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Your ED could be liable if suicide assessment is poor
Assessments often done "haphazardly" by staff
NOTE: This is the first in a 2-part series on liability risks of psychiatric patients in the ED. Next month, we'll report on risks related to medical clearance of psychiatric patients.
A man is brought to your ED by his wife, who claims her husband is suicidal. You ask him if this is true and he convincingly tells you, "Absolutely not," adding that his wife is overreacting.
Does your assessment end there? If so and this patient later harmed himself, you could be held liable-and ED physicians have been sued for just this scenario.
"Psychiatric patients often get marginalized in EDs because of long waits and ambulance diversion, and can end up waiting 8 or 10 hours or longer and then leave," he says Robert I. Simon, MD, clinical professor of psychiatry and director of the program in psychiatry and law at Georgetown University School of Medicine in Washington, DC. Simon is author of Assessing and Managing Suicide Risk: Guidelines for Clinically Based Risk Management; published in 2004 by American Psychiatric Publishing.
By doing a thorough assessment for suicide risk, you might learn additional details that would make it very apparent that the patient was at high risk for suicide. (See Table 1, SAD PERSONS Scale.)
For instance, a family member might reveal risk factors that are highly specific to the patient waiting in your ED-information you wouldn't otherwise know. "The family may tell you that he stutters and when he stops stuttering, he is at high risk for harming himself. Those are the kind of things you won't find in any textbook," says Simon.
Suicidal patients are more likely to go to general EDs, which lack the resources of psychiatric emergency services in large medical centers, adds Simon.
In many EDs, suicide risk assessment is done "pretty haphazardly," says Glenn Currier, MD, associate professor of psychiatry and emergency medicine at the University of Rochester (NY) Medical Center. "This is especially true of smaller EDs that don't evaluate many psychiatric patients, and also those without an electronic medical record to prompt disease-specific questions and guide assessment," he says.
Here are ways to reduce risks when caring for a potentially suicidal patient in the ED:
"Your assessment doesn't have to be fancy, but it does have to be adequate," says Simon. The purpose of a suicide risk assessment is to identify factors that inform patients' overall treatment and management requirements, with the goal of answering the question: Does the patient qualify for hospital admission or not?
A suicide risk assessment identifies acute and chronic factors as well as protective factors that may reduce risk, but it's the acute risk factors that will be the deciding factor in whether the patient is admitted or discharged from your ED. Your main concern is discharging the patient who is actually planning to harm themselves, but on the other end of the spectrum, patients may claim to be suicidal when they're actually looking for a place to sleep, says Simon. "It's important to assess behavioral risk factors, so as not to be totally dependent on what the patient is telling us," he says. These include agitation, severe depression, symptom severity, self-inflicted injuries, and responding to hallucinations.
There is no research showing that any one particular method can predict suicide, because none can. Your goal is to identify treatable risk factors which guide you as to whether the patient should be admitted or not. "You have to spend the time to do this," says Simon. "The problem is that many people have never been trained in how to do suicide risk assessments."
Assessments must be done consistently, no matter how "believable" the patient is. In one case, a physician was brought in by his family who told ED staff that he had made a noose and was threatening to hang himself. "He totally denies it, and because he's a physician, his statement is given credibility and is discharged," says Simon. The physician committed suicide within two hours after his ED visit.
After you do a risk assessment, you may learn that the patient is unable to work and is having marital problems. "Then all of a sudden you have a different picture," says Simon.
Your patient may have stashed a bottle of pills or purchased a gun with the intent of harming themselves, but ED staff may never learn this if only a cursory assessment is done.
Always ask the patient specifically whether they have access to a gun, advises Simon. If the patient is going to be discharged, then tell a responsible person to remove any guns from the house and secure them so that they cannot be obtained by the patient. Always ask for a call back from this designated person to confirm that these steps were taken, and document that you asked for this confirmation.
"It can be an element of a malpractice claim that a callback was not requested when significant others were instructed to secure guns," says Simon.
"I have testified in several malpractice cases involving the scenario of suicidal patients discharged from the ED," says Currier. "The one issue that appears almost constantly is that people do have a logic in mind for their decision, but they simply don't document it." As a result, the lawyers are free to challenge the thoroughness of the assessment.
"It's pretty clear that predicting suicide is an imprecise science, and physicians don't usually get nailed simply for making the wrong prediction about immediate risk," says Currier. Usually, once the physicians and nurses are deposed, it becomes clear that a reasonably thorough assessment was conducted but not documented by anyone. However, if better charting had occurred, the case would probably not have gone forward in the first place, says Currier.
If an ED physician decides to discharge a patient who was said to be potentially suicidal at triage, you should document the following at a bare minimum, says Currier:
Currier recommends memorizing and documenting the following "punchline" in the patient's chart: "Based on the information available, this patient appears reliable, declines voluntary psychiatric care, and is asking to be discharged today. I do not believe he/she is at higher than usual risk of self harm and is not legally detainable at present. Patient and family were advised to come back to the ED should suicidal thoughts or plans worsen, and they agreed to do so."
"It's a lot to write, but 5 minutes during the shift could save you a court date later," says Currier.
Sometimes ED physicians assume that since a social worker or other individual did the mental health assessment, or the decision to discharge was made based on a phone conversation with the patient's psychiatrist, that they will be "off the hook" if that patient leaves the ED and commits suicide, but this is a mistaken assumption. "The ED doc assumes that since the social worker is really guiding the decision, that individual would be the point of reference for any aftermath that occurs. But that's not the way it works out in court," says Currier.
To protect yourself, you must document the logic behind your decision. Give a detailed version of why the decision was made, and use this wording: "I don't believe that this patient is at imminent risk of harm." "Otherwise, a patient can commit suicide three years after the ED contact, and from a liability perspective it can be a problem for you," explains Currier.
The patient may vehemently insist they are not suicidal and were taken to the ED inappropriately, but instead of taking this at face value, "triangulate the history with somebody who knows the patient well," says Currier.
He gives the following example: A man who recently lost his job, is sullen and isolated, and has begun drinking alcohol more often than usual. He's brought in by police after making vague statements about not being able to "take it anymore" while being picked up for driving while intoxicated, but sobers up in the ED and flatly denies any intent to harm himself.
"The guy has no criminal or psych record and he talks a great game," says Currier. "But in talking to his wife, you get the feeling that there has been a really obvious decline in his ability to cope with even his own hygiene, and he has been eyeing his hunting rifles with a lot more interest lately, and recently bought ammunition even though hunting season is long over," says Currier. "That's the tipping point for admission."
Any decision to discharge this man that does not include written evidence of awareness of these new and important risk factors will be hard to justify. "Including this information in a note, but saying that the risk is nonetheless outweighed by other factors, is defensible no matter what the ultimate outcome," says Currier.
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1. Claassen CA, Larkin GL. Occult suicidality in an emergency department population Br J Psychiatry 2005;186:352-353.