I don't bring this up simply to play CYA medicine. The reason why I bring it up is because I don't want to be in a situation where I end up playing CYA medicine and end up admitting every single patient that's presented to me during my on call that is not at the PIP, or is reported to me after I leave PIP. This has its obvious problems.
                        I'm wondering if my thoughts are true, then I'm going to have to hold every single patient that comes in that I don't see them in person, or automatically tele-psyche them.
                        Thanks...sorry for the long and boring email.
                        James
                         
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                          I don't know if the chain of command is going to appreciate the e-mail, as it creates a legal paper trail showing that they have been alerted to the fact that they are not documenting properly. A suit could happen next week, and then the prosecution has them dead to rights. The e-mail might help CYA, though, should your superiors be unresponsive.
                          Perhaps it would be better to voice your concerns verbally in person or via telephone first, and if they are unresponsive then send an e-mail or letter to protect yourself?
                           

                          whopper

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                            Yeah I get your drift.

                            For better or worse, I noticed sometimes asking such questions are shunned upon, especially by those with the attitude that residents are slaves. As sarcastic as it sounds we all know there's truth to what I mentioned.

                            I did bring it up with my program director who is very open to suggestions and criticism of the program. He explained that at least in NJ, the system is set up and in fact even mandated by state law to work under the system where a screener reports to a psychiatrist who often is not present, and the psychiatrist is supposed to answer by phone if the patient can or can't be discharged. This is due to several factors such as a shortage of psychiatrists in the area.

                            While this sounded screwy to me at first, the guy has a fellowship in Forensics and he said it with full intent to take responsiblity for his words so I do believe him. It sounded screwy at first because my entire education had always pointed me in the direction that doctors must document everything. I also know full well that potential future lawsuits could end up changing this procedure, especially since the Capt. of the Ship Policy brought up in other lawsuits puts the doctor as the final level of responsibility.

                            It is unfortunate that some programs don't allow for feedback to be up & down. While my program is open to it, I know full well others aren't.

                            I can say for myself that if I was put into a situation where I could possibly be in legal peril and my program wouldn't want to deal with fixing the problem, I'd seriously consider hiring a lawyer to look into what I could do to protect myself should the situation turn ugly. IMHO, and I believe civil law would agree with me, a program has the responsibility to make sure it is following the standard of care. Of course I would hope it wouldn't get to that point.

                            I hope that is not in your case Wolfgang, and that you have amicable channels to work with.
                             
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