click the arrows to advance forward and backward. click the next link below to advance to the...

Click the arrows to advance forward and backward.

Click the Next link below to advance to the assessment.

The A B C & D’s of Suicide Assessment and Clinical

Documentation

This training is for educational purposes; the information was gathered from the American Psychiatric Association Clinical

Practice Guidelines on Suicide and the Harvard Risk Management Task Force on Suicide



Overview All organizations surveyed under either the Hospital or Behavioral Healthcare standards of the JCAHO will be required by January 1, 2007, to have a plan in place to assess patients at risk for suicide. Suicide is the #1 sentinel event reported to the JCAHO. For staff members working within the inpatient setting, there is heightened need to be able to effectively assess, monitor and treat suicidal individuals while they are in 24 hour treatment and as they make the transition to home and the community. We know that, as clinicians, you strive to provide the best quality of care to those individuals that you serve and assure their well being and safety. Therefore understanding the key elements of lethality and risk assessments and the necessary and appropriate documentation is imperative to meet your goals for exemplary patient care.



Objectives

Understand risk factors associated with suicideIdentify 3 areas of current professional focus relative to suicide assessmentDescribe assessment approaches contained in the APA Practice Guidelines for the “Assessment and Treatment of Patients with Suicide Behaviors” and how Kaleida Behavioral Health adopted the best practice approach in its lethality assessmentIdentify items that are included in a suicide assessment protocol and how it will be documented in the patient’s medical record



Suicide Statistics in the United States

Part 1

Source: National Institute of Mental Health

Data: Centers for Disease Control & Prevention. National Center for Health Statistics, 2002 – 2005.



United States Demographics & Statistics

Suicide rate: 12/100,000Total Deaths: 30,862Average rate: 85/dayOne person dies from suicide in the US every 18 minutesThird leading cause of death for college studentsNinth leading cause of death overall 5th in ages 5-14 years 5th in ages 25-44 years 4th in ages 65-85 years



United States Demographics & Statistics



Suicide & Mental Disorders

More than 90% of suicides are associated with mental or addictive disordersMood DisordersSubstance AbuseSchizophreniaPanic DisorderPersonality Disorder



Suicide & Mood Disorders

11 million persons in the US suffer depression each year, yet fewer than 1/3 seek treatmentDepression is the diagnosis most often associated with suicide (40-80%)Rate of suicidal ideation in depressed patients is 19%-90%Annual rate of suicide attempts among depressed individuals is 3.65%



Suicide & Mood Disorders15% lifetime risk of suicideRisk is increased by:Comorbid substance abuseAnxiety/Panic AttacksAnhedoniaHopelessnessSuicidal IdeationHistory of family member , self

attempting or committing suicide



Suicide & SchizophreniaIdeations in 60-80% of patientsAttempts in 30-55% of patients10% lifetime riskRisk increased by:Good premorbid functioningEarly phase of illnessRecognition of deteriorationHopelessness/depression as a

symptom to affective change



Suicide & Substance Abuse

3% lifetime riskAlcohol/drug abusers: 15-25% of suicidesIntoxication found in half of youthful suicidesRisk increased by:Active substance abuseAdolescence or Illness in the 2nd/3rd

decadeComorbid psychiatric illnessRecent or anticipated interpersonal

loss



Suicide & Panic Disorder

7-15% lifetime riskIndependent or secondary to comorbid disordersNot only during attacksRisk increased by:DemoralizationLossAgitation



Suicide & Personality Disorder

7% lifetime riskRisk increased by:Comorbid mood disorder or substance

abuse ImpulsivityHopelessness/despairAntisocial featuresSelf-mutilationPsychosis



Suicide & Age

Youth and Elderly rates remain highest (2002)Rate in 15-24 years old was 13.5/100,000Third leading cause of death in males 15-24Rate in 65+ years old was 18.06/100,000Rate in <5 years on age increased



