Medical Malpractice Insights: The challenge of suicide evaluation in the ED

The challenge of suicide evaluation in the ED

 “I’ve changed my mind. Killing myself would hurt my family.” But…

Facts: An adult male with a history of bipolar disorder and PTSD calls his brother in Alaska from the airport. He tells him that a few weeks earlier he had gone to Florida to kill himself by first setting fire to his ex-girlfriend’s sailboat then hanging himself in the rigging. He changed his mind but tells his brother that he’s now going back to Florida to finish the job. The brother’s wife calls the airport police who are able to locate him and send him to a nearby hospital.

0321: During triage one of the officers informs the nurse of the patient’s detailed suicide plan. The nurse completes the Columbia-Suicide Severity Rating Scale (C-SSRS) and documents that the patient’s recent thoughts of killing himself and his detailed plan makes him “High Risk” for suicide. He is seen briefly by a PA-C who institutes suicide precautions and request a consult from the in-house crisis counselor (CC#1).

0500: Labs are normal except for the presence of alcohol and benzos.

0521: CC#1 speaks briefly with the patient then calls the pt’s brother and learns of his long hx of mental health issues. Those include leaving ED’s in similar situations, failure to follow up after past suicide attempts and his current detailed suicide plan. Being the end of his shift, CC#1 defers calling the County Designated Mental Health Professional (CDMHP) to the oncoming counselor (CC#2).

0600: CC#2 arrives and is told by CC#1 that the pt needs further evaluation and tells her to “read my chart note.”

0700: The PA-C goes off-shift. There is no documented handoff to the on-coming emergency physician (EP) who assumes care.

0900: CC#2 sees the pt and documents that he has now changed his mind about killing himself because “It would hurt my family too much and besides, I’ve already missed my flight.” He is described as “alert, oriented, calm, cooperative, logical and coherent.” His current plan is “to fly home to Alaska and stay with my mom and my brother.” CC#2 decides that an MHP consult is not needed but does not discuss her findings with the EP.

0905: Pt’s brother calls CC#2, telling her that he fears the pt would kill himself if released and that their mother is already on a plane to see the pt. This, too, is not conveyed to the ED staff.

1025: The EP discharges the patient with a dx of “alcohol abuse with intoxication.” His note mentions patient’s evaluation by the CC’s, denial of suicidal ideation, plan to meet his mother at the airport and follow-up resources.

1111: Post-discharge CC#2 completes a second C-SSRS, relying only on the patient’s self-report, claiming later that input from others was hearsay. A CDMHP evaluation for involuntary detention was felt to be unnecessary.

1345: The patient is found dead at the airport, having jumped from the top of the parking garage.
A lawsuit is filed by the patient’s family against the PA-C, the oncoming EP, both CC’s, and the hospital.

Plaintiff Arguments:

• The patient lacked decisional capacity, being depressed and under the influence of both alcohol and benzos. He lacked insight and could not rationally consider the severity of his condition or the treatment options available to him.
• The hospital has:
  • no written policy on evaluating suicidal pts brought by police,
  • no policy, process or training in suicide prevention, particularly the use of the C-SSRS and input from collateral sources required by the C-SSRS,
  • no policy on the roles of the EP, PA-C and CC for suicidal pts,
  • inadequate policy on handoffs,
  • insufficient management supervision of CC’s.
• As a result,
  • 1) handoffs were poorly done and/or poorly documented,
  • 2) helpful collateral information required by the C-SSRS was disregarded as “hearsay,”
  • 3) CC’s communicated poorly with ED staff and patient’s family,
  • 4) suicidal pts with limited decisional capacity are allowed to create their own discharge plans,
  • 5) EP’s are allowed to rely almost entirely on CC’s’ recommendations without exercising independent clinical judgment and
  • 6) the EP’s only notes were a breakfast order and a brief discharge note reiterating the CC’s plan.

Also:

• The inconsistencies in the 2 C-SSRS records were never addressed and the 2nd one was completed after the patient’s discharge.
• The hospital updated their policies after this incident, indicating acknowledgement of the prior inadequacy thereof.
• Within reasonable medical certainty, the pt would not have died had medical and mental health staff adequately and appropriately assessed his mental status

Defense:

• Hospital policy required only self-reported information, not information (“hearsay”) obtained in a phone call.
• Our practice allows us to disregard inconsistencies between two C-SSRS assessments and completing a C-SSRS after discharge is an established practice .
• The patient denied having an alcohol problem.
• The patient was lucid enough to create his own discharge plan.
• Our supervision of CC’s is sufficient. We have a 2-hour meeting once a month and case consultations every 3 months.
• We were not responsible for the patient’s death.

Result:

• A motion for summary judgment (MSJ) was granted for all but the oncoming EP, CC#2 and the hospital as a corporate entity. An out of court settlement for an undisclosed amount was then reached. The family insisted on participating in the hospital’s overhaul of its practices and policies and the re-training of its staff.

Takeaways:

• Assure and document that a suicidal patient has “decisional capacity.” (See reference #1 below.)
• Understand and appropriately use the C-SSRS.
• Assess and document impulsivity, drugs, alcohol, PMH, current meds, intent, stressors and current triggers – and your gut impression.
• Assure and document the patient’s resources and safety net if discharged.
• If PA-C’s are allowed to care for suicidal patients, their privileges should so specify.
• Handoffs are a high-risk exchange. Do them well and document the process, preferably at the bedside.
• If patients remain a danger to themselves, a designated/certified MHP consultation is the standard of care. Unless the disposition is made by a CDMHP, the EP is ultimately responsible.(This may vary in other states or counties.)
• There’s no lab test for suicide. Treating suicidal patients is a team effort involving the EP, crisis counselor and CDMHP.

References: [A longer than usual list but helpful for anyone educating others about managing suicidal patients./CP]
1. Decisional Capacity. Mooney N. Blogpost
2. Assessment of Patients’ Competence to Consent to Treatment. Applebaum PS. N Eng J Med 2007;357:1834-40
3. Literature-based Recommendations for Suicide Assessment in the Emergency Department: A Review. Ronquillo L et al. J. Emerg Med. Oct 04, 2012.
4. Handoffs Pilcher C. Blogpost, June 2013.
5. A Patient Contemplates Suicide: Protect the Patient and Yourself. Buppert C. Medscape, January 08, 2019.
6. Just let me die, doc!. Giwa A. EP Monthly, Apr 4, 2019.
7. Core Competencies for the Assessment and Management of Individuals at Risk for Suicide. From Assessing and Managing Suicide Risk (AMSR), American Association of Suicidology (AAS).
8. Columbia-Suicide Severity Rating Scale (C-SSRS). Posner et al. Research Foundation for Mental Hygiene, Inc., 2008.