The ED physician did not fall below the standard of care by not consulting a psychiatrist. Many places, mine included, psych will not see patients in the ED. This patient had the capacity to make his own decisions, was not demonstrating signs or symptoms of AMS/intox/psychosis, and was not in any imminent danger to himself or others. While sad this man took his life, the ED physician did not contribute to his death. I would like to see the RN and physician documentation to see how they justified their assessment and decision making.
As a consult psychiatrist, I agree with you. Lot of good comments in this thread, frankly. Suicide risk triage is a personal interest of mine and (probably rightly so) a common source of liability anxiety in psychiatry, so I have a number of thoughts about this case.
1) Strictly speaking, I would probably have to yield to EM physicians on deciding what the SOC is for EM physicians, but I would be uneasy saying that failure to consult a specialist automatically rises to an SOC violation unless it's a matter that the EM physician does not have the training to sufficiently address. While this would be a totally reasonable psych consult, in my view EM physicians are perfectly capable of proposing psychiatric diagnoses and conducting suicide risk assessments if they feel comfortable in those arenas. Plaintiff's expert suggests that EM physicians should just stay totally hands-off of suicide risk assessment, and I think that's both asinine and, frankly, implausible in the many areas that have shortages of psychiatrists.
2) I think you hit a key point in questioning what the documentation looked like. That's honestly what would make the difference for me whether the SOC was met here, rather than failure to consult a psychiatrist. Suicide is *notoriously* unpredictable, both in the sense that it can occur with no particular warning signs, and that most patients who present as "high risk" on paper do not ultimately kill themselves. The SOC does *not* call for a clairvoyant prediction of the future. What I would look for is that a reasonable suicide risk assessment was performed, and that the EM physician's plan followed logically from that risk assessment. At least in psychiatry, liability does not automatically follow a successful suicide; it follows when the psychiatrist negligently fails to respond to a "foreseeable" suicide, which usually means that the risk assessment itself was negligent, or the risk assessment was accurate but the plan lacked the appropriate urgency.
3) Moreover, I respectfully disagree with MMR's interpretation of a high acute suicide risk. Suicidal statements are concerning, but in this case it didn't sound like it was accompanied by any preparatory actions or plan other than vague contemplations of method. It had a clear, abrupt trigger (as opposed to SI emerging in a severe, longstanding depression) and the patient disavowed the statements on evaluation, suggesting that his cognitions about the stressor had mellowed compared to when he made the statements. You could argue - accurately - that his acute risk is elevated compared to the average person, but that doesn't automatically punch your ticket to a psych hospital, and indeed in my state this presentation would not meet involuntary commitment criteria. So I struggle to see how the EM physician would be liable if the patient wanted to go home and could not be compelled to a different course of treatment, consultation or no.
4) The fact that the decedent killed himself *over 2 weeks* after the ED visit should seriously call into question any "causation" arguments. If the decedent urgently desired death and the EM physician somehow missed this, I fail to understand why, after securing discharge, he didn't simply go home and kill himself. As another commenter pointed out, if a patient truly wants to end their life, we don't always have great power to stop them. We can't be mind police.
5) One way I think about psychiatric hospitalization is that it is designed to emergently change the risk equation when you're facing a high acute risk and cannot quickly or confidently remove modifiable risk factors. The psych hospital is designed to ensure their safety while the modifiable risk factors are...well, modified. My question with hospitalization in this case would be, what endpoint are we looking for? He didn't make any suicide attempts or self-harm and disavowed suicidal ideation in the ED. So if he went to a psych unit, what would have to change to be suitable for d/c? Do we keep him there until he pinky-promises he won't kill himself? Do we keep him there until he moves on from his marriage? Do we keep him there until the Sun explodes because he'll always have the fixed risk of being an older male divorcee who owns guns? I guess what I'm asking is, what would the psych hospital treat? His statements?
6) The twist about the wife just really leaves a bad taste in my mouth. So she starts hanging around with another man, asks for a divorce, and then sues for $5 million when a suicide results 18 days after his contact with the defendant. I routinely interface with ED psychiatry, and cases like this add a troubling cognitive bias toward committing patients (despite actual need, or consequences of hospitalization) if they get anywhere close to the criteria for it, just to cover our asses.
Thanks for the thoughtful response and respectful critique! This may be a function of only having worked at large hospitals with lots of resources, but every place I've worked this patient would have been seen by someone from the psych department (often not the physician, could be a nurse or social worker). I'm curious how you feel about the need to get collateral information in a situation like this? Is collateral info mandatory to meet the standard of care? I'm not the mind police but a patient who tells his wife, police, and EMS that he's thinking about "blowing his brains out", then abruptly changes his mind a few minutes later seems particularly worrisome. I think I would have admitted him against his will. We can't modify the underlying social stressors that led to this, but we can at least place time and temporary distance between him them, and he would have gotten attention focused on his own personal psychiatric state rather than the marriage counselor who likely focuses just on the relationship itself.