Suicide, Gender & RaceSex: 4.5 times as many males (2005)Gender Orientation: increased risk among gay youthRace: (2005 data):More than 70% of US suicides are

white malesHighest rates in American Indian and

Alaskan NativesLatino, Native American, African

American suicides significantly increased since 1999

Black youth (10-19) rate especially increasing



Suicide & Adolescence:Special Concerns that Increase

Suicide RiskSeparating from familiesMaking new social connectionsSolidifying identity, finding roleNeed for rapid maturation of social skillsDrugs, Alcohol availabilityCompetition and self –imageOnset of severe mental disordersIncreasing rates in non white youth suicide



Suicide & ClustersDefinition: 3 or more linked eventsImitation effect is most clear with:Copier is adolescentPre-existing vulnerabilities are

presentCelebrity suicidesCopier identifies with completerCopier belongs to pro-suicide group Increased suicide

attempts/completion shown to follow teen suicide movie broadcasts



Suicide & Marital Status

Divorced rate 34.9/100,000Widowed rate 33.2/100,000Highest rates in young widowers age 15-34Patterns are similar for blacks and whites



Suicide Methods

Most common methods:Firearms most common (60%) More

males than females (80%) In hospitals hangings most

common(89%)Second most common method:

Hanging in menMedication/Drugs in women



Suicide Timing

Season: Higher rates in Fall and SpringDay: Monday has the highest rateHour: Early morning hours



Suicide Attempts in the US

Potentially self-injurious actionNonfatal outcomeEvidence of intent to kill selfMay or may not result in self-harmAttempts are the strongest single predictor of completion, especially in the elderly and in the hospital setting



Suicide Attempts in the US

240,000-600,000 attempts annually (2005)1900 attempts per dayIdeation 260 times as frequent as completion In the young, 100-200 attempts to 1

completion In the elderly, 4 attempts to 1

completion20-40% of attempters made prior

attemptsOf second or third time attempters 4-

12% completed



The Cycle of SuicidePerson has feelings of helplessness &

hopelessness

Starts to develop thoughts of how and

why“Things will be better

without me”

PlanThe person

develops/creates a plan

Makes up mind to commit to the plan

Give cues that end is near

Places affairs in order

Attempts or Commits the

Plan



The A B C & D’s of Suicide Assessment and Clinical

DocumentationPart 2

See Kaleida Form



Initial & Ongoing Suicide Lethality Assessment Forms

The forms we will be discussing are attached to the back of this

training session.



Purpose of Assessment Forms

Model for assessing suicidality in all clinical settingsExample to be incorporated into institution-specific protocolsUsed as a “best practice” and a “standard of care”Not exhaustive and allows for clinical judgment



When to Use the Assessment Forms

Psych ER & InpatientInitial interview (Mental Health Assessment)Admission to treatment facilityAfter self-destructive ideations/behaviorsAfter level of precaution changesAt discharge or termination



When to Use the Assessment Forms

OutpatientThe Initial Suicide Lethality Assessment should be completed at Intake as part of the Mental Health Assessment. The On-going Assessment is completed by the assigned counselor at the departmental level upon admission to that department as part of the Integrated Assessment. The Psychiatrist assigned to the patient reviews the On-going Assessment at the first visit and signs off on the form. The On-going Assessment if then completed yearly or as clinically dictated by the patients treatment plan and the treatment teams recommendations



A is for Assessment

Suicide IdeationsPresent PlanWhat is the plan? Document means,

method & how far has the present suicide plan proceeded

Past AttemptsWhat is the plan? Document means,

method & how far has the present suicide plan proceeded



B is for Beliefs & Risks

What was the reason for the attempt.To Express AngerTo Relieve PainTo Avoid/escapeTo DieTo Make a StatementTo Make Others Suffer



B is for Beliefs & RisksRisk Factors: Substance Abuse

Physical/Sexual Abuse Serious Mental Illness

Impulsivity Themes surround Death & Dying

Physical/Emotional Pain Suicidal Plan: Means

Assault History Prior Suicide Attempts Guilt Command Hallucinations to Kill or be Killed Hopelessness Age Helplessness Sex Strong Death Wish

Recent Loss Family History of Suicide Lives

Alone Financial Stress/Issues Legal

Problems



C is for Clinical Liabilities, Coping Skills & Protective

FactorsClinical Liabilities:Substance Abuse past or presentCognitive Deficits: Delirium.

