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Understanding physicians' duties toward suicidal patients

Physicians must prepare for the ethical and legal ramifications of patient suicide


 

Suicide is the third most-frequent cause of death in persons aged 10 to 54, and the tenth most-frequent cause of death across all age groups, according to the Centers for Disease Control and Prevention. Half of those who commit suicide saw a physician in the preceding month, and one third were being treated for mental illness, so physicians must be prepared to deal with the ethical and legal ramifications of patient suicide.

Say you are a family physician, and you are treating your longtime patient, Mr. Smith, for multiple chronic conditions and back pain. During a recent visit he looks disheveled and tired, and asks you about prescribing something to him for difficulty sleeping. 

You learn that he just lost a very close friend to cancer and has been feeling “blue” nonstop for about two months. He admits that his medical condition has really been bothering him and that he just, “wants it all to stop.” He assures you that he wouldn’t leave his family alone, but “bad thoughts” have crossed his mind. 

You are about to prescribe his usual monthly allotment of pain medication and are considering his request to add sleeping pills. But should you? What are your duties to this patient now that he has expressed to you that he has thought, even in a fleeting way, about ending his life? Should you contact a family member or police? What about doctor-patient confidentiality?

As the example illustrates, the issue is not limited to physicians who focus their practices on mental health. Depression and psychosis can have physical symptoms, such as sleeplessness or gastrointestinal distress, and because many significant illnesses such as cancer, HIV-AIDS, seizure disorders, or conditions that cause chronic pain result in higher suicide rates amongst sufferers, almost any type of physician may, at some point, face a patient who is considering self-harm.

What the law says 

While the law traditionally imposes no general duty to prevent another person from taking his or her own life or self-injury, the “special relationship” that exists between a physician and a patient can give rise to a duty where none would otherwise exist. 

The issue of whether a “special relationship” exists is fact-sensitive. A physician who becomes aware during a treatment visit that a patient is considering suicide would be ill-advised to do nothing with that knowledge. In those circumstances, a physician can face liability for medical malpractice and/or ordinary negligence, as discussed below.

The countervailing argument is the patient’s right to confidentiality in treatment. Most physicians are aware of the myriad privacy laws that prohibit them from disclosing personal health information (PHI) without a patient’s express consent. Violating privacy laws can result in civil liability and other sanctions. 

Studies have indicated that questioning a suicidal person about his or her plans does not increase the risk that suicidal thoughts will be acted upon, and can lessen a patient’s anxiety and shame. 

Thus, physicians should not be afraid to confront a patient who has expressed or is suspected of having suicidal thoughts in a treatment setting.  Such discussion may lead to the patient’s consent to further treatment and/or to the disclosure of PHI to others who can help. Such consent should be documented, however. 

Next: Disclosing protected health information

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