Dec 12, 2023·edited Dec 12, 2023Liked by Med Mal Reviewer
Honestly I think you're pretty justified in your worries. My (respectful) disagreement may be because I trained and work in a state with a very high threshold for involuntary commitment (basically, you have to show suicidal action, not just thoughts or plans). I also have a decent bit of experience working with borderline personality disorders, where there's a high tendency for frequent, but short-lived suicidal ideation in response to routine stress, so I think I've come to prioritize evidence of suicidal *action* rather than thoughts alone before I push for commitment.
If I were evaluating a patient like this in my state, I might offer voluntary hospitalization depending on the specifics of my risk assessment, but often the best we can do is proactive safety planning. Securing the firearms, orienting to crisis resources, clear return counsel, etc.
To your question, I *would* seek collateral especially if there's a disconnect between the secondhand story ("my husband said he's going to blow his brains out") and the face-to-face with patient. I think you actually had a previous case (where the patient jumped out of a car) where this point was highlighted.
I think you bring up key points that reinforce my desire to see documentation. I think if the defendant in this case did not document a suicide risk assessment, or did not attempt to interface with collateral, there could be a SOC point raised. I still think this case would fail at trial (assuming an informed jury) because the causation aspect should be torn apart by a competent defense attorney. If the defendant were "foreseeably suicidal" requiring psychiatric hospitalization, I would not expect him to take him 18 days to kill himself with neither his wife nor his marital therapist detecting anything amiss.
If an individual is determined to take his life, they will. As a neurologist, I once cared for a comatose patient who it turned out had taken an overdose in a suicide attempt. He survived and was discharged to a psychiatric facility. After several days there, he was discharged to home and promptly killed himself. Also, a local psychiatrist was sued a number of years ago after his patient killed himself. The judge reversed a jury verdict against the doctor reasoning that the psychiatrist should not be expected to predict the future with certainty. Even in psychiatric facilities, suicides can and have taken place.
This is a key point to emphasize. It's been pretty solidly established in psychiatric malpractice case law that psychiatrists aren't liable simply because they fail to divine the future. Nor are they liable for failing to control the actions of patients who have not met the criteria to be compelled to involuntary treatment. Both I think are relevant to this presentation. Liability from suicide results when psychiatrists negligently fail to respond to a "reasonably foreseeable" suicide. That's still frustratingly vague legal phrasing in my opinion, but the way I interpret it is that if a psychiatrist makes a reasonable suicide risk assessment, and their plan is sensible based on that risk assessment, they are generally insulated from liability. A risk assessment that winds up being "wrong in hindsight" is not necessarily the same thing as a "negligent" risk assessment.
I think there's a more fundamental question here: Why is one adult (ER doc) made responsible for the decision of another adult (decedent)? To do so removes agency from the patient. With removal of agency comes removal of dignity and self-determination. With removal of agency and self-determination comes loss of reason to exist/existence. One is made, factually, a child once again.
I'd be willing to bet that the answer, medico legally, lies in the concept of capacity. If you and I determine that an ED pt lacks capacity, s/he *is*, medico legally, a child, ie., a human who cannot make decisions for themselves.
Very interesting. I am a consult psychiatrist. My thoughts--
this patient would certainly have gotten a psych consult everywhere I have worked.
I do not think admitting the patient would have stopped his suicide. He committed suicide the day after thanksgiving. The chances someone like this, who was suicidal in the context of a psychosocial stressor and may or may not have met criteria for a mood disorder, being admitted to inpatient psych for *18* days, even assuming he met criteria in the beginning, are essentially zero in every inpatient psych unit I've ever worked. Even if he'd been admitted, he probably would have been discharged after 3-5 days, and whatever happened on or around thanksgiving (obvious speculation here--not being with his wife? being with her and finding out about the affair?) still would have happened.
that being said, as a psychiatrist, my documentation would undoubtedly have looked different from the ED docs by virtue of being a specialist. More speculation, but unless the patient had a prior depression diagnosis I likely would not have diagnosed depression on the basis only of the acute incident. it's classic of non-psychiatrists to assume that suicidal ideation = depression. also, my documentation would have clearly laid out chronic vs acute and modifiable vs. unmodifiable risk factors. If i could not admit a patient like this, in clearing for discharge i would likely have specified that the patient did not meet involuntary criteria per the legal requirements, rather than that they did not need or would not benefit from inpatient hospitalization at all.
How sad and awful that the ED physician’s estate was sued. I did not realize that was a thing.
I would agree that in my institution he would have had tele psych eval which is not a psychiatrist but a social worker. But a 72 hour involuntary hold would not have prevented his suicide 18 days later.
Yeah they can go after the dead physician's estate. I think a (small) part of the reason they settled is that it can be hard to convince a jury to take away money from a poor widow. That being said, out-of-pocket payments from a physician who loses a lawsuit are incredibly rare, and I think would be even more rare in this situation.
