Tough week

[DOswag]

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Officially lost my first patient to suicide this week. Well technically I did a one time eval of a patient when I was active duty that I later found out committed suicide but I wasn't managing her care at the time of the eval or when I found out she had committed suicide. This one was still a little different as I had only just met her for intake last month in early July, saw her for a quick f/u about 2 weeks later, saw her for another f/u last week after she had received 1 infusion of ketamine, then found out on Monday she had overdosed this past weekend. She expressed passive SI but each time I spoke with her was adamant she would not harm herself, she wouldn't do that to her family, didn't feel she needed to be involuntarily admitted to the hospital and she did not want to go voluntarily. I was saddened to hear the news, sad for her, sad for her family, and of course all the thoughts of myself that come along with it. Looking at the notes, could I have done something different, did I mess up, am I incompetent etc.... I think the hardest part was being informed of this sometime Monday morning and then having to put a smile on my face and greet the onslaught of 20 patients that day all dealing with their own struggles knowing in the back of my mind I had just lost a patient and feeling pretty shook about it. I think I'm doing ok now, still having the questions pop in my head. Any advice from those that have experienced this as well? Hopefully not too many of you have but I know it's part of the profession we have chosen.

 

[comp1]

Oh I think most of us have experienced this (or certainly will depending on our time in the job). As painful as it is, it's expected. Not every suicide is preventable. First and foremost, your reaction is completely normal. Time does help with this. You're still processing all of it on an emotional level. It's obviously too early to do any cognitive work about anything that could have been done differently, but I know it's impossible to avoid that train of thought. I think it's really good to power through with patient care for the moment.

 

[randomdoc1]

I think of this like many specialties. Many ailments have their statistical share of fatalities. It makes me think of cancer, MS, and other ailments. Some go into remission and sustain. Some progress. Some remit, relapse and repeat. But there are unfortunately always a share of terminal cases, no matter how great the care you deliver. Severe BPD comes to mind. While many do get better, some continue an onward decline into fatality. But we keep trying!

 

[aim-agm]

I'd consider taking out the potentially identifiable information in case something legal arises.

I'm not sure what else you could have reasonably done. It sounds like you were following her closely, timing appointments so you'd be able to assess effect of interventions as soon as feasible. If she declined voluntary admission and didn't meet involuntary criteria, there was nothing you could do on that front.

Its natural to reevaluate what we have done when there is a bad outcome, because we want to minimize it happening again. However, one trap we can fall into is looking for something else we could have done, because the alternative would be that even though we did everything right something tragic still happened - which means that we are more powerless than we'd hope, which can be an awful feeling.

 

[Merovinge]

I always like analogies to other areas of medicine. I hear of surgeon's talking about complications as though they are 100% the fault of the surgeon and that these are entirely within their realm of control. I know it's not apples to apples in comparison, but similarly no surgeon will have 0 complications and they are absolutely not all within the control of the surgeon. We operate in uncertain worlds with high numbers of patients and unfortunately small % chances inevitably occur in such circumstances.

Otherwise, this is unfortunately an occupational hazard, time to get support from loved ones, mentors, and other docs, just like you are doing here!

 

[Ceke2002]

I'm sorry for your loss, and just in case it needs reminding, it is not your fault. If someone really wants to die then generally speaking they'll find a way; sad reality, but suicide isn't always preventable. Hope you have someone on your team to talk things through, if you feel the need.

 

[splik]

Sorry this happened. It really is awful. Yes, other specialties deal with loss, but there is something especially personal and devastating about losing a patient to suicide. You can feel hurt, betrayed, angry, helpless, incompetent, and paranoid. It's not uncommon to worry about a potential lawsuit, or that others might see you as somehow responsible, or a marker or the care that you provided. If a patient overdoses on meds we provided, it can feel like an eff you. If we recently saw the patient and they did not provide an inclination they were actively suicidal, it is natural to feel deceived or to second guess yourself. It is absolutely a traumatic loss.

