Compassion and vigilance

Patient suicide is a rising issue in US healthcare. HRMR explores what can be done to reduce the risk and to ensure patients receive the help they need to survive such a crisis.

Some years ago, Dr Ronald Wyatt was stunned to learn that a female patient who had recently visited his practice had committed suicide.

“I had never detected any reason she would be at risk,” recalls Wyatt, who is now medical director in the Division of Healthcare Improvement at The Joint Commission.

“She seemed well: no chronic illnesses; her visits were mostly for things such as sinusitis and bronchitis, but I was in practice one day and a detective came to ask me if I had detected any signs that she might be suicidal. I had detected nothing. By all measures she was well adjusted.”

Wyatt’s record-keeping had been thorough so he was not deemed to have been negligent, but the case haunted him until one day he had a visit from the woman’s sister. She reassured him that it had not been his fault, and related a devastating tale of the events in the patient’s personal life that had led to her death. The patient had kept this information from Wyatt, so he had had no insight into her true state of mind.

This is one of the biggest problems with preventing patient suicide: the warning signs are not always plain to see, and very often are not even hinted at by the patient’s past medical history.

“We know that most people who die by suicide have received healthcare services in the preceding year,” says Wyatt. “However, most of them were seen for reasons other than risk of suicide—often not for mental health issues, and the suicidal ideation was not detected in that encounter.”

Digging deeper after a case of suicide, certain risk factors are often uncovered: a family history of suicide; trauma; death in the family; drug or alcohol abuse; a serious economic setback; or behavioral health issues.

In the case of the latter, the highest risk period is within the first 30 days of discharge from an outpatient or behavioral health setting, says Wyatt. The risk is especially high in the four weeks following discharge.

Other risk factors can include chronic illness, either of the individual him/herself or of someone close to them—a situation that can sometimes result in a homicide-suicide. Previous suicide attempts can double the risk of a completed suicide.

“The risk remains high beyond the first year and is higher in the first few weeks after the attempt,” says Wyatt. “However, there are people who commit suicide who don’t have any of those risk factors. There is no typical person who commits suicide.”

A difficult diagnosis

Richelle Heldwein, assistant vice president of clinical risk management for Western Litigation, agrees that the risk factors are not always easy to detect.

“More than 40,000 people commit suicide each year in the US; it’s the 10th leading cause of death—yet it involves less than 0.5 percent of inpatient psychiatric admissions,” she says.

“When a case involves a psychiatric inpatient, juries often feel—rightly or wrongly—that it was the hospital’s job to prevent the suicide, no exceptions." Andrew Efaw

Nevertheless, when you look at the broader healthcare environment, inpatient suicide is an issue that needs to be considered very carefully. The true scope of the problem is often difficult to glean from statistics, especially as most ‘inpatient’ suicides occur when the patient has discharged him/herself or is on approved leave.

“The risk of inpatient suicide is real,” says Heldwein. “It has always existed and always will; it is not possible to eradicate the phenomenon. Statistics about inpatient suicide rates can be informative but are often confounded. For example, fewer patients spending fewer days in the psychiatric unit means that more psychiatric patients are out on the street.

“Suicides among this group are not counted as part of the inpatient population. On the other hand, only the sickest patients remain. Theoretically, the suicide rate among this population will be higher. Our ability to draw specific conclusions from such statistics is limited.”

A rising problem

One thing is clear: the risk of suicide is increasing, both among the general population and within the inpatient setting.

“We know it’s on the rise—Centers for Disease Control and Prevention (CDC) data tells us that, and it includes pretty much all settings: inpatient, behavioral health settings, specialty care,” says Wyatt.

The CDC data shows that between 2000 and 2013 rates moved from 10.4 to 12.6 deaths per 100,000, making suicide the 10th leading cause of death in the US in 2013.

Besides the tragedy of suicide, the trauma for the victim’s loved ones and the emotional repercussions for their care providers, suicide cases raise legal issues, the most serious of which is a malpractice lawsuit.

“Liability associated with suicide used to be a non-issue,” says Andrew Efaw, a partner with law firm Wheeler Trig O’Donnell. “If you look back a few hundred years, it was generally considered an unforgivable sin for which no one was responsible but the suicider.”

More recently, says Efaw, suicide was considered an intervening act for which no healthcare provider could be responsible. The modern trend, however, examines foreseeability and supports liability against healthcare providers if a judge or jury decides that a particular suicide was foreseeable.

“When a case involves a psychiatric inpatient, juries often feel—rightly or wrongly—that it was the hospital’s job to prevent the suicide, no exceptions. The reality is that individual suicide is unpredictable. When a suicide becomes a lawsuit, healthcare providers and their lawyers must overcome hindsight bias. Hindsight bias is the tendency to overestimate the probability of a known outcome and the ability of decision makers to have foreseen it.”

Suicide is multifactorial event, adds Efaw. Individual suicide is not predictable, but healthcare givers must be able recognize broad risk factors that inform their decisions about suicidal patients. Comprehensive suicide risk assessment with a nationally recognized tool and scale for risk are an absolute must for patients.

However, the director of VA’s National Center for Patient Safety Field Office Dr Peter Mills adds that it is important to be mindful of the limitations of these risk assessments.