Dec 12, 2023·edited Dec 12, 2023Liked by Med Mal Reviewer
A smart articulate person who is suicidal and motivated can hold it together long enough to navigate any screening evaluation. In the event that such a person does get hospitalized, they'll just wait it out. Furthermore, this patient's depression and suicidality probably had longstanding premorbidity. Should every doctor who saw the patient in the preceding months or years be held accountable to some extent? Of course not. To simply blame the last doctor to see him doesn't make sense either. Maybe the wife was converting her own guilt into anger, or maybe she was just cashing in. Either way, this was an injustice against the EM physician (and his estate).
It sounds like there's a lot of mitigating details that would benefit the defense here.
I would say in general that regardless of what the patient is telling you, there are some high risk things here that for new docs should probably make you default toward requesting formal psychiatric evaluation for this type of patient. As you stated, Caucasian, '50s, guns, acute divorce. Definitely a high risk milleu.
I think General good practice in our CYA environment would be to just have this patient evaluated every time and save yourself the trouble to the extent that you can.
Having said that, completely agree that adults have autonomy and we should not be held responsible for the intentional decision of another adult. And this comes from a place of having experience with my own primary relative suicide. It was his decision and I would never think about trying to hold his doctor accountable.
18 days after the index visit. This is the part that's really absurd. I'd love to know the typical length of a psychiatric admission. I'm pretty sure it's a lot less than 18 days. Entirely stands to reason that formal evaluation and even if it resulted in full psychiatric admission, would have been very unlikely to change the outcome here. I think that that argument would be much easier to make if the patient was acutely psychotic or otherwise had some condition that would have been reasonably stabilized by medications. In this case you have what seems to be a rational adult with a unfortunate acute relationship and financial stressor. That wasn't going to go away by an admission to the hospital and it doesn't seem that medication was going to magically fix that and in fact could have made it worse by increasing the risk that he would kill himself in that initial phase of ssri treatment.
Completely agree with others The real backwards part of this case is the complete absurdity that the wife who is clearly the reason for the suicide is the one that is allowed to sue for wrongful death and benefit from a millions of dollars settlement in addition to all of his assets. Meanwhile she's out philandering with her new love interest. How is it justice that she gets a payout from the death that she instigated? Who is more responsible for the patient's death, the physician that tried to do their best in good faith under almost certain impossible practice conditions or his cheating wife who's trying to gut half of everything while she's out camping with her new boyfriend? That the jury wouldn't be allowed to see the whole picture is a testament to what a charade this entire legal system is. I hope this settled for basically nothing.
Hit the nail on the head. IMO, the doc should have consulted psych and the patient should have been voluntarily admitted and he likely still would have killed himself.
Dec 12, 2023·edited Dec 12, 2023Liked by Med Mal Reviewer
Well stated, all around. I can provide some insight for you: at least where I trained, a reality-based patient presenting voluntarily for psychiatric hospitalization with suicidal ideation, no plan, no action, would probably spend a week, maximum, in a psych hospital. Probably less if he maintained his disavowal of SI, and their insurance would probably fight you over anything past day 3.
I agree with MMR's reply to you. This would be an advisable psych consult, but doubtful that any action by this EM doc would have prevented the eventual suicide. The fact that the root cause of his suicide had the gall to sue for $5 million is an embarrassing caricature of malpractice tort law.
Well the COD definitely doesn't help the malpractice case, but now I'm curious as to whether this was because his guns were returned to him, was this an "illegally" obtained gun (either literally or just borrowed from a friend), or a legally purchased new firearm.
Each possibility brings up different questions, but none of them change my opinion that this most likely wasn't malpractice; however, a more thoroughly documented/validated assessment is something any ED physician would be smart to do before discharging such a patient home.
I could probably answer some of the questions by calling his wife and asking but that feels unethical. In the end it doesn't matter, the take-home points (re: well documented assessment) remain the same.
I know pathologists are not considered to be experts in bedside manner but even I know that's a bad idea.
I do wonder though particularly about the case of the police returning the guns. Would that work in favor of the defendant? Would the argument be that they have shared liability like the other therapist? Would the police argue that his discharge was evidence that it was safe to return the guns?
Interesting and revealing that the psych expert would have testified that hospitalizing likely would not have prevented his suicide. AFAIK there are only two interventions in psychiatry that are known to prevent suicide (lithium and clozapine). It's a good argument, but likely a tough one to make to a jury, and analogous to many other admission vs dc decisions we make. (How much benefit is there in admitting non-low-risk chest pain?)
When you step back and think about it, it is pretty wild that there are no RCTs demonstrating that admitting people to a psych floor reduces the odds of suicide... and yet, thats the single most important decision in emergency psychiatry.
