William H. Reid, MD, MPH Clinical Professor: TTUHSC, UT Dell, TAMU

1 ASKING THE PATIENT IS NOT ENOUGH Assessing Suicide Risk...

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1 ASKING THE PATIENT IS NOT ENOUGH Assessing Suicide Risk in Emergency and Primary Care SettingsWilliam H. Reid, MD, MPH Clinical Professor: TTUHSC, UT Dell, TAMU Assessing Suicide Risk (c) 2017, Wm.H.Reid, MD

2 Assessing Suicide Risk (c) 2017, Wm.H.Reid, MDThis presentation provides information about suicide risk assessment. It cannot cover everything necessary for assessment or care of any specific patient. We won’t focus on treatment. I assume most in this audience will transfer or refer patients for specialty care. Although some medicolegal topics are addressed, nothing in this presentation should be construed as legal advice. Assessing Suicide Risk (c) 2017, Wm.H.Reid, MD

3 Assessing Suicide Risk (c) 2017, Wm.H.Reid, MDTopics to be Discussed Introduction: Who commits suicide? Myths & Misunderstandings Risk, Risk Assessment, Reducing Risk Getting and Documenting Information Confidentiality & Suicide Risk Assessment Another Liability Issue Assessing Suicide Risk (c) 2017, Wm.H.Reid, MD

4 Assessing Suicide Risk (c) 2017, Wm.H.Reid, MDI spend a lot of my time reviewing patient suicides for plaintiffs’ and defendants’ malpractice lawyers, peer review bodies, and risk managers, looking for deviations from the standard of care that our patients have a right to expect. I’ve seen tragedies related to every topic in this talk. I hate suicide. Assessing Suicide Risk (c) 2017, Wm.H.Reid, MD

5 Assessing Suicide Risk (c) 2017, Wm.H.Reid, MDMost of my job today is to keep you from losing more patients than you have to. Part of it is to keep you from being sued, or successfully sued. Being sued is the pits, win or lose. Unnecessary patient mortality and morbidity is even worse. Assessing Suicide Risk (c) 2017, Wm.H.Reid, MD

6 Assessing Suicide Risk (c) 2017, Wm.H.Reid, MDWho Commits Suicide? It’s not always the person you suspect, and vice versa. Don’t assume that your thoughts and values apply to the person you’re evaluating. Trying to put yourself into the patient’s shoes can be misleading. Assessing Suicide Risk (c) 2017, Wm.H.Reid, MD

7 Who commits suicide?, cont.So-called “positive” factors such as family ties and future plans, or demographics like employment, age, gender or marital status should not, by themselves, shape your level of concern about individual suicide risk. Assessing Suicide Risk (c) 2017, Wm.H.Reid, MD

8 Who commits suicide?, cont.Severe depression is not the only psychiatric syndrome associated with greatly increased suicide risk. Anxiety, psychosis, loss, chronic pain, disability, intoxication, and related conditions are big concerns. Assessing Suicide Risk (c) 2017, Wm.H.Reid, MD

9 Myths & Misunderstandings“Suicide is a rare event.” True for the general population, but so is ruptured aortic aneurism. So what? Don’t apply “reassuring” general population statistics to individual patients who present with significant suicide risk. Assessing Suicide Risk (c) 2017, Wm.H.Reid, MD

10 Myths & Misunderstandings, cont.“If someone wants to die, he’ll do it regardless of anything you do.” Bull pucky. Do you think that way about heart disease? Cancer? Even if it were true, we aren’t talking about keeping the patient from ever killing himself, but about recognizing and reducing risk right now and for the near future. Assessing Suicide Risk (c) 2017, Wm.H.Reid, MD

11 Myths & Misunderstandings, cont.“You can’t predict suicide.” The point is assessing RISK, just as in the rest of medicine, not “predicting.” Statistically low risk is very often clinically unacceptable, and may translate to high clinical risk. Assessing Suicide Risk (c) 2017, Wm.H.Reid, MD

12 Myths & Misunderstandings, cont.“It was just a suicide ‘gesture.’” The word “gesture” trivializes suicidal behavior and creates misunderstanding of risk. Avoid it. Would you trivialize such behavior in your own child? The chance of death may be low, but the stakes are very high. Assessing Suicide Risk (c) 2017, Wm.H.Reid, MD

