Is It a "True" Emergency? Suicidal Patients' Access to Their Psychiatrists

Psychiatrists and other mental health professionals leave voice mail messages on their office phones advising patients what to do in case of an emergency. But when a suicidal patient in crisis calls the psychiatrist and hears the recorded message, "If you have a 'true' emergency, go to your nearest emergency room or call 911," the patient's risk of suicide may increase.

Psychiatrists and other mental health professionals must be accessible to suicidal patients or be able to provide for adequate coverage in their absence, because the psychiatrist may be the only person with whom the suicidal patient has a life-affirming relationship.

What, exactly, is a "true" emergency? Who can define it? "True" emergency is devoid of meaning, but the suicidal patient may perceive the intent of the above message as: "Don't bother me!" The "true" emergency message erects a barrier between the patient and the psychiatrist. Does this now increasingly heard message reflect an erosion of the doctor-patient relationship wrought by changes in mental health care delivery? Is it also a misguided effort at risk management?

Emergency accessibility

Leaving the message, "If you have a 'true' emergency, go to your nearest emergency room," or the variant "call 911," leaves a patient with few options. Suicidal patients are often reluctant to call 911. The police and rescue squad will arrive at the door with sirens blaring. A crowd of inquisitive neighbors will gather. The street scene is embarrassing and humiliating. Alternatively, the patient may be too impaired or unwilling to follow the message directives, instead choosing to attempt or complete suicide.

The general hospital emergency department (ED) is the main venue for suicidal patients who require immediate care. Based on a consultative model of care, the patient is first evaluated by the ED physician. If psychiatric consultation is requested, a crisis counselor usually sees the patient. An attending psychiatrist is available on- call for consultation, usually by phone. In most instances, general hospital EDs provide adequate care.

The ED experience, however, can add to the patient's distress. Psychiatric patients report enduring long waits to be evaluated in busy general hospital EDs-the patient may not be seen for hours or even a day or more. Hours of waiting in mental misery may only confirm the patient's feelings of hopelessness and abandonment, thereby increasing suicide risk. A suicidal patient with agitated depression or a psychotic patient with auditoryhallucinations that command suicide may leave the ED before being seenand attempt or complete suicide.

Psychiatric emergency services (PESs), staffed by psychiatrists and a full complement of other mental health professionals, are usually based at large medical centers or universities. They are open 24 hours a day, 7 days a week, andprovide "full service" comprehensive emergency psychiatric services.¹ Provision of "around-the-clock" service prevents patients from leaving before being evaluated.

Generally, a phone call to the patient by the psychiatrist is an intermediary step to determine an initial course of action. The psychiatrist may be able to assess the severity of a patient's suicidal crisis over the phone and, if necessary, arrange an emergency appointment. If possible, the patient may be managed by means other than referral to the ED. A return call from the psychiatrist can stabilize a suicidal patient until he or she can be seen on the same ornext day. Thus, the therapeutic alliance is preserved and strengthened.

It may be necessary to send a suicidal patient in need of immediate care to the ED or the patient may go to the ED without calling the psychiatrist. In the first instance, the psychiatrist should determine whether the patient is able to go to the ED alone or needs someone to take them. Clinicians have escorted patients to the ED. The suicidal patient may be so disturbed that he is unable to come to the psychiatrist's office or to speak coherently on the phone. The psychiatrist should try toenlist the assistance of others (eg, a family member, partner, friend, or the police) before sending the patient to the ED. If none are available, the psychiatrist may have no recourse but to call 911 or community crisis management services. A phone call to the PES or general hospital ED in advance of the patient's arrival will alert and inform the staff about the suicidalpatient. It also may help decrease the waiting time in the ED.

The psychiatrist or the covering clinician (who should be informed about suicidal patients who might call) must be available to respond within a reasonable period. Although hard-and-fast rules do not exist, if possible, an emergency call from a suicidal patient should be responded to within the hour. Cell phones facilitate accessibility and rapid response. For a patient in a suicide crisis, evenwaiting an hour may seem like an eternity.