I actually suspect I would have placed the consult, simply b/c the place I work sees 60K+ pts/yr, 2 nearby hospitals closed in recent months, and we closed our inpt geri psych unit, so my 42 room (+ a semi-infinite number of hallway spaces) ED is often boarding 30+ psych pts (plus the usual mix of MI, stroke, trauma, etc...). I simply don't have the time to do a (even by ED standards) comprehensive psych eval. Thankfully, we have a robust staff of (mostly) 24/7 MSW clinicians available to evaluate pts (since many of them are remote evals, esp at night). We are also blessed w/ a single psychiatrist who is in the ED a lot during the work week, so we can either consult him directly or the MSW will run cases past him. In a smaller place without those resources, I may have spent more time w/ pt and possibly decided he was not, in that moment, suicidal. I like to think my documentation would have been robust ;). I do think they would have suggested admission, since 1., their threshold is VERY low for recommending involuntary Section 12A for even the vaguest expressions of SI, and b/c they would likely have reached out.to the wife to hear a worrisome story.
Medical providers need to consider, from time to time, CYA. Since this is about law suites I think a CYA comment is warranted. A request for a consult to the ER from mental health would have been in order.
This could have helped in the treatment plan decision, and also protected the ER providers.
"CYA medicine" is widely criticized, but to completely ignore the medicolegal context in which we practice (at least those of us in the US) is also completely naive and foolish.
Obviously, these cases are always exceedingly difficult, but there is no law in MA, where I am, that all pts w/ a presumed urgent/emergent psych condition be evaluated by someone w/ specific expertise in psychiatry (in virtually all facilities in MA, that person is an MSW individual w/ psych training, not a psychiatrist). In addition, I have had many a psychiatrist tell me that their expectation is that many ED pts placed under a Section 12A (in MA, an involuntary hold applied- usually by a police officer- to an individual mandating psych eval) need to be eval'ed and possibly cleared by the EM physician (in MA, any physician can lift the 12A). As I type that, I also know that- many times- an MSW clinician can/will be more thorough at checking collateral sources (and that- again, in MA- their threshold for recommending involuntary inpt placement (ie., often committing the individual to a days/weeks long ED board, trying to find an inpt psych bed) is close to 0). As always, I think the key is clear documentation as to my clinical belief that the pt has capacity, expresses no ongoing SI thoughts, displays no confounding toxidrome, is low risk, has follow up., etc.
Such challenging cases. If you saw this patient in MA do you think you would have asked the MSW with psych training to come see the patient? And if so, do you think they would have recommended involuntary admission?
In general, when you have a relevant specialist available, choosing not to consult them might be reasonable - but it might be hard to justify later unless you can demonstrate that you did the same level of assessment they would have. In this guy, I think that includes some level of obtaining collateral, and documenting some protective factors that you think balance out his acutely and chronically increased risk of suicide. Removing the guns from the home is certainly one protective factor, but if he truly has no other social support and no other major protective factors, it's hard to get to an overall reassuring picture.
Much of today’s medicine includes CYA. Since this article is dealing with lawsuits, I think it is appropriate to consider CYA. A request for psychological/psychiatric evaluation in the emergency department is common in my opinion, very appropriate in this case. In my experience, much of the CYA has actually turned out to be very beneficial in the patient’s treatment plan. it does not sound like the emergency room. Physician was being cavalier, but the request for consultation could have been life-saving in this case.
Imagine that! The wife is unfaithful, says she wants a divorce (i.e. half of all their belongings), he kills himself so that she gets it all with a malpractice settlement to boot. As an atheist, I don't believe in the afterlife, but if i did, I would hope she would get her comeuppance in heaven ( or the other place).
I agree exactly with your conclusions, unlikely that this outcome was preventable by the ER doc, but I cannot see myself ever discharging a patient like this.
I don’t agree that the discharge of this patient from the ED was not “usual care” (standard of care is a term thrown about too much-despite plaintiff’s bar desire to have it nationally the same, there is geographical variation in what is done based on resources). A trained, careful ED physician can make a reasonable determination of mental status and suicidal risk of a competent and cooperative patient. Surely the same logic that allows for using our gestalt to evaluate chest pain patients applies (and we think a <2% miss rate is acceptable and “usual care” in those instances) here as well. If there was any short fall, it might have been more proactive to better nail down mental health or primary care follow up at time of discharge. I would testify in defense all day long.
There may be some geographic / resource-availability variation here but every place I've worked, it would be usual care to have someone from the psych department evaluate this person. I agree an ED doctor can do a competent SI evaluation but I don't see that it was done here, I think primarily evidenced by the fact that he didn't obtain any collateral information at all, which is especially important when a patient is giving mixed messages (tells 3 different people in 3 separate conversations he's going to blow his brains out, then suddenly tells you he's not going to). If I was an expert, I definitely wouldn't take this case for the plaintiff, but I also wouldn't for the defense.
