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Suicide assessment must be comprehensive to prevent malpractice

Phillip J. Resnick

NEW ORLEANS — During a presentation, Phillip J. Resnick, MD, of Case Western Reserve University, outlined how to comprehensively assess patients for suicide risk based on his experience with malpractice lawsuits involving patient suicide.

“If you have a patient in the hospital commit suicide, there’s a 50% chance that a lawsuit will follow,” Resnick said. “If you have an outpatient commit suicide, there’s a 25% chance that a lawsuit will follow.”

The standard for malpractice states that a clinician must exercise the degree of knowledge and skill ordinarily possessed by members of their profession in the same circumstance.

There are two types of errors that can be made in the eyes of the law: errors of fact and errors of judgment.

“An error of fact would be failing to gather the proper data, meaning not asking the right questions any prudent clinician would ask — such as, ‘Have you ever attempted suicide?’ — or not talking to ... family members or not seeking records from private clinicians,” Resnick said. “The law looks upon that as very serious and [it] can lead to a successful malpractice suit. Once you gather the necessary data and apply your judgment, you’re allowed to make an error of judgment. You don’t have to have the perfect performance, as long as your error in judgment is not so egregious that no prudent clinician would make that error.”

Suicide risk factors

To protect against a successful malpractice suit, Resnick explained the suicide risk factors clinicians should look for and classify.

Dynamic risk factors are subject to change by intervention. These include current suicidal thoughts, current psychiatric illness, substance abuse, unemployment, hopelessness, lack of social support, and life crises such as rejection or a fall in status.

Static risk factors are not subject to change by intervention. These include being male, white, adolescent or unmarried, and past suicide attempts, family history of suicide attempts and chronic medical illness.

Clinicians should assess for acute risk factors as well. These include severe psychic anxiety, anxious ruminations, global insomnia and recent alcohol use.

Suicide assessment

Once risk factors have been identified, an assessment should take place.

“I strongly encourage you not to use note taking, either by hand or electronic record, when you're doing suicide risk assessment,” Resnick said. “It’s important that you have the rapport of being face to face; the patient is less likely to misrepresent if they see you looking at them, and you can pick up clues if someone is looking down or avoiding eye contact when you're asking certain questions.”

He recommended using the suicide ladder, which asks the following questions:

• Do you wish you were dead?
• Do you have suicidal thoughts?
• Do you have a method for committing suicide?
• Do you intend to commit suicide?
• How close have you come to attempting suicide?

Some individuals have aborted suicide attempts and therefore may skirt around providing honest answers. Resnick emphasized the importance of phrasing for this patient population.

“There is a high correlation between aborted attempts and people who go on to complete,” Resnick said. “So, if you ask this person, ‘Have you ever attempted to kill yourself?,’ she can honestly answer ‘no’ because she didn’t pull the trigger. But if you say how close have you come to killing yourself, you elicit these aborted attempts.”

Be aware of the path to suicide, Resnick said, which includes a suicidal idea followed by a suicidal plan, preparation, rehearsal and a suicidal act.

Risk for suicide increases as plan specificity increases, such as availability of a lethal method or actual preparation.

Resnick instructed clinicians not to accept disavowal of suicidal plans. Look at objective data, such as patients’ current eating patterns, and involve family in treatment.

Relatives should look for mentions of suicide, giving up, putting affairs in order, making final goodbyes, and acquiring a weapon.

Standard of care

Resnick said a standard of care exists for the assessment of suicide risk but not the prediction of suicide.

“We are absolutely unable to accurately predict suicide. Study after study shows we are not able to accurately predict suicide,” he said. “You’re not held to the standard of predicting suicide. You are held to a standard of doing an adequate suicide risk assessment and then if the risk factors are overwhelming, taking appropriate steps.”

To conclude, he reminded the audience that once an individual has decided to commit suicide, he or she perceives the clinician as an adversary rather than an ally.

Further, although depression predicts suicidal ideals, actual suicide attempts are driven by anxiety and poor impulse control.

Lastly, the importance of documenting risk assessment is “the single best way to reduce a successful malpractice case,” Resnick said. – by Amanda Oldt

Reference:

Resnick PJ. Suicide risk assessment and malpractice prevention. Presented at: U.S. Psychiatric and Mental Health Congress; Sept. 16-19, 2017; New Orleans.

Disclosure: Resnick reports no relevant financial disclosures.