13 Myths & Misunderstandings, cont.“The best way to assess suicide risk is to ask the patient.” or “Patients rarely lie about their suicidal feelings.” No. Just no. Assessing Suicide Risk (c) 2017, Wm.H.Reid, MD

14 DO NOT RELY SOLELY ON PATIENTS’ DENYING SUICIDALITY.Suicidal patients very often lie. You can’t tell when they’re lying. Busch & Fawcett: ~75% of dead suicidal patients denied suicidal thoughts at their last clinical assessment. Assessing Suicide Risk (c) 2017, Wm.H.Reid, MD

15 Assessing Suicide Risk (c) 2017, Wm.H.Reid, MDIf doctors should believe patients who say they’re suicidal, why not believe those who say they’re not suicidal? Here’s the answer: If a patient in your office pulls out a gun, points it at you, and says he’s going to shoot you, you assume there’s danger. If the same patient pulls a gun, points it at you, but says he’s not going to shoot you, you still assume there’s danger. Assessing Suicide Risk (c) 2017, Wm.H.Reid, MD

16 Assessing Suicide Risk (c) 2017, Wm.H.Reid, MDEven honest patients are often inaccurate, mischaracterizing their own symptoms, situations, and risk. Even honest patients can’t predict their own future symptoms, stability, impulses and behaviors. Reliable history, with collateral information and interviews, is very important. Assessing Suicide Risk (c) 2017, Wm.H.Reid, MD

17 Myths & Misunderstandings, cont.“My patients usually provide accurate histories/HPIs.” Many patients give inaccurate or incomplete histories. Intentionally or not, many psych patients, especially those with increased suicide risk and/or clouded thinking, give unreliable histories. Assessing Suicide Risk (c) 2017, Wm.H.Reid, MD

19 Never rely on patient promises or so-called no-harm “contracts”(1) They don’t prevent suicide. (2) They give you & staff a false sense of safety, and decrease your vigilance. (3) They may communicate an uncaring “brush-off” to patients, especially in busy clinics and ERs. Assessing Suicide Risk (c) 2017, Wm.H.Reid, MD

20 Myths & Misunderstandings, cont.“Having ‘something to live for’ decreases suicide risk.” Rich people with caring families commit suicide, too. Severe suicidality is like tunnel vision. The focus on dying obscures everything else. (Even though patients may say other things matter in order to decrease your vigilance). Assessing Suicide Risk (c) 2017, Wm.H.Reid, MD

21 Assessing Suicide Risk (c) 2017, Wm.H.Reid, MDMajor risk factors (e.g., a recent suicide attempt or plan, morbid depression, or mental instability) trump “positive” statistical and demographic factors. Demographics and statistics apply to large groups. They’re irrelevant when assessing risk in individual patients who are at risk. Assessing Suicide Risk (c) 2017, Wm.H.Reid, MD

22 Myths & Misunderstandings, cont.“Catholics (Muslims, members of some other faiths, devout believers) have much lower suicide rates.” Their rates, when carefully examined, are close to those of other religions, or no religion. Assess the individual. Assessing Suicide Risk (c) 2017, Wm.H.Reid, MD

24 Assessing Suicide Risk (c) 2017, Wm.H.Reid, MDDon’t rely on the patient’s denial. Intoxication doesn’t cause suicidality, it just increases attempts and mortality rates. Will he stay sober? Evaluate the patient just as you would if he hadn’t been intoxicated, and note that he has the added risk of substance abuse. Assessing Suicide Risk (c) 2017, Wm.H.Reid, MD

26 Assessing Suicide Risk (c) 2017, Wm.H.Reid, MDHomes aren’t hospitals, and families aren’t mental health professionals. It’s not reasonable to expect professional-grade training, monitoring and protection from even the most willing family. Very few families will actually monitor a patient 24/7 (including in the bathroom). If you need for someone to watch the patient that closely, admit him/her. Assessing Suicide Risk (c) 2017, Wm.H.Reid, MD

27 Assessing Suicide Risk (c) 2017, Wm.H.Reid, MD“Risk Factors” Some risk factors are far more dangerous than others. Don’t just add up numbers or try to balance them. The presence of serious risk factors is much more significant than the absence of others, or so-called “protective factors.” Confluence and synergism are important. Instability and unpredictability are major risk factors. Assessing Suicide Risk (c) 2017, Wm.H.Reid, MD