The ED physician did not fall below the standard of care by not consulting a psychiatrist. Many places, mine included, psych will not see patients in the ED. This patient had the capacity to make his own decisions, was not demonstrating signs or symptoms of AMS/intox/psychosis, and was not in any imminent danger to himself or others. While sad this man took his life, the ED physician did not contribute to his death. I would like to see the RN and physician documentation to see how they justified their assessment and decision making.
As a consult psychiatrist, I agree with you. Lot of good comments in this thread, frankly. Suicide risk triage is a personal interest of mine and (probably rightly so) a common source of liability anxiety in psychiatry, so I have a number of thoughts about this case.
1) Strictly speaking, I would probably have to yield to EM physicians on deciding what the SOC is for EM physicians, but I would be uneasy saying that failure to consult a specialist automatically rises to an SOC violation unless it's a matter that the EM physician does not have the training to sufficiently address. While this would be a totally reasonable psych consult, in my view EM physicians are perfectly capable of proposing psychiatric diagnoses and conducting suicide risk assessments if they feel comfortable in those arenas. Plaintiff's expert suggests that EM physicians should just stay totally hands-off of suicide risk assessment, and I think that's both asinine and, frankly, implausible in the many areas that have shortages of psychiatrists.
2) I think you hit a key point in questioning what the documentation looked like. That's honestly what would make the difference for me whether the SOC was met here, rather than failure to consult a psychiatrist. Suicide is *notoriously* unpredictable, both in the sense that it can occur with no particular warning signs, and that most patients who present as "high risk" on paper do not ultimately kill themselves. The SOC does *not* call for a clairvoyant prediction of the future. What I would look for is that a reasonable suicide risk assessment was performed, and that the EM physician's plan followed logically from that risk assessment. At least in psychiatry, liability does not automatically follow a successful suicide; it follows when the psychiatrist negligently fails to respond to a "foreseeable" suicide, which usually means that the risk assessment itself was negligent, or the risk assessment was accurate but the plan lacked the appropriate urgency.
3) Moreover, I respectfully disagree with MMR's interpretation of a high acute suicide risk. Suicidal statements are concerning, but in this case it didn't sound like it was accompanied by any preparatory actions or plan other than vague contemplations of method. It had a clear, abrupt trigger (as opposed to SI emerging in a severe, longstanding depression) and the patient disavowed the statements on evaluation, suggesting that his cognitions about the stressor had mellowed compared to when he made the statements. You could argue - accurately - that his acute risk is elevated compared to the average person, but that doesn't automatically punch your ticket to a psych hospital, and indeed in my state this presentation would not meet involuntary commitment criteria. So I struggle to see how the EM physician would be liable if the patient wanted to go home and could not be compelled to a different course of treatment, consultation or no.
4) The fact that the decedent killed himself *over 2 weeks* after the ED visit should seriously call into question any "causation" arguments. If the decedent urgently desired death and the EM physician somehow missed this, I fail to understand why, after securing discharge, he didn't simply go home and kill himself. As another commenter pointed out, if a patient truly wants to end their life, we don't always have great power to stop them. We can't be mind police.
5) One way I think about psychiatric hospitalization is that it is designed to emergently change the risk equation when you're facing a high acute risk and cannot quickly or confidently remove modifiable risk factors. The psych hospital is designed to ensure their safety while the modifiable risk factors are...well, modified. My question with hospitalization in this case would be, what endpoint are we looking for? He didn't make any suicide attempts or self-harm and disavowed suicidal ideation in the ED. So if he went to a psych unit, what would have to change to be suitable for d/c? Do we keep him there until he pinky-promises he won't kill himself? Do we keep him there until he moves on from his marriage? Do we keep him there until the Sun explodes because he'll always have the fixed risk of being an older male divorcee who owns guns? I guess what I'm asking is, what would the psych hospital treat? His statements?
6) The twist about the wife just really leaves a bad taste in my mouth. So she starts hanging around with another man, asks for a divorce, and then sues for $5 million when a suicide results 18 days after his contact with the defendant. I routinely interface with ED psychiatry, and cases like this add a troubling cognitive bias toward committing patients (despite actual need, or consequences of hospitalization) if they get anywhere close to the criteria for it, just to cover our asses.
Thanks for the thoughtful response and respectful critique! This may be a function of only having worked at large hospitals with lots of resources, but every place I've worked this patient would have been seen by someone from the psych department (often not the physician, could be a nurse or social worker). I'm curious how you feel about the need to get collateral information in a situation like this? Is collateral info mandatory to meet the standard of care? I'm not the mind police but a patient who tells his wife, police, and EMS that he's thinking about "blowing his brains out", then abruptly changes his mind a few minutes later seems particularly worrisome. I think I would have admitted him against his will. We can't modify the underlying social stressors that led to this, but we can at least place time and temporary distance between him them, and he would have gotten attention focused on his own personal psychiatric state rather than the marriage counselor who likely focuses just on the relationship itself.
