Temas estratégicos

Case Example (continued)

Mr. J allowed the EMHS clinician to contact his father and his school for col-lateral information. His father reported that Mr. J “has a mighty temper” but had never committed any acts of violence toward others or property. The school reported that he had been suspended for disruptive behaviors in class but was not considered a dangerous student. When evaluated by the clinician, Mr. J was calm and stated he felt he could maintain his safety as an outpatient.

Although Mr. J was initially reluctant to allow the clinician to talk to his psy-chiatrist, he eventually agreed. The EMHS clinician and psychiatrist deter-mined that the most appropriate disposition for him would be to go home and continue psychopharmacological treatment with his psychiatrist, with a strong consideration of a mood stabilizer trial. In addition, the EMHS team felt that Mr. J would benefit from a referral to a psychotherapist who could help him learn techniques aimed at affect modulation. This referral was made, and Mr. J was discharged after agreeing to the plan. He was given phone num-bers for a suicide hotline and EMHS, with a recommendation to return to EMHS if he were to feel suicidal or unsafe.

The clinician has a duty of care to the patient and, as such, is expected to act affirmatively to protect the patient from self-injurious behaviors. Also, the clinician is expected to practice within the accepted standard of care, which is defined as the conventional practice undertaken by professionals of similar training under similar clinical circumstances. Negligence is determined by a court of law by establishing that the clinician violated his or her duty of care to the patient through omission or commission and that the clinician did not practice within the established standard of care. Although it is not possible to predict suicidal behavior, the clinician is expected to make a reasonable eval-uation of foreseeability based on the interpretation of the data gathered dur-ing the assessment (Berman 2006). Furthermore, the data gathered, the interpretation of that data, and the assessment of the patient based on that data should be rooted in scientific evidence and not solely on clinical

experi-ence (Berman 2006; Simon 2006). Whether duty of care and standard of care were met and practiced in a reasonable and prudent manner is determined through documentation. Therefore, documentation should include the as-sessment of suicide risk, the interventions, and the aspects of the asas-sessment that justify the interventions. The clinician must also document the rationale and the decision-making process for the clinical choices made or rejected at each major transition in the patient’s care (e.g., discharge, change in obser-vation level, admission) (American Psychiatric Association 2003; Berman 2006).

Clinicians must be mindful to assess and document a patient’s proximal suicide risk, based on the presence of a suicide note, access to firearms, a his-tory of near-lethal attempts, a recent and severely stressful life event, and inca-pacitating physical illness (American Psychiatric Association 2003; Moscicki 1997). Restricting the means by which a patient can commit suicide, especially by removal of firearms, must be attempted, and the efforts to restrict means must be documented (American Psychiatric Association 2003).

An integral component of the risk assessment is the collection and docu-mentation of collateral information from family or care providers. In emer-gency situations, and to protect the patient from self-harm or harm to others, the clinician may breach the patient’s confidentiality and contact family and care providers without the patient’s consent as long as the clinician does not disclose patient information (American Psychiatric Association 2003). Prior to any breach of confidentiality, the patient’s permission to contact family and care providers should be aggressively sought, because in addition to obtaining information from the family, it is also essential to involve and educate the family in the patient’s care as a means of attenuating the patient’s risk (Ber-man 2006). Table 2–2 outlines risk (Ber-management and documentation issues relative to suicide assessment and management.

Suicide Prevention Contracts

The suicide prevention contract, also known as the no-harm contract, was originally developed in 1973 to facilitate the management of the patient at sui-cide risk (Centre for Suisui-cide Prevention 2002). Even today, clinicians readily report that patients are either able or unable to “contract for their safety.”

However, despite the widespread use of verbal and written suicide contracts in

clinical practices, no studies have proved their effectiveness in reducing or pre-venting suicide. Clinicians should be warned that suicide prevention contracts are based on subjective rather than objective evidence, are not legally binding, and should not serve as a substitute for careful clinical assessment. Under no Table 2–2. General risk management and documentation considerations in the assessment and management of patients at risk for suicide

Good collaboration, communication, and alliance between clinician and patient Careful and attentive documentation, including:

Risk assessments

Record of decision-making processes Descriptions of changes in treatment

Record of communications with other clinicians

Record of telephone calls from patients or family members Prescription log or copies of actual prescriptions

Medical records of previous treatment, if available, particularly treatment related to past suicide attempts

Critical junctures for documentation:

At first psychiatric assessment or admission With occurrence of any suicidal behavior or ideation Whenever there is any noteworthy clinical change

For inpatients, before increasing privileges or giving passes and before discharge Monitoring issues of transference and countertransference in order to optimize clinical judgment

Consultation, a second opinion, or both should be considered when necessary Careful termination (with appropriate documentation)

Firearms

If present, document instructions given to the patient and significant others If absent, document as a pertinent negative

Planning for coverage

Source. Reprinted from “Practice Guideline for the Assessment and Treatment of Patients With Suicidal Behaviors.” American Journal of Psychiatry 160(suppl):41, 2003. Copyright 2003, American Psychiatric Association. Used with permission.

circumstance should a patient’s willingness or reluctance to enter into a verbal or written suicide contract be used as an indicator for discharge planning, es-pecially from an emergency department setting (Jacobs et al. 2003).

