Patients who are at risk for suicide need to have hotline phone numbers readily available since they may not be able to find a hotline phone number during a suicide crisis. Hotline phone numbers should be verified as correctbefore being given to any patient. The psychiatrist should document the prearranged safety plan, including the patient's understanding and agreement.
Standard of care requires that psychiatrists or their designees be accessible to suicidal patients and that they respond within a reasonable time. This also applies to psychiatrists and psychotherapists providing conjoint or "split" treatment. Each is individually, as well as jointly, clinically responsible for the patient.3Case Vignette
While a psychiatrist is having dinner with her family at a restaurant, she receives an emergency page from a patient who is at chronic risk for suicide. The psychiatrist discussed with the patient at the beginning of treatment how she could be reached if she became suicidal. The psychiatrist calls the patient, who screams, "My bastard boyfriend dumped me. I want to die!" She has bought a gun and intends to use it. The patient abruptly hangs up. The psychiatrist calls the patient repeatedly but the line is constantly busy.
The psychiatrist calls 911. The rescue squad and police arrive at the patient's apartment but the door is barricaded. The police break it down. The patient refuses to tell the police where the gun is hidden. A search finds the gun in a kitchen cabinet. The patient vehemently denies that she is suicidal, stating, "It was just a fleeting thought." The patient leaves the apartment with a coat over her head to avoid "nosy neighbors." The police take the patient to a general hospital ED.
The patient is initially uncooperative in the ED, and only reluctantly provides her psychiatrist's name and phone number. The ED crisis counselor calls the psychiatrist to obtain information about the patient. The psychiatrist states that she has treated the patient for more than a year for bipolar disorder II and borderline personality disorder. The patient, aged 36 years, made a serious suicide attempt by medication overdose at age 25 following the break up of a romantic relationship. The patient has been at moderate to high chronic risk for suicide over the years, requiring hospitalization during acute suicidal episodes, usually precipitated by a failed, abusive relationship. The psychiatrist informs the crisis counselor that the patient is receiving once-a-week psychotherapy and provides the names of medications she is taking.
The crisis counselor and psychiatrist agree that the patient needs to be admitted to the psychiatric inpatient unit. The patient initially refuses hospital admission and tries to leave the ED but, after the psychiatrist speaks to her by phone, the patient agrees to be voluntarily admitted. The psychiatrist calls the admitting psychiatrist to provide additional clinical information.Abandonment
Abandonment is legally defined as negligentlyfailing to attend a patient, absent the proper termination of the doctor-patient relationship.4 It may either be overt or implied (eg, failure to attend, monitor, or observe the patient). Some courts have expanded the concept of abandonment to include situations in which delay and inattention in providing care caused the patient injury, termed "constructive abandonment" (ie, as if actual abandonment had occurred).5 For example, in Bolles v Kinton,6 the court stated that a physician cannot discharge a patient by simply not attending him without sufficient notice. Other courts have found abandonment when psychiatrists were inaccessible to patients, particularly if a crisis was occurring or if the crisis was foreseeable. Failure to provide patients with a way to contact the psychiatrist between sessions and failure to provide adequate clinical coverage when the psychiatrist isaway from the practice have been construed by courts as negligent acts amounting to abandonment.
When a psychiatrist agrees to treat a patient, a psychiatrist-patient relationship is formed, creating the duty to provide treatment for the patient as necessary.7 The accessibility of the psychiatrist to the suicidal patient who calls for help can prevent a suicide attempt or completion. Psychiatrists' availability to their patients can also result in fewer emergency calls. Patients are less anxious when they know they can reach their psychiatrist. The patient who calls frequently, claiming a suicidal crisis when none exists, is rare.
When a psychiatrist or the covering clinician is inaccessible to a suicidal patient who calls and who subsequently attempts or completes suicide, the psychiatrist may be sued for abandonment. A distraught, acutely suicidal patient may not be able or willing to follow the recorded message, "If you have a 'true' emergency, please go to the nearest emergency room or call 911." The patient may conclude, "Nobody cares, not even my psychiatrist."Risk management
As a risk management strategy, leaving a "true" emergency message is worse than useless. It is irrelevant and gratuitous. It is more likely to invite a lawsuit than to prevent one. Suicidal patients know that they can always go to an ED. In a crisis, they want to speak to their therapist.
Effective risk management depends on adequate documentation of an emergency call from a suicidal patient. The following should be documented: the date andtime of the patient's call, the nature of the emer- gency, the discussion with the patient,immediate interventions implemented, and the follow-up actions taken.8 Clinical care that conforms to the standard of care regarding emergency accessibility can help provide a solid defense against a claim of abandonment.
In their absence, psychiatrists must arrange for adequate coverage of their practices by similarly qualified clinicians.9 The covering clinician should be informed about suicidal patients who might call and should respond to patient calls in a timely manner, if necessary, seeing the patient for an emergency appointment. The covering clinician also has legal liability exposure for abandonment, if failure to attend to the patient caused harm.Conclusion
Psychiatrists and other mental health professionals who undertake the care of patients at risk for suicide must be accessible in an emergency. A prearranged safety plan with the patient will facilitate management of a suicidal crisis. The psychiatrist should respond to patient calls in a timely manner. Whenever possible, the psychiatrist should try to contact the patient before referring the patient to the ED. Patients' crises can sometimes be managed over the phone or may require an emergency appointment, rather than automatic referral to the ED. Clinician inaccessibility to suicidal patients in crisis may be the basis for a legal claim of abandonment, if the patient is thereby harmed.