First, I acknowledge the horror we feel at the death of a person by PROXIMATE action. This is what we commonly call Suicide (self-death, for the Latin survivors.) I've seen plenty and enough. These are likely not truly preventable by physicians as much as we like to self-aggrandize. Witness the increase in suicides despite increasing mental health outreach. This is likely a societal problem about which we can advise but not fix. "Deaths of despair" are not amenable to our ministrations. (This is another whole discussion, I recommend Viktor Frankl and Albert Camus. Read them then come back.)
Strangely, we don't feel the revulsion/reaction at the much more common self-killing: tobacco, alcohol, poor life choices. Instead, we "blame the victim." The only difference is proximity, not cause.
In my not-very-humble opinion, we need a little more humility. We need to start a discussion on self-determination and respect for self-determination.. This absolutely does not mean we abandon the high position of seeing, advising and treating people wanting help. However, we need to acknowledge that, unless we are willing to take these patients home with us, live in our homes, use our bathrooms and kitchens, we have limited (at best) control over the outcomes.
The right of self-determination and, ultimately, knowingly taking responsibility for the consequences (whatever they be: refuse vaccination and accept the disease the the transmission thereof, jaywalk irresponsibly, smoke, use substances, not take prescribed meds, etc., etc.) is, in the end, respect for the individual.
We, as a profession, need to have a hard discussion.
To what degree does MDD, an underlying, organic condition, not a "life choice" such as smoking, interfere with, if not completely remove, a patient's "right of self-determination"?
And on a slightly different level, depending on one's opinion regarding the categorization of behaviors such as smoking (nicotine addiction), drinking (alcohol addiction), substance abuse (drug addiction), and obesity (food addiction...notice a trend here?) as diseases, rather than conscious life-style choices, how do these likewise affect a patient's "right of self-determination"?
I was just talking with a resident last night about how difficult suicide risk stratification is and therefore how difficult it is to teach. The evidence for specific risk factors is murky at best, the evidence that any of our interventions are particularly effective is probably worse, and the patients who are the highest risk are not going to seek help and are going to obfuscate if forced to do so.
All this leads to a situation where your actual risk assessment is largely based on vibes and everything else is just trying to protect yourself legally. And unfortunately we've created a system where there is strong incentive to take patients' rights away in a way that can follow them for life in order to administer questionably effective treatment just to cover ourselves from liability.
"As far as I’m aware, there are no RCTs to suggest that admitting suicidal patients reduces the likelihood of suicide (please leave a link in the comments if I’ve missed one)"
That seems like a difficult study to get through the IRB and to enroll.
I agree with the discussion points. I am adding my conjecture below. (I am unaware of specific data relating unit design and self-destruction.)
Modern unit design seems to mitigate acute suicide risk much better than therapy, medicines, verbal agreements, and close observation. Doors with slants cut out at the top and hinges without gaps would have prevented this specific outcome. Likewise, commodes with no bowl of water, windows that cannot open, and door openers without knobs or levers all reduce access to self-destruction.
Dr, these measures while they might promote "safety" are often degrading and humiliating.... I wish there was more talk about how inhumane a lot of the "safety precautions" are. I think it would be better to modify tort law such that doctors are sued for suicide rather than take away EVEN more rights from patients....
Hello again Midge. I agree that confinement is often degrading and humiliating, but I wish you could see the architecture I am referring to. It is not oppressive; it’s just different than the rectangles and knobs we are accustomed to. I had the same feeling seeing how windows and doors operate in European homes.
I do not wish for anyone to see the aftermath of death by hanging. It is extremely degrading. It is brutal, grotesque, traumatizing, and worth preventing.
This case represents a serious instance of negligence that led to the preventable loss of a human life. The patient was clearly at high risk for suicide, with evident signs of depression, recurrent hospital visits, hopelessness, and a loss of purpose. Despite these warning signs, the medical evaluation underestimated his risk level, categorizing it at a level lower than high, and failed to provide adequate supervision and a safe, ligature-resistant environment.
Furthermore, the hospital was also negligent for not providing a safe environment. The responsibility does not fall solely on the physician but also on the hospital, which had the duty to ensure that the facilities were adapted to prevent self-harm in high-risk patients.
This situation involves a human life, which cannot be taken lightly or overlooked. Preventive measures should have been implemented to ensure the patient’s safety, and with the right precautions, he could still be alive today. This tragedy underscores the critical responsibility healthcare providers and institutions have in protecting their patients’ lives and the importance of not dismissing warning signs in high-risk cases.
I'm a little confused, is it just the hospital/company being sued? I don't see a "[redacted], MD/DO" in the plaintiff expert affidavit or the settlement offer.