Conclusion

Suicide is a major health problem and one of the most common reasons why people present to psychiatry emergency rooms in crisis. More than 33,000 completed suicides occur in the United States each year, which is equivalent to 91 suicides per day or 1 suicide every 16 minutes. Although only a small mi-nority of suicide attempts end up in death, each attempt increases the risk of death, serious long-term physical injury, and psychological suffering. The prevalence and lethality of suicide differ across age groups, gender, and race/

ethnicity.

Research has clearly identified several risk factors related to suicide. The major demographic features linked to increased risk for suicide are marital state, age, gender, sexual orientation, and race/ethnicity. Approximately 90% of people who have completed suicide have been diagnosed with a major psychi-atric disorder. Psychological factors found to potentiate suicide risk are anxi-ety and hopelessness. Other important risk factors to ask about include access to firearms, childhood trauma, family history, and physical illness.

The depth and breadth of information obtained from a psychiatric eval-uation will vary with the setting, the patient’s ability or willingness to provide information, and the availability of information from collateral sources. A thorough psychiatric evaluation is essential to the suicide assessment. Infor-mation regarding the patient’s psychiatric and medical history, current cir-cumstances, and mental state must be obtained during this evaluation. Two important predictors of suicide are current suicidal ideation and history of suicide attempts. A comprehensive suicide inquiry should include assessment of suicidal ideation, suicide intent, a suicide plan, suicidal behavior, and sui-cide history.

Psychiatric management of suicidal behaviors includes establishing and maintaining therapeutic alliance, attending to the patient’s safety, and deter-mining the patient’s psychiatric status, level of function, and clinical needs to arrive at a plan and setting for treatment.

Key Clinical Points

• The prevalence and lethality of suicide differ across age, gender, racial, and ethnic groups. Understanding that different risk factors and meth-ods used for self-harm pertain to each group can help with determin-ing the most appropriate assessment and treatment planndetermin-ing for an individual.

• Research has clearly identified several risk factors related to suicide.

Demographics, past psychiatric history, psychological and cognitive di-mensions, psychosocial didi-mensions, childhood trauma, family history, and physical illness can all influence an individual’s risk of suicide. The cumulative effect of these factors places a patient at greater risk.

• A thorough psychiatric evaluation should include a review of psychiat-ric signs and symptoms, past suicidal behavior, past psychiatpsychiat-ric and medical history, family psychiatric history, current psychosocial stres-sors and functioning, psychological strengths and vulnerabilities, and a suicide inquiry.

• The essential features of a suicide inquiry are assessment of suicidal ide-ation, suicidal intent, suicide plan, suicidal behavior, and suicide history.

• The management of suicidal patients who present to the emergency department includes a broad array of therapeutic interventions target-ing the suicidal behavior, as well as any comorbid major mental illness-es, personality disorders, psychosocial issuillness-es, and interpersonal difficulties that may be present.

• Perhaps the most important decision made during the evaluation of a suicidal patient in an emergency setting is the determination of appro-priate treatment setting. Psychopharmacological treatment options should also be considered. In the emergency setting, medications can provide significant immediate relief but have time-limited effects that require close supervision of the patient’s mental status, because the ef-fects of the medications can wear off and symptoms may reemerge, with subsequent recurrence of suicidal impulses.

• Those patients at high risk for suicide must be monitored closely or hospitalized until the crisis resolves.

• Documentation should include the assessment of suicide risk, the in-terventions, and the aspects of the assessment that justify the interven-tions. The clinician should note the rationale and decision-making

process for the choices made or rejected at each major transition in the patient’s care (e.g., admission, change in observation level, discharge).

Restricting the means by which a patient can commit suicide must be attempted, and the efforts to restrict means must be documented. Col-lection and documentation of collateral information from family or pro-viders is important.

• Despite the widespread use of suicide contracts in clinical practices, no studies have proved their effectiveness in reducing or preventing sui-cide. Suicide prevention contracts are based on subjective rather than objective evidence, are not legally binding, and should not serve as a substitute for careful clinical assessment.

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Suggested Readings

American Psychiatric Association: Practice guideline for the assessment and treatment of patients with suicidal behaviors. Am J Psychiatry 160(suppl):1–60, 2003

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