Suicide and Psychiatric Malpractice

The foreseeability of a patient suicide and the appropriateness of steps taken to prevent it will probably always be the subject of clinical and legal debate, but there is a consensus that to establish or negate claims of negligence in cases of a particular suicide, the following questions must be addressed:

1. Was the possibility of suicide explicitly considered and the patient assessed for degree of suicidal potential?

2. Was that potential explicitly reflected in treatment decisions, e.g., quantity and lethality of medications prescribed; treatment in an open versus closed setting?

3. Was there an established procedure for responding to the possibility of suicide?

4. Were those procedures followed?

5. If critical decisions regarding suicide potential and responses thereto were made consensually by several care-providers working together, was communication between those responsible adequate?

6. In the event of diagnostic uncertainty, were appropriate and timely consultations obtained?

7. Were changes in the treatment program or hospital security procedures that ultimately proved so inimical to the patient explicitly made for reasons that were clinically justified at the time?

8. If the patient’s decision to commit suicide appeared well-considered and included such factors as a deliberate withholding of information, did the patient in fact have the mental capacity to make such a judgment? That is, to what degree was the patient legally competent to contribute to his own death?

Many (though not all) patients who plan to take their lives give ample warning of suicidal intentions–they are visibly depressed, express hopelessness, and may ruminate about “everyone being better off if I were dad.” Often there is a previous suicide attempt or suspicious “accident.”

Standard psychiatric practice requires that such patients be watched closely and, not infrequently, undergo at least a brief hospitalization in a closed setting that provides 24-hour surveillance and sequestration from instruments of destruction (e.g., belts, razor blades) until self-destructive impulses have subsided. Orders for suicide precautions should be clearly inscribes by the attending physician in the hospital chart.

Oftentimes the depressed patient who attempts suicide was for many years a well-functioning, active individual who then develops a psychiatric illness for which there are curative treatments. Protected from himself during his brief but intense period of self-destructiveness, in most cases the patient would have recovered fully, returned to previous levels of competence, and usefully lived out a normal life expectancy. This generally good long-term prognosis makes suicide a particularly poignant psychiatric tragedy.

Defense of the psychiatrist whose patient has taken his own life rests on one or more of the following:

* Most depressed people do not attempt suicide, and most of those few who do are acting on momentary, unpredictable impulse. To deny freedom of action to all depressives as to protect those few who might go on to suicide would mean the unnecessary confinement of tens of thousands of people each year.

* It can take but a moment to end one’s life. If a patient is determined to kill himself, there may be little that can be done in the long run to prevent it.

* Psychiatric treatment requires more patient collaboration than does other medical or surgical treatment. Most doctors do things for or to their patients; psychiatrists do things with theirs. Often a psychiatrist must weigh a decision to order involuntary confinement of his patient against the loss of rapport that may result.

* Even severely disturbed patients do best on an open ward. Locked doors and complete loss of privacy convey to the patient that indeed he or she cannot be trusted, that they are different–inferior to other people–thereby confirming their own deprecatory attitudes and undermining still further their already sagging self-esteem.

* Even when certain potentially hazardous prescription drugs are parceled out in safe amounts, there is nothing to prevent the patient from secretly accumulating a lethal dose.