Anyway, this is a classic malpractice predicate in psychiatry, but it bears repeating, psychiatrists are not liable because they failed to see the future. Suicide is *notoriously* unpredictable, both in the sense that many patients who complete suicide gave no warning, and in the fact that many patients who are adjudged "high risk" do not ultimately complete suicide in any acute time frame (or ever, in many cases). And in this patient, I would say moderate risk is the ceiling (and even that's a stretch as described so far) because he hasn't described any active intent, hasn't developed or rehearsed a plan (idly mulling about wandering into the woods isn't a plan), and hasn't shown any action to advance a suicidal effort. For patients not presenting an objectively active suicide threat, q15 checks is the standard at every hospital I'm familiar with, and this balances patient safety, patient dignity, and the practical staffing resources at IP facilities.
Psychiatric liability in these cases comes down to whether a psychiatrist's risk assessment was negligent, or whether their plan was negligent in light of the risk assessment. Again, that doesn't mean seeing the future; it means acting to prevent "foreseeable" suicide. And at least based on the data here, a patient presenting with vague SI, passive thoughts about "going into the woods and waiting to die," would be highly questionable in my view as foreseeably dying by suicide. For one thing, if the patient was actively seeking death, why would he present several times seeking help from the ED? If he just wanted to "wait to die," why was he eating lunch (I'm assuming from the fact he was in the dining room at noon, but it seems to fit)? Why did he make it several days on an IP unit without any suicide attempts?
All this to say, what clues was a reasonable psychiatrist supposed to use to foresee that in a span of less than 15 minutes, this patient would go from "eating lunch" to "dead by suicide?" At least as alleged by the plaintiff expert, I don't see it. If the suit is against the hospital specifically arguing that the presence of ligature points was negligent, I'm less qualified to comment on that discussion (as per MMR's point #1), but a $3 million ask against the psychiatrist for this (at least as argued so far) would be insane. The logic that would ask us to accept is that for any patient on a psych unit who has ever mentioned SI, they need to have a staff person watching them at all times. That is wildly impractical and grossly dehumanizing for the vast majority of IP psych patients, even those admitted with suicidal thoughts.
Mandating patients with this presentation be put on 1:1 would be an efficient way to wipe out most of the remaining inpatient psychiatric bed capacity. Admins looking to shut down units with bad labor economics would love a push from cases like this.
I can't find negligence in the healthcare delivered here. He was being monitored q15 minutes and this still occurred. Are they to remove every bedsheet from every room now going forward?
Some patients on the medical floor have poor outcomes regardless of what we do. In some patients, we know this will happen and we try to de-escalate to comfort measures, but I have run into some patients who say they don't mind dying while undergoing CPR and that's their decision. For some people, outside the healthcare setting if they are 100% committed to suicide, it happens and we cannot stop them but if they are in the healthcare setting, I imagine that is a NEVER event.
I can't see anyone talking about the delay to CPR. It reads like it only commensed AFTER EMS arrived. Surely all hospital staff is ALS trained and can perform CPR.
Returning oxygenated blood to the brain 5 minutes earlier could have changed something.
I'm not sure if they're referring to 12:18 as when CPR started, or if it was going on beforehand and 12:18 is just when EMS took over CPR. It also probably took some time to cut him down from the doorway so that could also explain the delay.
15 minutes is plenty of time to be dangerous. He was admitted because he was deemed to be dangerous. Having been to the ED 3 times, he was indicating his concern that he couldn't control his dangerousness despite wanting to. If someone tells you they're dangerous, and you don't know them, then you should watch closely. If this facility had the capacity to monitor more closely, and didn't utilize that capacity, then they are going to have difficulty defending this case. As for the risk assessment and his seemingly passive suicidal ideation - that goes along with how little this problem is understood. $400 million on the Golden Gate Bridge net is emblematic of growing interest in trying to do better, as well as tremendous interest in matching physical deterrents to observed patterns.
Voted no based on what was provided but if I were actually on a jury I would want to see more of the documentation surrounding his behavior and statements prior to that. To me, the case hinges on whether he should have been on constant observation or not and "I want to walk into the woods and let myself die" normally does not get constant obs in a psych unit. Maybe on a medical floor where there isn't q15 checks and a more dangerous environment but not on a psych unit. By that standard you'd have e*very* patient in there who isn't admitted for psychosis on constant obs.
You can never know if or when someone may do this. Having come for help or just having ate does not mean one cannot suddenly make this decision. He is known to have or have had SI. Unless medication has changed his thought processes he may still decide on this course of action anyway because he doesn't know himself when he is going to feel this way again.