Dementia, Developmental DisabilitiesCo-Morbid Illness: Medical or

Psychiatric (e.g.. Depressed Mood, Psychosis, Mania)

Affective Lability History of Poor Impulse Control



C is for Clinical Liabilities, Coping Skills & Protective

FactorsCoping Skills & Protective Factors:Ability to form a therapeutic allianceCapacity for affective self regulationAbility to use coping skillsWilling to participate in treatmentStrong Support SystemReligious ProhibitionFuture Goals



D is for Disposition & DocumentationSUICIDE/LETHALITY RISK

ASSESSED AS: MILD MODERATESEVERE

RISK REDUCTION STRATAGIES AS IMMEDIATE INTERMEDIATE LONG TERM



D is for Disposition & Documentation

After all the information is gathered a summary note

should be documented from the face to face encounter

and any other clinical interventions or plan



Ongoing Assessment Form

The Ongoing Assessment form will be used after the Initial Assessment form is

completed and updates the data and information. This

form will allow for the clinician to see changes in

key elements of suicide lethality



Ongoing Assessment FormKey Elements:Ongoing AssessmentChange in Risk FactorsChange in Protective FactorsClinical DeterminationRisk Reduction StrategiesDiscussion of the lethality assessment

& clinical planReview & Comments



Elements of Treatment Planning for the Suicidal Patient

Part 3



Elements of Treatment Planning

Identify range of treatment alternativesChoose appropriate level of treatmentInvolve the patientConsider acute and chronic aspectsDocument the treatment planning processConsider risk management issues



Identify Range of Treatment Alternatives

Greater risk leads to more intensive treatmentAssess risk and benefits of alternativesIncorporate current treatments/providersConsider Risk Reduction StrategiesConsider other options:Psychosocial interventionsPsychoeducation interventionsPharmacotherapeutic Interventions



Psychosocial & Psychoeducational Interventions

Address underlying and/or comorbid disordersCurrent providers should become involvedPsychotherapist ICM or CMCounselorDoctor, PMDIncreased contact may help during

crisis



Psychosocial & Psychoeducational Interventions

Psychoeducation/treatment for significant others on risk and risk reductionUse of community resourcesMHANAMIReligious groups



Pharmacotherapeutic Interventions

Treat underlying or comorbid disordersMedication is an implement for suicide or self harmDrug interactions or indications (Can medication “make people suicidal”?“Does medication reduce suicidal risk”?With the risks assessed “Do we give 30 day supply of medication”?



Medications is an Implement for Suicide or Self Harm

Paradox: Riskiest patients possess dangerous medicationsMany overdoses use prescribed medicationsOften combined with other methodsAntidepressants are the most

commonSome medications have a narrow

margin of safety in dosage



Discharge PlanCurrent suicide risk assessmentLiving arrangementsWork planInvolvement with significant othersUse of community resourcesFollow up appointmentsMedications, prescriptionsIndividualized crisis plan



Risk Management and Suicide

Part 4

Informational to all clinicians

Mandatory for Psychiatrists



Malpractice Suits: The risk is real….

20% of psychologists and 50% of psychiatrists will lose a patient to suicideSuicide related malpractice claims arethe largest category for psychiatriststhe sixth largest category for

psychologists

Awards are disproportionately large in these type of cases



…but adverse decisions are rare.

Few claims go to trial (5-10%)Majority of trials are won by defendantThe distress,nonetheless, is enormousThe best risk management is preventativeSound clinical managementAppropriate documentation



Most Frequent Scenarios

Inpatient suicide with “inadequate care and supervision”Suicide after discharge of inpatientOutpatient suicide with “inadequate treatment”



What is Malpractice?

A “Tort”: A civil wrong committed by one individual that caused injury to another individual.