“There are many tools on the market that allow staff to do an assessment of the patient to see if they are at risk for suicide,” he says. “Unfortunately, these tools rely on the patient answering questions honestly to categorize them correctly, and they can be very subjective. So while it is good to screen all patients with an assessment, it is not a guarantee that it will identify all patients at risk.”

Wyatt’s opinion is similar: sometimes the patient’s outward presentation will not be aligned with his/her true thoughts and intent. However, he does have faith in risk assessment tools to give a clearer, if not perfect, picture.

“Some suicidal patients are as calm as can be. Other patients might be hysterical and excited but not suicidal even though they say they are. That’s where a reliable risk assessment tool can be applied: it gets you closer to knowing their true risk level.”

The other issue is knowing when it is appropriate to carry out a suicide risk assessment. It is not something healthcare providers will do on every visit but, says Wyatt, but it should be done as part of a periodic health assessment, especially if you pick up anything that changes clinically.

Gaining a comprehensive medical history is an important part of assessing suicide risk, he adds. This should include the family history, as this can reveal risk factors.

Sounding the alarm

While many suicidal patients are reluctant to open up about their thoughts, others directly seek help from their healthcare providers.

“Sometimes a patient comes in and says, ‘I’m going to kill myself’,” says Wyatt. “In that case the risk assessment is considered done and the priority is to get them into care as soon as possible. The rest of your working day needs to be laid aside while you dedicate every resource and energy to getting them to that safe place.

“The problem is that one of the biggest weaknesses in our health system is mental health provision, so they can end up in the emergency department, who will have to recruit the resources to go one on one with the patient until you get them assessed.”

In this type of scenario, a suicidal patient can end up in the care of people who are not trained in the risk of suicide, and in a setting that has not been adapted to help keep that patient safe.

“Most average hospital rooms are not laid out for suicide prevention,” says Wyatt. “Patients have been known to use bandages, sheets, oxygen tubing, shower heads and curtains to commit suicide.”

Putting a person in an environment that decreases that risk of suicide to zero is almost impossibly challenging for a hospital to do. Even in a behavioral health setting, which is generally better equipped for protecting patients, patients do manage to commit suicide. It has been known for fellow patients to stand as lookouts for the person who wants to commit suicide.

“On other occasions patients in a behavioral health setting have used an event, such as another patient attacking staff, to commit suicide while staff attention is elsewhere,” says Wyatt. “We’ve also had situations where staff come in and interrupt the suicide attempt but are so horrified and mortified they don’t know how to act because they have not been properly trained.”

Efaw agrees that total safety is nigh-on impossible.

“The environment of a psychiatric unit can be safer with furniture fastened in place, break-away shower rods and sprinkler heads, and limiting access to sharp objects,” he says. “However, no unit can be made ‘suicide-proof’. Clinical judgement ultimately must be used to decide what level of artificiality will make for a safe patient environment.”

This ‘level of artificiality’ is likely to include surveillance. However, it is not enough to have video surveillance in place, says Wyatt: there needs to be adequate staffing to have it monitored in real time.

“The single most effective thing that a provider can do is conduct a robust assessment of the patient, and then place the patient under appropriate supervision,” agrees Efaw. “However, no foolproof method exists to prevent inpatient suicide.”

He adds that is important to note that all treatment must be balanced against patient rights.

“Suicidal patients could be physically and chemically restrained indefinitely and thereby sharply decrease the chance of suicide. However, such a methodology doesn’t effectively advance patient rights or the therapeutic goals of treatment. Effective treatment inherently involves risk.”

The importance of follow-up

Deciding whether a patient is at risk of suicide is just one part of an effective response. It is also vital to ensure that they get the care they need, both in the short term and in terms of follow-up care.

A large part of decreasing the risk of suicide, says Wyatt, is to have strong leadership and strong, well-established links that will help get a suicidal patient to the safest setting possible.

When it comes to the longer term care, it is worth remembering that the statistics show that patients remain at risk of suicide over the weeks and months following a suicidal crisis. It is vital to involve family and friends where possible, and also to link the patient and their support network to community resources that can aid their survival and recovery.

“Referral to a proper level of care, and appropriate levels of observation, are critical to keeping patients safe, as are providing resources and a safe discharge that include follow-up care and treatment,” says Mills.

Successful follow-up care includes not just involving family and friends and keeping them informed but also reviewing the patient’s risk of suicide, says Wyatt. It is vital to ensure they have a strong support network, be it made up of family and friends or other agencies that can help. The home environment may need to be reviewed to remove objects that could cause harm.

There also needs to be a system that is activated if a patient misses a medical appointment.

“Being proactive and making sure you know the services that can respond to them is important,” says Wyatt. “Texts, phone calls—all you can do to decrease the risk of suicide matters. You need to be getting back in touch with them and getting them into ongoing care.”

Ultimately, he adds, providers need to remember to be compassionate, and to present a caring, human face to patients in the depths of crisis.

“It comes down to documenting that you really care. Let them know when you care about them: they will feel it. You may be their last opportunity to stay alive, and you have to be really sensitive to that.”