First, I acknowledge the horror we feel at the death of a person by PROXIMATE action. This is what we commonly call Suicide (self-death, for the Latin survivors.) I've seen plenty and enough. These are likely not truly preventable by physicians as much as we like to self-aggrandize. Witness the increase in suicides despite increasing mental health outreach. This is likely a societal problem about which we can advise but not fix. "Deaths of despair" are not amenable to our ministrations. (This is another whole discussion, I recommend Viktor Frankl and Albert Camus. Read them then come back.)
Strangely, we don't feel the revulsion/reaction at the much more common self-killing: tobacco, alcohol, poor life choices. Instead, we "blame the victim." The only difference is proximity, not cause.
In my not-very-humble opinion, we need a little more humility. We need to start a discussion on self-determination and respect for self-determination.. This absolutely does not mean we abandon the high position of seeing, advising and treating people wanting help. However, we need to acknowledge that, unless we are willing to take these patients home with us, live in our homes, use our bathrooms and kitchens, we have limited (at best) control over the outcomes.
The right of self-determination and, ultimately, knowingly taking responsibility for the consequences (whatever they be: refuse vaccination and accept the disease the the transmission thereof, jaywalk irresponsibly, smoke, use substances, not take prescribed meds, etc., etc.) is, in the end, respect for the individual.
We, as a profession, need to have a hard discussion.
In general, very much agree...with one caveat...
To what degree does MDD, an underlying, organic condition, not a "life choice" such as smoking, interfere with, if not completely remove, a patient's "right of self-determination"?
And on a slightly different level, depending on one's opinion regarding the categorization of behaviors such as smoking (nicotine addiction), drinking (alcohol addiction), substance abuse (drug addiction), and obesity (food addiction...notice a trend here?) as diseases, rather than conscious life-style choices, how do these likewise affect a patient's "right of self-determination"?
Just asking...
And, BTW, I voted "no" on the poll.
Very much agree with Thomas above.
I was just talking with a resident last night about how difficult suicide risk stratification is and therefore how difficult it is to teach. The evidence for specific risk factors is murky at best, the evidence that any of our interventions are particularly effective is probably worse, and the patients who are the highest risk are not going to seek help and are going to obfuscate if forced to do so.
All this leads to a situation where your actual risk assessment is largely based on vibes and everything else is just trying to protect yourself legally. And unfortunately we've created a system where there is strong incentive to take patients' rights away in a way that can follow them for life in order to administer questionably effective treatment just to cover ourselves from liability.
"As far as I’m aware, there are no RCTs to suggest that admitting suicidal patients reduces the likelihood of suicide (please leave a link in the comments if I’ve missed one)"
That seems like a difficult study to get through the IRB and to enroll.
I agree with the discussion points. I am adding my conjecture below. (I am unaware of specific data relating unit design and self-destruction.)
Modern unit design seems to mitigate acute suicide risk much better than therapy, medicines, verbal agreements, and close observation. Doors with slants cut out at the top and hinges without gaps would have prevented this specific outcome. Likewise, commodes with no bowl of water, windows that cannot open, and door openers without knobs or levers all reduce access to self-destruction.
Dr, these measures while they might promote "safety" are often degrading and humiliating.... I wish there was more talk about how inhumane a lot of the "safety precautions" are. I think it would be better to modify tort law such that doctors are sued for suicide rather than take away EVEN more rights from patients....
Hello again Midge. I agree that confinement is often degrading and humiliating, but I wish you could see the architecture I am referring to. It is not oppressive; it’s just different than the rectangles and knobs we are accustomed to. I had the same feeling seeing how windows and doors operate in European homes.
I do not wish for anyone to see the aftermath of death by hanging. It is extremely degrading. It is brutal, grotesque, traumatizing, and worth preventing.
This case represents a serious instance of negligence that led to the preventable loss of a human life. The patient was clearly at high risk for suicide, with evident signs of depression, recurrent hospital visits, hopelessness, and a loss of purpose. Despite these warning signs, the medical evaluation underestimated his risk level, categorizing it at a level lower than high, and failed to provide adequate supervision and a safe, ligature-resistant environment.
Furthermore, the hospital was also negligent for not providing a safe environment. The responsibility does not fall solely on the physician but also on the hospital, which had the duty to ensure that the facilities were adapted to prevent self-harm in high-risk patients.
This situation involves a human life, which cannot be taken lightly or overlooked. Preventive measures should have been implemented to ensure the patient’s safety, and with the right precautions, he could still be alive today. This tragedy underscores the critical responsibility healthcare providers and institutions have in protecting their patients’ lives and the importance of not dismissing warning signs in high-risk cases.
I'm a little confused, is it just the hospital/company being sued? I don't see a "[redacted], MD/DO" in the plaintiff expert affidavit or the settlement offer.
