Medicolegal Issues

Caring for your patient after discharge

Current Psychiatry. 2007 April;6(4):75-77

References

1. Geddes JR, Juszczak E, O’Brien F, et al. Suicide in the 12 months after discharge from psychiatric hospital in Scotland, 1968-1992. BMJ 1995;311:357-60.

2. Roy A. Risk factors for suicide in psychiatric patients. Arch Gen Psychiatry 1982;39:1089-95.

3. Oquendo MA, Kamali M, Ellis SP, et al. Adequacy of antidepressant treatment after discharge and the occurrence of suicidal acts in major depression: a prospective study. Am J Psychiatry 2002;159:1746-51.

4. Desai RA, Dausey DJ, Rosenheck RA. Mental health service delivery and suicide risk: the role of individual patient and facility factors. Am J Psychiatry 2005;162:311-18.

5. Packman WL, Pennuto TO, Bongar B, et al. Legal issues of professional negligence in suicide cases. Behav Sci Law 2004;22:697-713.

6. Bell v. New York City Health and Hospitals Corporation 456 NYS2d 787 (1982).

7. Johnson v. United States, 409 F. Supp. 1283 (D Fla 1981).

8. Simon RI. Commentary: medical errors, sentinel events, and malpractice. J Am Acad Psychiatry Law 2006;34:99-100.

9. Berman AL. Risk management with suicidal patients. J Clin Psychol 2006;62:171-84.

10. Linehan MM, Goodstein JL, Nielsen SL, et al. Reasons for staying alive when you are thinking of killing yourself: the reasons for living inventory. J Consult Clin Psychol 1983;51:276-86.

11. Simon RI. Suicide risk assessment: is clinical experience enough? J Am Acad Psychiatry Law 2006;34:276-8.

12. Fawcett J, Scheftner WA, Fogg I, et al. Time-related predictors of suicide in major affective disorder. Am J Psychiatry 1990;147:1189-45.

13. Abille v. United States, 482 F. Supp. 703 (ND Cal 1980).

14. Simon RI. The suicidal patient. In: Lifson LE, Simon RI, eds. The mental health practitioner and the law: a comprehensive handbook. Cambridge, MA: Harvard University Press; 1998:166-86.

15. Maunz v. Perales, 276 Kan. 313, 76 P.3d 1027 (Kan 2003).

Cases are selected by Current Psychiatry from Medical Malpractice Verdicts, Settlements & Experts, with permission of its editor, Lewis Laska of Nashville, TN (www.verdictslaska.com). Information may be incomplete in some instances, but these cases represent clinical situations that typically result in litigation.

Dr. Grant is associate professor of psychiatry, University of Minnesota Medical Center, Minneapolis

In the second case, reasonable care encompasses a discharge plan and continuity of care. Discharge plans should include safety precautions and treatment. Follow-up after discharge ensures that the treatment plan has been carried out. Educate family members about monitoring the patient, communicating observations about changes or concerns, and safeguarding the home, such as removing firearms (Box 2).¹³

Box 2

Issues to discuss with previously suicidal patients and their families

Emphasize the need for follow-up therapy and/or medication adherence
Inform the patient and family of crisis management procedures and steps. Patient needs to know how to the contact treatment provider and what to do when the clinician is not immediately accessible in an emergency
Obtain the patient’s permission for you to talk with family members as is clinically necessary
Instruct the family to monitor the patient and communicate changes or concerns to the outpatient providers
Enlist the family to help safeguard the home, for example, removing firearms
Evaluate the patient’s understanding and acceptance of the aftercare plan.

Family members should be aware of any problems in the patient’s understanding or acceptance of the plan.

Source: Reference 9

The discharge records should indicate:

information sources (such as patient report, family report) the psychiatrist used when deciding to discharge the patient
factors that went into the decision to discharge (such as response to medications)
how these factors were balanced against the option of keeping the patient in the hospital.

Clinical Point

Patient anxiety about leaving the security of the hospital can precipitate a crisis and should be part of the risk-benefit analysis

Consider and record the risks and benefits of discharge versus continued hospitalization. Patient anxiety about leaving the security of the hospital can precipitate a crisis and should be part of the risk-benefit analysis.¹⁴

Comparative negligence. In some suicide cases, courts have allowed a comparative negligence defense, either against the family or the patient. In Maunz vs Perales, the psychiatrist instructed the patient’s family to remove all guns from the home, referred the patient to an outpatient clinic, advised the family to make an appointment 1 week later, and then discharged the patient. The next day, the patient bought a gun and shot himself.

The court held that “people generally have a duty to exercise ordinary care for their own safety. To rule otherwise would make the doctor the absolute insurer of any patient exhibiting suicidal tendencies. The consequence of such a ruling would be that no health care provider would want to risk the liability exposure in treating such a patient, and, thus, suicidal persons would be denied necessary treatment.”^5,15

Caring for your patient after discharge

References

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