Here is what I suggest:
1. It is okay to take some time off or even cancel a clinic last minute to allow yourself time to process this devastating news.
2. It is okay to cry, to grieve, and to commemorate and honor the death of the patient in which ever way feels appropriate.
3. Contact your malpractice carrier immediately, or if employed in a larger setting, risk management.
4. Never, ever edit or change documentation after the fact. It is okay to enter notes in after the event if you didn't do it before, but never change anything.
5. Talk with trusted friends or colleagues.
6. If needed, seek support from a therapist even if it is just one session.
7. If there is a partner or parents etc who wish to meet with you, it is okay to do so. Provide them up to an hour of time at no charge. Make sure they know you cannot meet beyond this or if you are willing to, that it would be limited and at cost. Offer referrals for therapy if indicated.
8. While it is okay to attend the funeral if invited, I personally do not. It just feels a bit weird if people ask who you are. It is perfectly appropriate to send flowers or make a donation to charity in the patient's name.
9. Never ever return/refund money the decedent paid for treatment. As someone who does a fair bit of malpractice work - this will be taken as an admission of guilt and wrongdoing in the event of a lawsuit.
10. Most states do allow quality improvement reviews including morbidity and morality reviews to be privileged (i.e. can't be disclosed if there is a lawsuit) so do not feel worried about having a formal review of the case. Even if there were things you could have done differently, this was most likely not your fault.
11. Be mindful of undoing defenses and overcompensation. It is not uncommon for some physicians to respond to the traumatic loss by becoming overly risk averse which can be quite harmful. If you are unsure about what to do in a given case, consult with other clinicians.
12. Typically the executor of the estate has the right to records after the patient has died. However, confidentiality extends after death, so if there are things you believe the patient would not have wanted others to know you need not disclose this and should redact the records accordingly.
13. In many cases, a request for the entire chart from the executor, is usually the first indication of a possible lawsuit. After that, the plaintiff's attorney will have an expert do a preliminary review. Depending on the state, it would either move forward with a complaint, OR the expert has to produce a certificate of merit.
14. As members of decendent's estate are typically grief stricken, it is usually a year or more before a lawsuit occurs.
15. Medical board complaints related to this are far less common than malpractice suits (probably because there is no money in the former case).
16. It is a general truism that patients and families do not tend to sue doctors that they like. If the family was involved in the care and has a connection with you they will likely value the care their loved one received. Unfortunately, suicidal patients are much more likely to have utterly dysfunctional familes who often externalize and blame the psychiatrist as a defense against their own feelings of culpability. Of course, if you are privy to that dysfunction and have the receipts, it usually helps make the suit go away.

 

[AD04]

@DOswag

Sorry about your loss.

Depending on our personality traits, how we deal with this differs a lot. When I was an intern, I was rotating on the pulmonary service. It was a brutal service. Just me (a lowly PGY-1 at the time) and the pulmonary / critical care fellow. One of the patient was in his 30's and was recently married and with a kid. The patient was just diagnosed with stage IV metastatic cancer. The pulmonary fellow, a cool and calm dude usually, just couldn't keep it together. I remember him tearing up and running out of the room after he saw that patient. I guess the patient's age was really close to his and it hit too close to home.

During my first year out of residency, I had likeable patient around my age. Married with a young daughter. He was doing well until he slipped out and relapse on recreational drugs. But after that slip up, he seemed to stay sober for a bit. But then one day, I had a fax from his estate requesting his records. I assume he died and I was a bit shocked because he did so well in the last visit with me. As @splik wrote in the very good post above, I was thinking I might get hit with a lawsuit. I didn't lose sleep over it. My notes were well documented and he didn't have suicidal risk at the time of the last visit. I never received a lawsuit and statute of limitation is passed for that state. I still don't know how he died.

I had several more patients die on me. Really sick people. Some because of medical complications. Some because of addiction. I warned them about their addictions but they didn't want to stop. People do silly things when under influence of alcohol or recreational drugs. I didn't lose sleep over any of the deaths.

This is the part where having a surgeon personality trait helps: the ability to detach from the outcome after knowing you did your best and reviewing the case to see what you can improve on and accepting that some patients will die no matter how good of a care you provide. I don't know if this personality trait that can be trained. It is innate for me.

My senior partner is also the same way. He had a patient die from ECT. This was the first death ever from ECTs in the institution. The day I found out, I went to him to make sure he was doing ok. He was totally fine. The news of the death was like water off a duck's back. Detached and still able to do great work.

For you, the feeling will get better with time. The longer you practice, statistically the more deaths you'll face and the more you'll get used to it.

 

[oliversacks4thewin]

So sorry to hear this happened. It is always a difficult moment to process. I strongly endorse the advice above and would add following up with case consultation and supportive peer to peer programs if they are offered through your work system. They can be an extremely beneficial area of reflection on the case and are typically emphasized to be protected places to freely discuss feelings and thoughts related to the case, without the added stress of threat of legal ramifications.

