When someone takes their own life – and it happens about 30,000 times in America every year, or once every 17 ½ minutes – not just one life has been ruined. Suicide sends ripples of destruction throughout families and can have long-lasting consequences for anyone who was close to the person who committed suicide. About half of the people who kill themselves are under care with a mental health therapist at the time of their demise. Many of those in active therapy who commit suicide do it while they are inpatients in hospitals or have just been discharged from a hospital. So it’s natural for surviving family members to ask if the suicide could have been prevented, and if the therapists did all that they could and should have done. It can be appropriate to undertake a medical malpractice investigation when suicide has occurred.
Many questions need to be asked
- Was the suicide risk adequately investigated by the therapist?
- Were there changes in the patient just before the event that look ominous at least in hindsight?
- What was the therapy plan?
Much of this will be revealed by close study of the therapist’s records, but interviews will need to be conducted with others who interacted with the suicide patient just before the event.
The American Psychiatric Association published a practice guideline in 2003 about dealing with patients who have any potential suicide issues. The guideline is technically out of date since it is more than five years old, but it still has a lot of insight. For example, this table from the guideline shows how thorough the assessment needs to be of suicidal risk in any patient who has any hints whatsoever that they might be thinking of suicide.
Current presentation of suicidality
- Suicidal or self-harming thoughts, plans, behaviors, and intent
- Specific methods considered for suicide, including their lethality and the patient’s
- expectation about lethality, as well as whether firearms are accessible
- Evidence of hopelessness, impulsiveness, anhedonia, panic attacks, or anxiety
- Reasons for living and plans for the future
- Alcohol or other substance use associated with the current presentation
- Thoughts, plans, or intentions of violence toward others
- Current signs and symptoms of psychiatric disorders with particular attention to mood disorders (primarily major depressive disorder or mixed episodes), schizophrenia, substance use disorders, anxiety disorders, and personality disorders (primarily borderline and antisocial personality disorders)
- Previous psychiatric diagnoses and treatments, including illness onset and course and psychiatric hospitalizations, as well as treatment for substance use disorders
- Previous suicide attempts, aborted suicide attempts, or other self-harming behaviors
- Previous or current medical diagnoses and treatments, including surgeries or hospitalizations
- Family history of suicide or suicide attempts or a family history of mental illness, including substance abuse
- Acute psychosocial crises and chronic psychosocial stressors, which may include actual or perceived interpersonal losses, financial difficulties or changes in socioeconomic status, family discord, domestic violence, and past or current sexual or physical abuse or neglect
- Employment status, living situation (including whether or not there are infants or children in the home), and presence or absence of external supports
- Family constellation and quality of family relationships
- Cultural or religious beliefs about death or suicide
Individual strengths and vulnerabilities
- Coping skills
- Personality traits
- Past responses to stress
- Capacity for reality testing
- Ability to tolerate psychological pain and satisfy psychological needs
A key part of this assessment is the “lethality” of the patient’s suicide plan. That is why any patient with access to a firearm can be at higher risk for successfully carrying out a suicide than someone who doesn’t have such access, even if the patient with a firearm has no specific current suicide plan. Other aspects of the lethality assessment include the patient’s thoughts about the specific method they would use to kill themselves, their skill and knowledge about the method, and the presence of protective family members or other safeguards.
This short article only scratches the surface of the post-mortem investigation that needs to be carried out to see if a malpractice suit is justified for a failure to prevent suicide. All such lawsuits are difficult. They stir up uncomfortable emotions in the survivors. Juries need to be carefully educated to understand that not every person who commits suicide is unswervingly bent on doing themselves in, but instead is sometimes the victim of a terrible impulse that can be survived if they get short-term protection and help.
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