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Residency Policies & Procedures
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.
- Call the psychiatry residency office to inform the training director.
- Inform your attending (the attending of record) as well as your supervisor
(if this differs from your attending).
- Make a plan with your attending for completing subsequent tasks:
- 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.
- 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.
- 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.
- 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.
- 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.
- 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.
- 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.
- 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.
- 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).
- 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.
(Approved by the RESC on 12/11/2006)
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