28 Assessing Suicide Risk (c) 2017, Wm.H.Reid, MDInstability and unpredictability are often critical risk factors, and must be dealt with before releasing the patient to an unprotected setting. Some patients & diagnoses are inherently unpredictable and/or unstable. Be very careful with them! Assessing Suicide Risk (c) 2017, Wm.H.Reid, MD

29 Assessing Suicide Risk (c) 2017, Wm.H.Reid, MDLack of information = risk, just as it is in every medical assessment scenario. Incomplete assessments often require protective action until the situation is clarified. Assessing Suicide Risk (c) 2017, Wm.H.Reid, MD

31 Assessing Suicide Risk (c) 2017, Wm.H.Reid, MDSorry to get your hopes up. There are lots of lists, few are great, some are good, and some are poor. We don’t have time today to get specific. Don’t focus solely on lists! Focus on applying priority concepts (coming up) to the individual patient, getting complete information, using competent consultation, and erring on the side of caution. Assessing Suicide Risk (c) 2017, Wm.H.Reid, MD

32 Assessing Suicide Risk (c) 2017, Wm.H.Reid, MDCompetent consultation: Many counselors in ERs (even psychologists & psychiatric PAs) don’t understand suicide risk. Some work for contract services that use the cheapest people they can find. Some psychiatrists do a poor job, too (AVOID LIGHTNING BOLT), but psychiatrists overall have more training, understand the medical issues better, can help with psychiatric admissions, and are usually the best choice. Assessing Suicide Risk (c) 2017, Wm.H.Reid, MD

33 Assessing Suicide Risk (c) 2017, Wm.H.Reid, MDGetting consultation is good. It enhances accuracy and care, and decreases liability. But remember that you are responsible for the patient’s care and protection. The standard of care may require that you reasonably know your consultant is qualified before you rely on him/her. Know your consultants. Choose good ones. Assessing Suicide Risk (c) 2017, Wm.H.Reid, MD

34 What Increases Risk? (not a complete list)Any wish to die Anything that impairs judgment Anything that impairs impulse control Prior attempts (esp. recent, but many suicides are first attempts) & plans. Some prior suicidal behaviors aren’t obvious. Misperception of reality (e.g., perceived hopelessness of morbid depression or severe anxiety, psychosis, intoxication) Assessing Suicide Risk (c) 2017, Wm.H.Reid, MD

35 What Increases Risk, con.tAnxiety Pain and/or chronic illness/disability Loss (death [esp. by suicide], breakup, loss of health, anniversary of loss) Family history of suicide Early improvement of morbid depression Instability Unpredictability Assessing Suicide Risk (c) 2017, Wm.H.Reid, MD

36 Assessing Suicide Risk (c) 2017, Wm.H.Reid, MDRisk factors interact synergistically, not just additively. Adding up numbers on checklists is not the whole story. Most checklists do a poor job of prioritizing risk factors. Assessing Suicide Risk (c) 2017, Wm.H.Reid, MD

37 Assessing Suicide Risk (c) 2017, Wm.H.Reid, MDChecklists Are not complete assessments. Their usefulness is often overshadowed by rote reliance on them. Good ones are useful for standardizing procedures, being sure important topics aren’t missed, and screening. Be sure you use good one and apply it in a context of complete, narrative assessment. “Screening” is for groups & populations. The assessments we’re discussing are for individual patients. Assessing Suicide Risk (c) 2017, Wm.H.Reid, MD

38 Psych Diagnosis & Suicide RiskDon’t rely too heavily on diagnosis; assess the individual. Depression/mood disorder is an obvious concern, but far from the only one. Don’t assume that “personality disorders” imply low risk. Past diagnoses may be inaccurate or misreported. Assessing Suicide Risk (c) 2017, Wm.H.Reid, MD

39 Some Ways to Reduce RiskExpand the Assessment. so you don’t miss the risk. Protect the Patient. Limit his ability to harm himself. Get Help from Others. Outside info., family, consultation Closely Monitor the Patient. Admit. Assessing Suicide Risk (c) 2017, Wm.H.Reid, MD

