Medical Malpractice Insights: The “No Harm Contract”

Author: Chuck Pilcher, MD, FACEP (Editor, Med Mal Insights) // Editors: Alex Koyfman, MD (@EMHighAK) and Brit Long, MD (@long_brit)

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Chuck Pilcher, MD, FACEP

Editor, Med Mal Insights

Would you discharge a patient who refuses to sign a “No Harm Contract”?

Patient hangs self in jail following ED evaluation

Facts: An adult male slashes his wrist when arrested following a police chase and is taken to the ED for a mental health evaluation prior to booking. His risk factors include depression, bipolar disorder, legal problems, impulsivity, prior suicide attempt, recently failed relationship, unemployment, and PTSD. His wounds are superficial and require no sutures. He is evaluated by a social worker. A psychiatrist is consulted by phone and believes him to be safe to go to jail. When presented with his Discharge Instructions and a “No Harm Contract,” he refuses to sign the latter unless he is released by the police. Still, he is discharged – only 25 minutes after arrival. There is no documentation of any discussion with the patient or amongst the staff about his refusal to sign. Two days later he is found dead after hanging himself in his cell.

Plaintiff: My brother’s life was in danger. He was telling you he would kill himself. You knew that or you wouldn’t have asked him to sign the “No Harm Contract.” He told you that he would only sign if he were released from custody, and that was not an option. You should have admitted him or at least have him seen by a psychiatrist. All you did was call the jail and tell the jailer to “put him naked in a bare cell.” A jail is for incarceration, not suicide prevention.

Defense: He was safe to go to jail. We evaluated your brother properly. In fact we did a triage evaluation, vital signs, registration, financial agreement, nursing assessment, an 11-item “ED Mental Health Evaluation,” a complete history (including HPI, PFSH, and review of 8 systems), exam of 10 systems including neuro and psych, dressing of wounds, telephone conversations with a psychiatrist and Lincoln County jailer, complete medical decision making and treatment plan, DC instructions, a “No Harm Contract,” and dictated a report prior to transfer. [Editor’s Note: All that in 25 minutes?]

Result: Settlement for undisclosed amount.

Takeaways:

• When evaluating suicidal patients, take and document a complete [and honest] history, then pay attention to what you’ve found.
• Patients with suicidal ideation, homicidal ideation, or hallucinations require close evaluation and often admission.
• Evaluate for Red Flags for depression and high risk of completing suicide (older age, access to firearms, plan, history of depression/prior attempts, Caucasian, etc.).
• Some with a host of risk factors deserve more than a 25 minute evaluation – especially when they then refuse to sign a “No Harm Contract.”
• “No Harm Contracts” or “Safety Contracts”, whether the patient signs or not, do not actually guarantee patient safety. Any concern requires evaluation and admission if high risk.

References:

Suicidal ideation and behavior in adults, Schreiber J, Culpepper L.. UpToDate Online, Feb 19, 2018. https://www.uptodate.com/contents/suicidal-ideation-and-behavior-in-adults#H1175693686 The key part of this UTDOL article says:

[Regarding] a “no harm contract” [this implies] that patients can promise clinicians that they will try not to harm themselves when they have suicidal thoughts and will seek help if necessary… Despite their wide use, there is little evidence that such contracts actually reduce suicide. Contracting for safety may thus provide a false sense of security. Better tools include open dialogue between patients and clinicians to establish a therapeutic alliance, as well as ongoing assessments of suicide risk over time.

See also: Talisman or taboo: the controversy of the suicide-prevention contract. Miller MC, Jacobs DG, Guthell TG. Harv Rev Psychiatry. 1998 Jul-Aug;6(2):78-87. https://www.ncbi.nlm.nih.gov/pubmed/10370451

Experience is simply the name we give our mistakes.

Oscar Wilde