Secondly, I always emphasize to the individuals I train that while it seems like our job is to fight death; the medical profession, as a whole, is actually designed to ease suffering. If we were all focused on fighting death, none of us would have a winning record. Focus on how you were there for this patient and how those moments align with the standards of the entire medical practice, and likely, your own values, of providing help in those moments. Importantly, it is so human and important to be affected by this. Take time to grieve, it is a part of the process.

 

[randomdoc1]

If this also puts things in perspective, the quote "if not you, then who?" comes to mind. We may have done a lot more help than we think. I have lost my share of patients to various causes over the career. I remember one patient was no longer under my care when she passed. But the family updated me on her passing and they said they were thankful for the quality years she was able to get due to great care. That really snapped things into perspective.

 

[Merovinge]

So sorry to hear this happened. It is always a difficult moment to process. I strongly endorse the advice above and would add following up with case consultation and supportive peer to peer programs if they are offered through your work system. They can be an extremely beneficial area of reflection on the case and are typically emphasized to be protected places to freely discuss feelings and thoughts related to the case, without the added stress of threat of legal ramifications.

Secondly, I always emphasize to the individuals I train that while it seems like our job is to fight death; the medical profession, as a whole, is actually designed to ease suffering. If we were all focused on fighting death, none of us would have a winning record. Focus on how you were there for this patient and how those moments align with the standards of the entire medical practice, and likely, your own values, of providing help in those moments. Importantly, it is so human and important to be affected by this. Take time to grieve, it is a part of the process.

Guérir quelquefois, soulager souvent, consoler toujours​

Cure sometimes, relieve often, comfort always. I heard this quote at the start of medical school and it always stuck with me. The French just have a way of saying things…

 

[oliversacks4thewin]

Guérir quelquefois, soulager souvent, consoler toujours​

Cure sometimes, relieve often, comfort always. I heard this quote at the start of medical school and it always stuck with me. The French just have a way of saying things…

That's beautiful. Thank you, I will intend to share this more too.

 

[jbomba]

I'm sorry to hear that. I've had two such experiences so far. And both time they were absolutely not the ones you would expect. At the end of the day I sometimes wonder if there's anything more we can actually do to intervene, although I'm fairly pessimistic on this. It will get better with time. Sounds like you did everything you should have.

 

[Ceke2002]

I'm sorry to hear that. I've had two such experiences so far. And both time they were absolutely not the ones you would expect. At the end of the day I sometimes wonder if there's anything more we can actually do to intervene, although I'm fairly pessimistic on this. It will get better with time. Sounds like you did everything you should have.

That was something I got asked a lot after people knew I'd attempted suicide (it was a long time ago), and honestly, short of sectioning me into hospital, there really wasn't anything anyone could have said or done that would have made any difference. Even sectioning wasn't a very likely prospect, because 1: I was completely avoiding health professionals of any description and 2: If by some strange circumstance I had come to the attention of someone who had the power to force me into hospital I just would have lied through me teeth anyway. I wasn't planning on actually surviving: I chose a method with a relatively high success rate, I didn't mention or hint about my intentions to anyone, I didn't start giving possessions away, I didn't say goodbye to friends or family, heck I didn't even write a note. I can't imagine how much it must suck to lose a patient that way, but none of you should expect to be miracle workers. Go easy on yourselves.

I'm also happy to answer questions, and talk about my own experience with anyone via message, if it would be at all helpful.

 

[MedMan80]

I had a patient do this after 1-2 visits only as well, he said the same thing, "i'll never do it". Now every time I have a patient say this his case crosses my mind.

 

[FatherPsychiatry]

Guérir quelquefois, soulager souvent, consoler toujours​

Cure sometimes, relieve often, comfort always. I heard this quote at the start of medical school and it always stuck with me. The French just have a way of saying things…

Beautiful.

 

[smalltownpsych]

When this has happened in my career as it just did again recently, it drives home the importance of our work and how challenging it can be. Too many people in our society or the media minimize or mock the work we do with silly memes about the “worried well”. Some of our diagnoses have incredibly high mortality rates and we have limited tools to help them, yet we keep on trying and save lives. Not just in the sense of preventing a suicide, but recovery is about helping the patient to build a life that is worthwhile. I had a recent patient with long hx of suicidality and hospitalizations with a psychotic disorder who performed professionally for the first time in over ten years. This was in contrast with the patient with a similar dx who died a few weeks prior. It’s hard, but I personally will keep fighting and struggling with my patients to recover and build a life worth living.

