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Psychiatry Residency Training Program
 
  Applicants Department GME Office Home School of Medicine UW UWHA

Residency Policies & Procedures
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V. CLINICAL ROTATIONS

Guidelines following Patient Suicide


Patient suicide is a dreaded potential consequence of psychiatric illness. Such an event requires the treating psychiatrist to respond in a manner that fulfils a number of roles and responsibilities that arise, while also attending to powerful emotions. The ideal outcome of this painful process is the organized completion of immediate responsibilities and the careful resolution of emotional responses to promote higher levels of personal and professional growth and responsibility.

The guidelines and recommendations outlined below are intended to be helpful in identifying immediate responsibilities and potential resources and sources of support for residents following a patient suicide. Since every case is unique, and presents its own issues, these are intended only as general guidelines, to be modified as appropriate for the individual situation. However, in every case of a patient suicide, and other serious adverse outcomes (e.g. the non-suicide death of a patient, violence, arrest of a patient), the resident should immediately notify the supervising attending and residency director for guidance.

I. Attend to Immediate Responsibilities
A psychiatrist has a number of responsibilities following patient suicide. Carrying out these responsibilities often occurs during a period of shock and disbelief upon hearing of the suicide of a patient. The following protocol is meant to help organize the immediate responsibilities following this event.

  1. Call the psychiatry residency office to inform the training director.
  2. Inform your attending (the attending of record) as well as your supervisor (if this differs from your attending).
  3. Make a plan with your attending for completing subsequent tasks:
  4. a. Chief of Service - Your attending should notify the Chief of Psychiatry at the clinical site and the Director of the clinical service(s) involved in the care of the patient, and the Assistant Training Director at the site.
    b. Risk management - Call the risk management office at your training site for information and suggestions on how to proceed with contacting the patient's family members and completing the medical record. At VA sites, write an incident report and contact the Chair of the Suicide Committee.
    c. Family members - The patient's privacy rights do not end at death. You may call the patient's legally authorized representative and/or those in the patient's family who you know were involved in the care of the patient and were aware of their treatment to express sympathy and support. Offer to meet with the family with your attending or supervisor. Disclosures of protected health information about the deceased patient are still limited by the HIPAA privacy regulations and ethical and legal requirements for confidentiality remain in place. Only discuss protected health information of which the family has knowledge. You may need to inform family members that your disclosures are limited by State and Federal privacy laws.
    d. Staff - Your attending should notify other staff members who may have been involved in the patient's care or who may be affected by the patient's death.
    e. Other patients - If other patients were involved in treatment settings with your patient, make a plan with your attending about disclosing information to other patients. You may contact the entity Privacy Officer for assistance as well. Points to consider include - to whom to disclose information; what information to disclose; when to disclose information. A general guideline is to disclose only information that has been available through third-party, public sources - i.e. information that is not confidential, protected health information, and/or only provide that information which had already been available to the other patients in the treatment setting and public sources.
  5. Administrative case review - Following an adverse outcome, administrative and clinical leaders will routinely review the circumstances of the event for medical-legal and quality assurance purposes. This administrative case review differs from a suicide case review conference that is meant for educational purposes. Psychiatry residents may or may not participate in the administrative case review process.

References:
Cotton PG, Drake RE Jr, Whitaker A, Potter J. Dealing with suicide on a psychiatric inpatient unit. Hospital and Community Psychiatry 1983; 34(1):55-9.

Kaye MS, Soreff SM. The psychiatrist's role, responses and responsibilities when a patient commits suicide. American Journal of Psychiatry 1991; 148(6):739-43.

 

II. Access support for managing emotional experiences
After an initial response of shock and disbelief, common emotional responses to patient suicide include grief, guilt, anger, betrayal, sadness and sometimes relief. Levels of distress in the therapist survivor are sometimes comparable to distress in clinical populations of bereaved individuals seeking treatment after the death of a relative. "Severe distress" is often characterized by grief and guilt. Effective understanding and management of emotional responses following patient suicide facilitates personal and professional growth.

