Medicolegal Issues

Failing the 15-minute suicide watch: Guidelines to monitor inpatients

Current Psychiatry. 2007 June;6(6):41-43

References

1. Shugar G, Rehaluk R. Continuous observation for psychiatric inpatients. Compr Psychiatry 1990;30:48-55.

2. Busch KA, Fawcett J, Jacobs DG. Clinical correlates of inpatient suicide. J Clin Psychiatry 2003;64:14-9.

3. Bowers L, Gournay K, Dufy D. Suicide and self-harm in inpatient psychiatric units: a national survey of observation policies. J Adv Nursing 2000;32:437-44.

4. Proulx F, Lesage AD, Grunberg F. One hundred in-patient suicides. Br J Psychiatry 1997;171:247-50.

5. Shah AK, Ganesvaran T. Inpatient suicides in an Australian mental hospital. Aust NZ J Psychiatr 1997;31:291-8.

6. Moore P, Berman K, Knight M, Devine J. Constant observation: implications for nursing practice. J Psychosoc Nurs Ment Health Serv 1995;33:46-50.

7. American Psychiatric Association. Practice guideline for the assessment and treatment of patients with suicidal behaviors. Available at: http://www.psych.org/psych_pract/treatg/pg/SuicidalBehavior_05-15-06.pdf. Accessed April 19, 2007.

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

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

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.

Risk analysis

The courts look to see if the suicide assessment was “clinically reasonable”.⁸ To meet this standard, perform a “suicide risk-benefit analysis” each time you make a significant clinical decision, such as ordering 15-minute checks. The record should include information sources you used (such as family members or previous medical records), factors that entered the clinical decision, and how you balanced these factors in a risk-benefit assessment (Box 1).⁹

Clinical Point

The court cannot adequately determine deviations in the standard of care unless the clinician documents his or her thought processes

Risk factors. There are no documented suicide risk factors specific to an inpatient setting.⁴ Suicidal ideation at the time of admission has been associated with greater chance for inpatient suicide,⁵ but other research has found less than one-half of patients who committed suicide in a hospital were admitted with suicidal ideation.^2,7 Of those who were admitted with suicidal ideation and then committed suicide in the hospital, 78% denied these thoughts during their last communication with hospital staff.² Therefore, denial of suicidal ideation alone is not a reliable basis to determine suicide risk.

Document decisions. Mistakes in clinical judgment do not necessarily constitute negligence,⁸ but deviations in the standard of care cannot be adequately determined in a court of law unless the clinician had documented his or her thought processes at the time of the decision.

Predicting which patients will re-experience or deny suicidal ideation is impossible,⁷ but if the patient is determined to be at high risk for suicide, then implement and document a plan to address this risk. In addition, communicate information regarding the risk-benefit assessment to staff responsible for implementing these precautions.

Box 1

Suicide risk factors to consider in the risk-benefit analysis

Suicidal thoughts or behaviors—ideas, plans, attempts
Psychiatric diagnoses—depression, bipolar disorder, schizophrenia, substance use, Cluster B personality disorders
Physical illnesses—HIV, malignant cancers, pain syndromes
Psychosocial features—lack of support, unemployment
Childhood traumas
Genetic and familial effects—family history of suicide
Psychological features—hopelessness, agitation, impulsiveness
Cognitive features—polarized thinking
Demographic features—adolescents, young adults, and elderly patients
Other factors—access to firearms, intoxication.

Source: Reference 7

When is this assessment made? The waxing and waning nature of suicidality requires that assessments be repeated over time.⁷ Conduct a suicide risk assessment when:

a patient is admitted for inpatient treatment
observation status changes
a patient’s clinical condition changes substantially
acute psychosocial stressors are discovered during the hospitalization.⁷

In the patient’s chart, document this risk assessment, your decision-making process, changes in treatment, and communication with family members when you change the level of observation.⁷

Failing the 15-minute suicide watch: Guidelines to monitor inpatients

References

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