Honestly I think you're pretty justified in your worries. My (respectful) disagreement may be because I trained and work in a state with a very high threshold for involuntary commitment (basically, you have to show suicidal action, not just thoughts or plans). I also have a decent bit of experience working with borderline personality disorders, where there's a high tendency for frequent, but short-lived suicidal ideation in response to routine stress, so I think I've come to prioritize evidence of suicidal *action* rather than thoughts alone before I push for commitment.
If I were evaluating a patient like this in my state, I might offer voluntary hospitalization depending on the specifics of my risk assessment, but often the best we can do is proactive safety planning. Securing the firearms, orienting to crisis resources, clear return counsel, etc.
To your question, I *would* seek collateral especially if there's a disconnect between the secondhand story ("my husband said he's going to blow his brains out") and the face-to-face with patient. I think you actually had a previous case (where the patient jumped out of a car) where this point was highlighted.
I think you bring up key points that reinforce my desire to see documentation. I think if the defendant in this case did not document a suicide risk assessment, or did not attempt to interface with collateral, there could be a SOC point raised. I still think this case would fail at trial (assuming an informed jury) because the causation aspect should be torn apart by a competent defense attorney. If the defendant were "foreseeably suicidal" requiring psychiatric hospitalization, I would not expect him to take him 18 days to kill himself with neither his wife nor his marital therapist detecting anything amiss.
If an individual is determined to take his life, they will. As a neurologist, I once cared for a comatose patient who it turned out had taken an overdose in a suicide attempt. He survived and was discharged to a psychiatric facility. After several days there, he was discharged to home and promptly killed himself. Also, a local psychiatrist was sued a number of years ago after his patient killed himself. The judge reversed a jury verdict against the doctor reasoning that the psychiatrist should not be expected to predict the future with certainty. Even in psychiatric facilities, suicides can and have taken place.
This is a key point to emphasize. It's been pretty solidly established in psychiatric malpractice case law that psychiatrists aren't liable simply because they fail to divine the future. Nor are they liable for failing to control the actions of patients who have not met the criteria to be compelled to involuntary treatment. Both I think are relevant to this presentation. Liability from suicide results when psychiatrists negligently fail to respond to a "reasonably foreseeable" suicide. That's still frustratingly vague legal phrasing in my opinion, but the way I interpret it is that if a psychiatrist makes a reasonable suicide risk assessment, and their plan is sensible based on that risk assessment, they are generally insulated from liability. A risk assessment that winds up being "wrong in hindsight" is not necessarily the same thing as a "negligent" risk assessment.
I think there's a more fundamental question here: Why is one adult (ER doc) made responsible for the decision of another adult (decedent)? To do so removes agency from the patient. With removal of agency comes removal of dignity and self-determination. With removal of agency and self-determination comes loss of reason to exist/existence. One is made, factually, a child once again.
Or maybe I've read too much Camus.
I'd be willing to bet that the answer, medico legally, lies in the concept of capacity. If you and I determine that an ED pt lacks capacity, s/he *is*, medico legally, a child, ie., a human who cannot make decisions for themselves.
Very interesting. I am a consult psychiatrist. My thoughts--
this patient would certainly have gotten a psych consult everywhere I have worked.
I do not think admitting the patient would have stopped his suicide. He committed suicide the day after thanksgiving. The chances someone like this, who was suicidal in the context of a psychosocial stressor and may or may not have met criteria for a mood disorder, being admitted to inpatient psych for *18* days, even assuming he met criteria in the beginning, are essentially zero in every inpatient psych unit I've ever worked. Even if he'd been admitted, he probably would have been discharged after 3-5 days, and whatever happened on or around thanksgiving (obvious speculation here--not being with his wife? being with her and finding out about the affair?) still would have happened.
that being said, as a psychiatrist, my documentation would undoubtedly have looked different from the ED docs by virtue of being a specialist. More speculation, but unless the patient had a prior depression diagnosis I likely would not have diagnosed depression on the basis only of the acute incident. it's classic of non-psychiatrists to assume that suicidal ideation = depression. also, my documentation would have clearly laid out chronic vs acute and modifiable vs. unmodifiable risk factors. If i could not admit a patient like this, in clearing for discharge i would likely have specified that the patient did not meet involuntary criteria per the legal requirements, rather than that they did not need or would not benefit from inpatient hospitalization at all.
How sad and awful that the ED physician’s estate was sued. I did not realize that was a thing.
I would agree that in my institution he would have had tele psych eval which is not a psychiatrist but a social worker. But a 72 hour involuntary hold would not have prevented his suicide 18 days later.
Yeah they can go after the dead physician's estate. I think a (small) part of the reason they settled is that it can be hard to convince a jury to take away money from a poor widow. That being said, out-of-pocket payments from a physician who loses a lawsuit are incredibly rare, and I think would be even more rare in this situation.