 

[Liquid8]

It really sucks. At the start of my private practice career I had about one patient death a year on average.

Can remember one of my admitted patients not returning after going out on day leave – at the time a senior colleague told me that if you never had a patient who killed themselves, you probably weren’t seeing the right kinds of patients.

 

[Stagg737]

I'm sorry OP has experienced this and hope they are doing okay, but also good to realize it's an unfortunate inevitability for pretty much all of us in this field who practice long enough. A lot of great advice in this thread, just a couple more thoughts to add.

1. We are bad at predicting who will complete suicide despite being the medical and often societal experts in this area. Plenty of studies out there showing that even the best tools and clinical evaluators aren't much better at predicting who will or won't attempt and complete than a coin flip. We are not surgeons who are going to "save" someone with a relatively easily correctable problem. We work with individuals with complex, often chronic, issues which we typically have to approach from a multi-faceted mindset where resources are often lacking or absent and which also requires motivation from the patient and attempting to assess something so subjective that we often can't even agree on what to call the problem we're treating. Add on that time is a zero-sum resource and there are limits to what we can actually do to help. Do your best with the time you have and recognize that we just can't get this correct all the time.

2. As Ceke referenced, we are not really in control of our treatments. One of my attendings in residency told us all after another residents' patient completed suicide after discharge, "We do the best we can, but if someone is really determined to kill themselves then there is nothing we are really going to be able to do to stop them." I share a similar lesson with all of my residents that unless we want to "imprison" someone in isolation with CO, then someone who is really determined to attempt or complete is going to do it. We may be able to justify this in the short-term if we truly believe this is an acute problem/exacerbation that can be treated, but that this is not a long-term solution. For those patients who are chronically depressed/suicidal, this is not something we are always going to be able to "fix". It's obviously upsetting for everyone that grim outcomes can be inevitable, but like others have said, we focus on what we can do and hopefully walk away at the end of the day knowing you did your best and did make some difference in their lives.

3. As others have said, make taking care of yourself a priority. Another life lesson I pass on was something our paramedic instructor taught us. When you arrive at a scene, if it's not safe then stay away until it is. Running into danger to try and save someone is pointless if you just become another victim and need to be saved yourself. Not quite the same, but the underlying lesson of taking care of yourself first so you can take care of others is something I think is valuable in all areas of life. If you need to take some time off to be able to serve our patients to the best of your ability, then do it. A lot of physicians in general neglect this (including myself at times), but imo this is the fastest road to burn out.

 

[FlowRate]

This is the part where having a surgeon personality trait helps: the ability to detach from the outcome after knowing you did your best and reviewing the case to see what you can improve on and accepting that some patients will die no matter how good of a care you provide. I don't know if this personality trait that can be trained. It is innate for me.

This is how I dealt with the patient suicide that happened in roughly my first year as an attending, as well. I really tried everything I could think of--within the bounds of good quality care and personal values--to help the patient. A subtype of MDD presentation that I sorta "expect" to end in suicide because of how clearly miserable they are but also very difficult to tell exactly when. (Severe acute MDD with very severe anxious distress refractory to lots of medication trials but was always adamant about zero suicidal ideation.)

It's also why I'm particularly resentful toward pseudo-medical shysters and their overpromising. So much effort trying to convince him to do ECT but the family preferred the fancy looking website for the qEEG+EKG+TMS hucksters over my recommendations. And the cost of that out of network/superfluous care limited getting an adequate TMS course or trying other more appropriate steps.

 

[Candidate2017]

Any advice from those that have experienced this as well? Hopefully not too many of you have but I know it's part of the profession we have chosen.

Actually, all of us should have experienced this. If not, this means we haven't had enough patient contact and/or enough patient acuity.

We're physicians. We deal with life and death. Sure, some of us can mostly avoid dealing with this fact by ditching white coats, stethoscopes, and general medical knowledge in favor of business casual and working in low acuity outpatient practices (i.e., Adderall for all the kiddies, psychic botox for all the mommies), but even so, you never know. Yes, this isn't oncology, critical care, trauma surgery, or even dermatology in terms of adverse fatal outcomes. But we are physicians nonetheless.

In the end, we do not control adverse outcomes. Nor do we believe we can do so (hello surgeons, narcissists, social workers). All we can do is adhere to the standard of care, for which many patients will greatly benefit, either through remission or slowing of disease progression to the point where a number of extra years will added to their lives before they eventually succumb. Of course, a certain percentage will not benefit at all.