40 Don’t be talked out of admitting.Once you believe suicide risk is high, stick to your plan. Resist changing your mind or negotiating once you’ve found high risk. Know how to begin an involuntary admission process. Don’t let friendships or “VIP” patients cloud your judgment. (VIPs often get bad care.) Assessing Suicide Risk (c) 2017, Wm.H.Reid, MD

41 Assessing Suicide Risk (c) 2017, Wm.H.Reid, MDBe adequately trained & experienced. Have access to necessary resources. Be prepared to spend the necessary time. It takes much longer to verify low risk than to decide to admit or call for help. With that in mind . . . Assessing Suicide Risk (c) 2017, Wm.H.Reid, MD

43 Eliciting InformationBe clear. Don’t be shy when asking about suicide. Be specific Be simple. Don’t assume the patient or family knows your clinical terms. Don’t accept vague answers. Clarify. Follow up questions to get the whole story. Assessing Suicide Risk (c) 2017, Wm.H.Reid, MD

44 Confidentiality & SuicideCall the pt.’s other caregivers/counselors for info! Contact with another clinician or facility in the interest of patient care does not generally require consent. People who say it does don’t understand confidentiality statutes. When asking patients for permission to talk with others, don’t just accept “no.” Explain the need and keep asking. Assessing Suicide Risk (c) 2017, Wm.H.Reid, MD

45 Confidentiality & Suicide, cont.Consider “one way” communication. For example, talk with a family member who knows the pt. is seeing you. Explain that you can’t give information without consent, but you need to receive information. Ask relevant but non-revealing questions and encourage the person to share whatever he/she thinks may be important. (Don’t be secretive. Discuss the call/talk with the pt.) Assessing Suicide Risk (c) 2017, Wm.H.Reid, MD

46 Confidentiality & Suicide, cont.I can’t give you legal advice, but here’s how juries and I think about this issue: Censure for good-faith breach of privilege is rare. We value confidentiality & privacy, but they have limits when patients are in danger. I know of no successful breach of confidentiality lawsuit in which the breach was intended to address suicide risk. Assessing Suicide Risk (c) 2017, Wm.H.Reid, MD

47 Assessing Suicide Risk (c) 2017, Wm.H.Reid, MDWhich would make you lose more sleep: Thinking someone might criticize you for seeking important information? Or a patient’s suicide? Which would you rather defend in court, or to your conscience? Which has the greater effect on the patient and his/her family? Assessing Suicide Risk (c) 2017, Wm.H.Reid, MD

48 Assessing Suicide Risk (c) 2017, Wm.H.Reid, MDDocumentation Documentation must meet the needs of you, other caregivers & team members, and future clinicians. Document positive and negative specifics carefully. Document completely, in a narrative format. “No SI” is poor documentation, unreliable, and a red flag for lawyers. Assessing Suicide Risk (c) 2017, Wm.H.Reid, MD

49 Assessing Suicide Risk (c) 2017, Wm.H.Reid, MDDocumentation, cont. Documenting specifics and your judgment process decreases malpractice vulnerability. Plaintiff’s lawyers are very unlikely to question your judgment if they see evidence that it followed a reasonable assessment. Whoever started the old rumor, “If you don’t write it down, they can’t hang you with it,” didn’t understand malpractice litigation. Assessing Suicide Risk (c) 2017, Wm.H.Reid, MD

50 Wanna be a shrink? Liability stuff.Emergency and primary care physicians can do a lot to assess, recognize, and manage suicide risk, but be aware that you may be held to a “psychiatric” standard of care if you keep the patient. Psychiatrists, PCPs, and ER docs may all have to meet psychiatric standards of care when working in similar patient situations. Assessing Suicide Risk (c) 2017, Wm.H.Reid, MD

51 Assessing Suicide Risk (c) 2017, Wm.H.Reid, MDLiability stuff, cont. A patient is entitled to assume that the physician who diagnoses or treats a particular condition is competent to do so. . IMHO, if you choose to assess & treat a psychiatric patient without psychiatric consultation or referral, you are accepting the status of “psychiatrist.” That has potential patient consequences and potential legal ones. Assessing Suicide Risk (c) 2017, Wm.H.Reid, MD

William H. Reid, MD, MPH Clinical Professor: TTUHSC, UT Dell, TAMU

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