Thinking of getting sued is consuming me

[calvnandhobbs68]

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Its not bulletproof and it of course my conclusion must have justification. But for a number of reasons it becomes very difficult to surmount, e.g. now the standard is "reasonable" so they must prove (I think) that no reasonable fact finder could come to the same conclusion I did vis a vis whether the patient met involuntary crtieria, rather than that I failed to meet the standard of care.

The argument that the law FORBADE you from admitting a patient voluntarily is a bit of a stretch, although I see what you're saying. Involuntary, you could definitely use that argument, but I don't know if anyone is going to interpret most voluntarily admission state statutes as forbidding you legally from admitting someone to an inpatient unit if they're coming in saying they want to kill themselves and want to be admitted to an inpatient unit.

The much better line of reasoning to discharge a voluntary patient is what you aluded to, that you need to explain in your note why you feel an acute inpatient stay would not modify the patient's risk or in fact be harmful long term (which you can certainly argue for personality disorders) or why you think the patients actual short term risk is lower than it would appear on the face of things (ex. malingering, chronic persistent SI, etc).

 

[aim-agm]

The argument that the law FORBADE you from admitting a patient voluntarily is a bit of a stretch, although I see what you're saying. Involuntary, you could definitely use that argument, but I don't know if anyone is going to interpret most voluntarily admission state statutes as forbidding you legally from admitting someone to an inpatient unit if they're coming in saying they want to kill themselves and want to be admitted to an inpatient unit.

The much better line of reasoning to discharge a voluntary patient is what you aluded to, that you need to explain in your note why you feel an acute inpatient stay would not modify the patient's risk or in fact be harmful long term (which you can certainly argue for personality disorders) or why you think the patients actual short term risk is lower than it would appear on the face of things (ex. malingering, chronic persistent SI, etc).

It depends on state law, but in my state the law states that patients cannot be admitted to psychiatric hospitals (voluntarily or involuntarily) except through the defined statutory pathways. To potentially be admitted on a voluntary status the patient must have a mental illness for which care and treatment in a psychiatric hospital is appropriate.* In fact, the statute stipulates periodic review of patients by the state department of mental health to ensure that they meet voluntary criteria and obliges the department to order their release if the don't meet criteria for voluntary or involuntary, and states that not complying with that order is sufficient grounds to revoke the operating certificate of a psychiatric hospital.

Also, to clarify, the way I structure the assessment is to start with the medical decision making and rationale, which I use to arrive at the legal conclusions, e.g. "impression is BPD because of ABC...admission is not expected to reduce dangerousness in BPD because of XYZ...therefore the patients dangerousness is a product of a mental illness for which treatment in a psychiatric hospital is not appropriate, and as such state law does not permit admission."

*: The state department of mental health actually added more requirements indirectly, but they technically don't have the power to do that (long story)

 

[jbomba]

I do add language that future unforeseen stressors could increase their risk of self harm or violence above and beyond what I am currently observing at the time of discharge. I like to think this helps in some way.

 

[psychma]

This isn’t quite the same, but I faced a board complaint by a colleague who saw me as competition and openly threatened me. It was a terrible experience and I had to prove my competence. I couldn’t sleep, was anxious and distressed. My attorney turned in my response (answers to questions to prove my competence) as well as evidence to support my competence (certifications, letters from past supervisors and professors and peers, etc. ). Within a few days of everything being turned in, the complaint was dismissed and sealed. It was a stressful process and it made me doubt myself, but I got through it. If something happens, you will too with support from friends and family.

Get some counseling to explore this.

 

[Stagg737]

Can’t you just keep them until they deny SI? I see people doing that all the time lol

Sometimes, but if a patient is truly malingering for shelter they’ll just keep reporting SI and when you discuss discharge they’ll start discussing specific plans. I think you underestimate the determination of some malingerers…

 

[whopper]

I've worked in an ER for about 10 years. I've kicked out probably thousands of malingerers. NONE OF THEM COMMITTED SUICIDE.

I've had patients commit suicide. None of these were patients I suspected or knew were malingering. My first patient who killed herself I knew she was going to do it. The problem was I knew she was going to do it months to years down the road. That wasn't enough to allow me to keep her committed. I remember when she was discharged I told a nurse I worked with that I wasn't scared she'd die within weeks but I said something to the effect of "6 months? That's where I'd be getting scared." She killed herself 6 months later and I was not her outpatient doctor.

Every other patient I've had that committed suicide were people in a zone where there was no way I could tell. E.g. I met a guy once, didn't see him again for over a year, he didn't follow up as recommended, then I find out later on he committed suicide.

I've also had accidental death patients where the patient overdosed. Again like the above it was out of my control. E.g. a patient openly tells me he doesn't want treatment, wants to continue drug abuse, walks out of my office then I find out months later the person died of an accidental overdose.

I haven't been sued yet at least as of now. I've had idiot complaints against me. E.g. I terminated a patient who was on Clozapine because he wouldn't get the labs done, then call me up and ask for Clozapine and I told him I couldn't get him the meds and he needed to go to the ER because they were the only people who at that point could get an immediate lab done. Add to the idiocy that at that time he was already terminated for 3 months, so I also asked him why he wasn't calling his current psychiatrist as I no longer treated him. So the board complaint was literally for me following the rules with Clozapine for a patient where I had no treatment relationship, and YES-I did terminate him per standard of care. I gave a termination letter via certified mail with 3 referrals and he did have an established psychiatrist at the time he called me. Add to the insult when a person complains to the board they have to check off a box as to what the doctor did wrong. They checked "other" and wrote in "because he doesn't care."

Ahem, not caring? That doesn't merit a board complaint per existing guidelines (and by the way I do care. If I didn't care I wouldn't have bothered to tell him for over 2 hours over the course of 6 phone calls that I couldn't prescribe Clozapine and he needed to go to the ER).

So far 3 complaints against me with a board but all 3 of them tossed out. First one was I was accused of being the head of a multinational conspiracy controlling sexy supermodels to control the world. My nurses were the alleged muscle, where if the super models didn't submit sexually they nurses would come in and make them do the dirty work. The state board even apologized to me that they were investigating me and told me to not even worry but that they had to investigate me because I was running an inpatient unit, and by law any sexual complaint in an inpatient unit had to be investigated. The second complaint was the one I mentioned above. The 3rd complaint some lady kept begging for benzos and I said no cause of the addiction risk.

Frankly for the 2 non-sex conspiracy complaints I was bugged they even investigated it. It was apparent from the surface these were bogus. I cannot prescribe Clozapine if the person doesn't do the labs, and legally there's no merit to complaining against a doctor where a treatment relationship doesn't exist. So if that's the case why did the board even waste time on it? They should've tossed it out before even doing an investigation. The 3rd complaint lady did later develop a benzo addiction. I found out cause she later showed up to an addiction clinic where I worked asking for help for benzo addiction.

(The irony being that if I could somehow be the head of a multinational conspiracy to control the world though super-models that actually sounds pretty cool, but I don't know how to get that to realistically happen as a physician. 😛)