  1. Informal peer support - Case reports and surveys of therapist survivors consistently report that informal peer support from family, friends and professional colleagues is the most beneficial factor in managing emotional experiences following patient suicide. Residents may choose to devote a portion of T-group time to discussing these experiences.
  2. Supervision - Discussions with past and current supervisors are often helpful in managing responses to patient suicide. This is especially the case if the supervisor can share personal experiences of patient suicide.
  3. Literature review - Many therapist survivors have written case reports describing their experience with patient suicide. Reviewing these reports may decrease the sense of isolation that follows patient suicide.
  4. Personal psychotherapy - Individual psychotherapy may be helpful to residents in dealing with emotional responses to a patient suicide.

References:
Gitlin MJ. A psychiatrist's reaction to a patient's suicide. Am J Psychiatry 1999; 156:1630-1634.

Kolodny S, Binder RL, Bronstein AA, Friend RL. The working through of patients' suicides by four therapists. Suicide and Life-Threatening Behavior 1979; 9(1)33-46.

Reeves G. Terminal mental illness: resident experience of patient suicide. Journal of the American Academy of Psychoanalysis and Dynamic Psychiatry 2003; 31(3):429-41.

 

III. Suicide Case Review
Following the suicide death of a patient, a suicide case review allows for an examination of the circumstances surrounding the death - including the suicide risk factors, protective factors for suicide and treatment interventions - as well as an opportunity to express emotions related to the case. While it is never clear whether any specific action or inaction played a causal role in patient suicide, case review fosters professional responsibility by allowing the clinician to learn from the negative outcome in a way that may benefit future patients. An ill-timed case review or a case review conducted with a blaming tone can be harmful to clinicians. To avoid these harmful effects, a case review should be conduced after some resolution of negative emotional experiences (especially grief and guilt) and with the acknowledgement of the uncertainty involved in predicting suicidal behavior.

  1. Setting of a case review - A suicide case review may take place in any professional setting that fulfils the educational function of the process. For cases involving a treatment team, this may be in a staff conference or larger morbidity and mortality conference, which should be approved by the Chief of Service to ensure that appropriate institutional confidentiality requirements are observed. For patients seen in individual psychotherapy, this may be in individual psychotherapy supervision.
  2. Components of a case review - For educational purposes, a case review should consist of the following components:
    a. General circumstances of the case - Treatment setting, presenting symptoms, events leading up to the suicide.
    b. Risk factors for suicide
    c. Protective factors for suicide
    d. Assessment of suicide risk
    e. Treatment interventions for suicide
    f. Other interventions that may have been implemented to modify risk or protective factors.

References:
Hendin H, Haas AP, Maltsberger JT, Koestnere B, Szanto K. Problems in psychotherapy with suicidal patients. American Journal of Psychiatry 2006; 163(1):67-72.

Schneidman ES. Suicide, lethality and the psychological autopsy. International Psychiatry Clinics 1969; 6(2):225-50.

 

IV. Professional Growth and Responsibility
Following an experience with patient suicide, clinicians may benefit from modifying their professional practices and engaging in altruistic activities to help others prepare for or cope with this experience. Please discuss with your supervisor activities such as public sharing and publication of experiences, to ensure that you are following appropriate confidentiality and HIPAA guidelines.

  1. Suicide risk assessment and documentation - Clinicians should review their suicide risk assessment and documentation practices. Documentation should include a review of relevant risk factors, assessment of suicide risk, interventions to modify suicide risk and justification for the level of care (justification for not initiating higher levels of intervention).
  2. Altruistic activities
    i. Public sharing of experiences
    ii. Organizing educational activities related to patient suicide
    iii. Publishing literature
    iv. Reaching out to other therapist survivors

References:
Reeves G. Terminal mental illness: resident experience of patient suicide. Journal of the American Academy of Psychoanalysis and Dynamic Psychiatry 2003; 31(3):429-41.

Sung, J. Clinician's Response to Patient Suicide.

 

(Approved by the RESC on 12/11/2006)

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