A smart articulate person who is suicidal and motivated can hold it together long enough to navigate any screening evaluation. In the event that such a person does get hospitalized, they'll just wait it out. Furthermore, this patient's depression and suicidality probably had longstanding premorbidity. Should every doctor who saw the patient in the preceding months or years be held accountable to some extent? Of course not. To simply blame the last doctor to see him doesn't make sense either. Maybe the wife was converting her own guilt into anger, or maybe she was just cashing in. Either way, this was an injustice against the EM physician (and his estate).
It sounds like there's a lot of mitigating details that would benefit the defense here.
I would say in general that regardless of what the patient is telling you, there are some high risk things here that for new docs should probably make you default toward requesting formal psychiatric evaluation for this type of patient. As you stated, Caucasian, '50s, guns, acute divorce. Definitely a high risk milleu.
I think General good practice in our CYA environment would be to just have this patient evaluated every time and save yourself the trouble to the extent that you can.
Having said that, completely agree that adults have autonomy and we should not be held responsible for the intentional decision of another adult. And this comes from a place of having experience with my own primary relative suicide. It was his decision and I would never think about trying to hold his doctor accountable.
18 days after the index visit. This is the part that's really absurd. I'd love to know the typical length of a psychiatric admission. I'm pretty sure it's a lot less than 18 days. Entirely stands to reason that formal evaluation and even if it resulted in full psychiatric admission, would have been very unlikely to change the outcome here. I think that that argument would be much easier to make if the patient was acutely psychotic or otherwise had some condition that would have been reasonably stabilized by medications. In this case you have what seems to be a rational adult with a unfortunate acute relationship and financial stressor. That wasn't going to go away by an admission to the hospital and it doesn't seem that medication was going to magically fix that and in fact could have made it worse by increasing the risk that he would kill himself in that initial phase of ssri treatment.
Completely agree with others The real backwards part of this case is the complete absurdity that the wife who is clearly the reason for the suicide is the one that is allowed to sue for wrongful death and benefit from a millions of dollars settlement in addition to all of his assets. Meanwhile she's out philandering with her new love interest. How is it justice that she gets a payout from the death that she instigated? Who is more responsible for the patient's death, the physician that tried to do their best in good faith under almost certain impossible practice conditions or his cheating wife who's trying to gut half of everything while she's out camping with her new boyfriend? That the jury wouldn't be allowed to see the whole picture is a testament to what a charade this entire legal system is. I hope this settled for basically nothing.
Hit the nail on the head. IMO, the doc should have consulted psych and the patient should have been voluntarily admitted and he likely still would have killed himself.
Well stated, all around. I can provide some insight for you: at least where I trained, a reality-based patient presenting voluntarily for psychiatric hospitalization with suicidal ideation, no plan, no action, would probably spend a week, maximum, in a psych hospital. Probably less if he maintained his disavowal of SI, and their insurance would probably fight you over anything past day 3.
I agree with MMR's reply to you. This would be an advisable psych consult, but doubtful that any action by this EM doc would have prevented the eventual suicide. The fact that the root cause of his suicide had the gall to sue for $5 million is an embarrassing caricature of malpractice tort law.
Well the COD definitely doesn't help the malpractice case, but now I'm curious as to whether this was because his guns were returned to him, was this an "illegally" obtained gun (either literally or just borrowed from a friend), or a legally purchased new firearm.
Each possibility brings up different questions, but none of them change my opinion that this most likely wasn't malpractice; however, a more thoroughly documented/validated assessment is something any ED physician would be smart to do before discharging such a patient home.
I could probably answer some of the questions by calling his wife and asking but that feels unethical. In the end it doesn't matter, the take-home points (re: well documented assessment) remain the same.
I know pathologists are not considered to be experts in bedside manner but even I know that's a bad idea.
I do wonder though particularly about the case of the police returning the guns. Would that work in favor of the defendant? Would the argument be that they have shared liability like the other therapist? Would the police argue that his discharge was evidence that it was safe to return the guns?
I'd imagine that they return the guns as required by law, not based on any professional decision-making.
Interesting and revealing that the psych expert would have testified that hospitalizing likely would not have prevented his suicide. AFAIK there are only two interventions in psychiatry that are known to prevent suicide (lithium and clozapine). It's a good argument, but likely a tough one to make to a jury, and analogous to many other admission vs dc decisions we make. (How much benefit is there in admitting non-low-risk chest pain?)
When you step back and think about it, it is pretty wild that there are no RCTs demonstrating that admitting people to a psych floor reduces the odds of suicide... and yet, thats the single most important decision in emergency psychiatry.