In solo practice, the psychiatrist or covering clinician must be accessible to calls from suicidal patients 24 hours a day, 7 days a week, by cell phone, pager, or other means of direct communication (excluding e-mail). Twenty-four-hour coverage for patient emergencies is an established medical practice and standard of care.

Psychiatrists in group practice or institutional settings have on-call schedules that provide continuous coverage for patients. Some psychiatrists provide their home phone number to patients during a period of increased suicide risk.

The Opinions of the Ethics Committee on the Principles of Medical Ethics With Annotations Especially Applicable to Psychiatry² takes a firm position on the emergency coverage of patients.

Question: One of our members is concerned that psychiatrists in his area do not routinely check in with their answering machines after hours, leave no number where they may be reached, or leave a message for patients to contact the local emergency department in case of emergency. Is this member's concern about the ethics of these psychiatrists warranted?

Answer: Yes. Ethical psychiatrists are obliged to render competent care to their patients. That competent care would include either being available for emergencies at all times or making appropriate arrangements. Certainly, a message telling patients to call an emergency department is not adequate coverage. Even in rather stable practices, including analytic practices with relatively stable patients, emergencies do arise. Care must be taken that, if and when such emergencies do arise, the patient is not abandoned.

Patient education: a prearranged safety plan

With the current limitations on access to hospital services, most patients at risk for suicide, even long-term high-risk patients, are treated as outpatients. Some psychiatrists provide and discuss with new patients a safety protocol to be followed in an emergency. The spirit of the discussion is, "We're in it together." Alliance-building encourages the patient, who might not do so otherwise, to call the psychiatrist during a crisis. Psychiatrists must explain how they can be reached in an emergency.

The psychiatrist or covering clinician, however, may not be able to return the patient's call in time when an acutely suicidal patient needs immediate assistance. In the prearranged plan, the patient will leave a message with a phone number for the psychiatrist indicating that he has gone to a safe "holding place" to await the psychiatrist's call (eg, at home, with family or a friend, or other) or if necessary, to a predetermined ED. The psychiatrist will call the ED at the first opportunity to assist in the patient's assessment and management. If a PES is accessible to the patient, the address and phone number should be provided.

Some patients at risk for suicide do not have family, partners, friends, or other supportive resources. If unable to wait for a callback from the psychiatrist, the patient should be provided with suicide prevention hot- line numbers as a source of assistance. The National Suicide Prevention Lifeline (800-273-TALK; or www. suicidepreventionlifeline.org) can refer the patient to local hotlines and other sources of help.

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.³

Case 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.

References:

References1. Breslow RE. Structure and function of psychiatric emergency services. In: Allen MH, ed. Emergency Psychiatry. Washington, DC: American Psychiatric Publishing; 2002:1-31.
2. American Psychiatric Association. The Opinions of the Ethics Committee on the Principles of Medical Ethics With Annotations Especially Applicable to Psychiatry. Section 1-AA. Washington, DC: American Psychiatric Association; 2001.
3. Meyer DJ, Simon RI. Split treatment. In: Simon RI, Hales RW, eds. The Textbook of Suicide Assessment and Management. Arlington, Va: American Psychiatric Publishing; 2006.
4. Simon RI, Shuman DW. Clinical Manual of Psychiatry and Law. Arlington, Va: American Psychiatric Publishing; 2007.
5. Mains J. Medical abandonment. Med Trial Tech Q. 1985;31:306-328.
6.Bolles v Kinton, 83 Colo 147,153, 263, p 28 (1928).
7. Fochtmann LJ. Emergency services. In: Simon RI, Hales RE, eds. The American Psychiatric Publishing Textbook of Suicide Assessment and Management. Arlington, Va: American Psychiatric Publishing; 2006.
8. Simon RI. Assessing and Managing Suicide Risk: Guidelines for Clinically Based Risk Management. Arlington, Va: American Psychiatric Publishing; 2004.
9. Simon RI. Clinically based risk management of the suicidal patient: avoiding malpractice litigation. In: Simon RI, Hales RE, eds. The American Psychiatric Publishing Textbook of Suicide Assessment and Management. Arlington, Va: American Psychiatric Publishing; 2006.