The Four D’s of Malpractice

Dereliction (negligence) ofDuty (reasonable care)Directly (proximately) causingDamages (emotional or physical)



What is Reasonable Care?Discipline-specific legal dutyImplied by presence of therapist-patient relationshipDegree of care which a reasonably prudent professional should exercise in similar circumstancesIncludes documentation“Reasonable” does not mean “optimal”



Negligence

Failure to meet legal standard of careCommissionOmissionAssumption that foresight leads to prevention



Negligence in Outpatient Treatment

Failure to evaluate for/give suitable pharmacotherapyFailure to hospitalizeFailure to maintain appropriate relationshipsFailure in supervision and consultationFailure to evaluate risk at intake or transitions



Negligence in Outpatient Treatment

Failure to secure prior records, take adequate history, conduct MSE, or diagnoseFailure to establish formal treatment planFailure to safeguard outpatient environmentFailure to adequately document



Failure to evaluate for/give suitable pharmacotherapyMedications are helpful but also dangerousHistory of similar drug treatment must be taken into considerationToo little or wrong medicationDocument rationale for not using medicationHoarding medications can increase risk



Risk Management & PrescribingTreat, and optimize dose (Don’t

undertreat)Use least toxic drug availableNo routine refills without monitoringLimit quantities of refills appropriatelyEmploy pill counts with high risk patientsBeware of attempt to obtain instrument for suicideDon’t stop medications abruptlyFollow up on missed appointmentsIncrease intensity of treatment as appropriate



Failure to hospitalize

Define level of treatment on basis of level of riskHospitalization does not prevent suicide1% of suicides occur in hospitals15 minute checks may be inadequate



Failure to maintain appropriate relationshipsBoundary violationsSexual intimacies followed by patient’s suicideNonsexual boundary violationsRegressive therapies



Failure in supervision & consultation

Majority of psychologists do some supervisionNegligent supervision: “lawsuit of the failure”Respondent superior (vicarious

liability)Assignment of high risk activities to

traineesSupervisor must be knowledgeable in

treatment areaSupervisor must assess training,

competence of traineePatient must give informed consent to

treatment with trainee



Failure to evaluate risk

At intakeAt “one-shot” consultationAt management transitionsAt discharge



Failure to take adequate history or to secure prior

recordsDetermine access to weaponsConsult prior providers or recordsPast suicidal behaviorPast treatment and effectsFamily history of mental illness



Failure to conduct MSE & Diagnose

Mood disturbanceThought disorderCognitive impairmentSubstance abuseMedical diagnosis



“If it isn’t written down, it didn’t happen” -- GutheilDocument the assessment of riskWhat information was consideredHigh-risk factors, low risk factorsWhat questions were asked, what answers were givenHow did this information lead to plan“Thinking out loud for the record”



Failure to document adequately

The chart is a “contemporaneous record”Record collateral contacts, relevant phone callsRecord consultationsNever alter record subsequently



Negligence in Inpatient Treatment

Failure to predictFailure to control, supervise, or restrainFailure to remove belt or dangerous objectsFailure to place in secure roomFailure to take proper testsFailure to medicate properlyFailure to observe continuously or frequentlyFailure to take adequate history



Bell v New York City Health & Hospital Corporation

(1982)Negligent care with bad outcomeEarly release of patient preceded suicideDefendant psychiatrist found liable, failed to: Inquire re nature of auditory

hallucinationsRequest prior treatment recordsNotice recent restraints in chartCommunicate with hospital staff



Dillman v Hellman (1973)

Reasonable care with bad outcomePatient jumped from psychiatric hospital window following transfer to less secure area of hospitalPsychiatrist defendant not liableAccepted standard of care had been

metPhysicians “cannot ensure results”Documentation in chart was deciding

factor for care



Summary of Risk Management

Manage risk preventatively, not retroactivelyUnderstand how to assess suicide riskAssess risk initially and repeatedlyKnow legal and ethical guidelines for treatmentPlan and implement treatment & risk reduction strategies appropriatelyConsult when indicatedDocument effectively

click the arrows to advance forward and backward. click the next link below to advance to the...

Documents