I actually suspect I would have placed the consult, simply b/c the place I work sees 60K+ pts/yr, 2 nearby hospitals closed in recent months, and we closed our inpt geri psych unit, so my 42 room (+ a semi-infinite number of hallway spaces) ED is often boarding 30+ psych pts (plus the usual mix of MI, stroke, trauma, etc...). I simply don't have the time to do a (even by ED standards) comprehensive psych eval. Thankfully, we have a robust staff of (mostly) 24/7 MSW clinicians available to evaluate pts (since many of them are remote evals, esp at night). We are also blessed w/ a single psychiatrist who is in the ED a lot during the work week, so we can either consult him directly or the MSW will run cases past him. In a smaller place without those resources, I may have spent more time w/ pt and possibly decided he was not, in that moment, suicidal. I like to think my documentation would have been robust ;). I do think they would have suggested admission, since 1., their threshold is VERY low for recommending involuntary Section 12A for even the vaguest expressions of SI, and b/c they would likely have reached out.to the wife to hear a worrisome story.
Medical providers need to consider, from time to time, CYA. Since this is about law suites I think a CYA comment is warranted. A request for a consult to the ER from mental health would have been in order.
This could have helped in the treatment plan decision, and also protected the ER providers.
"CYA medicine" is widely criticized, but to completely ignore the medicolegal context in which we practice (at least those of us in the US) is also completely naive and foolish.
Obviously, these cases are always exceedingly difficult, but there is no law in MA, where I am, that all pts w/ a presumed urgent/emergent psych condition be evaluated by someone w/ specific expertise in psychiatry (in virtually all facilities in MA, that person is an MSW individual w/ psych training, not a psychiatrist). In addition, I have had many a psychiatrist tell me that their expectation is that many ED pts placed under a Section 12A (in MA, an involuntary hold applied- usually by a police officer- to an individual mandating psych eval) need to be eval'ed and possibly cleared by the EM physician (in MA, any physician can lift the 12A). As I type that, I also know that- many times- an MSW clinician can/will be more thorough at checking collateral sources (and that- again, in MA- their threshold for recommending involuntary inpt placement (ie., often committing the individual to a days/weeks long ED board, trying to find an inpt psych bed) is close to 0). As always, I think the key is clear documentation as to my clinical belief that the pt has capacity, expresses no ongoing SI thoughts, displays no confounding toxidrome, is low risk, has follow up., etc.
Such challenging cases. If you saw this patient in MA do you think you would have asked the MSW with psych training to come see the patient? And if so, do you think they would have recommended involuntary admission?
Also in MA - likely yes to both.
In general, when you have a relevant specialist available, choosing not to consult them might be reasonable - but it might be hard to justify later unless you can demonstrate that you did the same level of assessment they would have. In this guy, I think that includes some level of obtaining collateral, and documenting some protective factors that you think balance out his acutely and chronically increased risk of suicide. Removing the guns from the home is certainly one protective factor, but if he truly has no other social support and no other major protective factors, it's hard to get to an overall reassuring picture.
Much of today’s medicine includes CYA. Since this article is dealing with lawsuits, I think it is appropriate to consider CYA. A request for psychological/psychiatric evaluation in the emergency department is common in my opinion, very appropriate in this case. In my experience, much of the CYA has actually turned out to be very beneficial in the patient’s treatment plan. it does not sound like the emergency room. Physician was being cavalier, but the request for consultation could have been life-saving in this case.
Imagine that! The wife is unfaithful, says she wants a divorce (i.e. half of all their belongings), he kills himself so that she gets it all with a malpractice settlement to boot. As an atheist, I don't believe in the afterlife, but if i did, I would hope she would get her comeuppance in heaven ( or the other place).
Whether or not the wife was unfaithful is not confirmed.
It was confirmed by the wife herself under oath during deposition.
Unless your definition of unfaithful doesn't include "walks with future romantic partners".
I agree exactly with your conclusions, unlikely that this outcome was preventable by the ER doc, but I cannot see myself ever discharging a patient like this.
I honestly didn't expect the range of opinions on this case. I'm not discharging this guy unilaterally.
I don’t agree that the discharge of this patient from the ED was not “usual care” (standard of care is a term thrown about too much-despite plaintiff’s bar desire to have it nationally the same, there is geographical variation in what is done based on resources). A trained, careful ED physician can make a reasonable determination of mental status and suicidal risk of a competent and cooperative patient. Surely the same logic that allows for using our gestalt to evaluate chest pain patients applies (and we think a <2% miss rate is acceptable and “usual care” in those instances) here as well. If there was any short fall, it might have been more proactive to better nail down mental health or primary care follow up at time of discharge. I would testify in defense all day long.
There may be some geographic / resource-availability variation here but every place I've worked, it would be usual care to have someone from the psych department evaluate this person. I agree an ED doctor can do a competent SI evaluation but I don't see that it was done here, I think primarily evidenced by the fact that he didn't obtain any collateral information at all, which is especially important when a patient is giving mixed messages (tells 3 different people in 3 separate conversations he's going to blow his brains out, then suddenly tells you he's not going to). If I was an expert, I definitely wouldn't take this case for the plaintiff, but I also wouldn't for the defense.