Anyway, this is a classic malpractice predicate in psychiatry, but it bears repeating, psychiatrists are not liable because they failed to see the future. Suicide is *notoriously* unpredictable, both in the sense that many patients who complete suicide gave no warning, and in the fact that many patients who are adjudged "high risk" do not ultimately complete suicide in any acute time frame (or ever, in many cases). And in this patient, I would say moderate risk is the ceiling (and even that's a stretch as described so far) because he hasn't described any active intent, hasn't developed or rehearsed a plan (idly mulling about wandering into the woods isn't a plan), and hasn't shown any action to advance a suicidal effort. For patients not presenting an objectively active suicide threat, q15 checks is the standard at every hospital I'm familiar with, and this balances patient safety, patient dignity, and the practical staffing resources at IP facilities.
Psychiatric liability in these cases comes down to whether a psychiatrist's risk assessment was negligent, or whether their plan was negligent in light of the risk assessment. Again, that doesn't mean seeing the future; it means acting to prevent "foreseeable" suicide. And at least based on the data here, a patient presenting with vague SI, passive thoughts about "going into the woods and waiting to die," would be highly questionable in my view as foreseeably dying by suicide. For one thing, if the patient was actively seeking death, why would he present several times seeking help from the ED? If he just wanted to "wait to die," why was he eating lunch (I'm assuming from the fact he was in the dining room at noon, but it seems to fit)? Why did he make it several days on an IP unit without any suicide attempts?
All this to say, what clues was a reasonable psychiatrist supposed to use to foresee that in a span of less than 15 minutes, this patient would go from "eating lunch" to "dead by suicide?" At least as alleged by the plaintiff expert, I don't see it. If the suit is against the hospital specifically arguing that the presence of ligature points was negligent, I'm less qualified to comment on that discussion (as per MMR's point #1), but a $3 million ask against the psychiatrist for this (at least as argued so far) would be insane. The logic that would ask us to accept is that for any patient on a psych unit who has ever mentioned SI, they need to have a staff person watching them at all times. That is wildly impractical and grossly dehumanizing for the vast majority of IP psych patients, even those admitted with suicidal thoughts.
Mandating patients with this presentation be put on 1:1 would be an efficient way to wipe out most of the remaining inpatient psychiatric bed capacity. Admins looking to shut down units with bad labor economics would love a push from cases like this.
I can't find negligence in the healthcare delivered here. He was being monitored q15 minutes and this still occurred. Are they to remove every bedsheet from every room now going forward?
Some patients on the medical floor have poor outcomes regardless of what we do. In some patients, we know this will happen and we try to de-escalate to comfort measures, but I have run into some patients who say they don't mind dying while undergoing CPR and that's their decision. For some people, outside the healthcare setting if they are 100% committed to suicide, it happens and we cannot stop them but if they are in the healthcare setting, I imagine that is a NEVER event.
I can't see anyone talking about the delay to CPR. It reads like it only commensed AFTER EMS arrived. Surely all hospital staff is ALS trained and can perform CPR.
Returning oxygenated blood to the brain 5 minutes earlier could have changed something.
I'm not sure if they're referring to 12:18 as when CPR started, or if it was going on beforehand and 12:18 is just when EMS took over CPR. It also probably took some time to cut him down from the doorway so that could also explain the delay.
15 minutes is plenty of time to be dangerous. He was admitted because he was deemed to be dangerous. Having been to the ED 3 times, he was indicating his concern that he couldn't control his dangerousness despite wanting to. If someone tells you they're dangerous, and you don't know them, then you should watch closely. If this facility had the capacity to monitor more closely, and didn't utilize that capacity, then they are going to have difficulty defending this case. As for the risk assessment and his seemingly passive suicidal ideation - that goes along with how little this problem is understood. $400 million on the Golden Gate Bridge net is emblematic of growing interest in trying to do better, as well as tremendous interest in matching physical deterrents to observed patterns.
Voted no based on what was provided but if I were actually on a jury I would want to see more of the documentation surrounding his behavior and statements prior to that. To me, the case hinges on whether he should have been on constant observation or not and "I want to walk into the woods and let myself die" normally does not get constant obs in a psych unit. Maybe on a medical floor where there isn't q15 checks and a more dangerous environment but not on a psych unit. By that standard you'd have e*very* patient in there who isn't admitted for psychosis on constant obs.
You can never know if or when someone may do this. Having come for help or just having ate does not mean one cannot suddenly make this decision. He is known to have or have had SI. Unless medication has changed his thought processes he may still decide on this course of action anyway because he doesn't know himself when he is going to feel this way again.
Surprised he did not receive a 1:1 sitter. In my 14 years in healthcare even “low risk/passive” SI patients got 1:1 sitters.
Negligent? No.
Will the hospital lose the suit? Almost certainly.
Remember, there is malpractice only if we, the physicians, say so.