Pearls

Discharging your patients who display contingency-based suicidality: 6 steps

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Discharging patients from a hospital or emergency department despite his (her) ongoing suicidal ideation is a clinical dilemma. Typically, these patients do not respond to hospital care and do not follow up after discharge. They often have a poorly treated illness and many unmet psychosocial and interpersonal needs.1 These patients may communicate their suicidality as conditional, aimed at satisfying unmet needs; secondary gain; dependency needs; or remaining in the sick role. Faced with impending discharge, such a patient might increase the intensity of his suicidal statements or engage in behaviors that subvert discharge. Some go as far as to engage in behaviors with apparent suicidal intent soon after discharge.

A complicated decision

Such patients often are at a chronically elevated risk for suicide because of mood disorders, personality pathology, substance use disorder, or a history of serious suicide attempt.2 Do not dismiss a patient’s suicidal statements; he is ill and may end his own life.

Managing these situations can put you under a variety of pressures: your own negative emotional and psychological reactions to the patient; pressure from staff to avoid admission or expedite discharge of the patient; and administrative pressure to efficiently manage resources.3 You’re faced with a difficult decision: Discharge a patient who might self-harm or commit suicide, or continue care that may be counterproductive.

We propose 6 steps that have helped us promote good clinical care while documenting the necessary information to manage risk in these complex situations.

1. Define and document the clinical situation. Summarize the clinical dilemma.

2. Assess and document current suicide risk.4 Conduct a formal suicide risk assessment; if necessary, reassess throughout care. Focus on dynamic risk factors; protective risk factors (static and dynamic); acute stressors (or lack thereof) that would increase their risk of suicide above their chronically elevated baseline; and access to lethal means—firearms, stockpiled medication, etc.

3. Document modified dynamic or protective factors. Review the dynamic risk and protective factors you have identified and how they have been modified by treatment to date. If dynamic factors have not been modified, indicate why and document the recommended plan to address these matters. You might not be able to provide relief, but you should be able to outline a plan for eventual relief.

4. Document the reasons continued care in the acute setting is not indicated. Reasons might include: the patient isn’t participating in recommended care or treatment; the patient isn’t improving, or is becoming worse, in the care environment; continued care is preventing or interfering with access to more effective care options; is counterproductive to the patient’s stated goals; or compromising the safety benefit of the structured care environment because the patient is not collaborating with his care team.

5. Document your discussion of discharge with the patient. Highlight attempts to engage the patient in adaptive problem solving. Work out a crisis or suicide safety plan and give the patient a copy and keep a copy in his (her) chart.

If the patient refuses to engage in safety planning, document it in the chart. Note the absence of any conditions that might impair the patient’s volitional capacity to not end their life—intoxication, delirium, acute psychosis, etc. Explicitly frame the patient’s responsibility for his life. Discuss and document a follow-up plan and make direct contact with providers and social supports, documenting whether contacting these providers was successful.

6. Consult with a colleague. An informal non-visit consultation with a colleague demonstrates your recognition of the complexity of the situation and your due diligence in arriving at a discharge decision. Consultation often will result in useful additional strategies for managing or engaging the patient. A colleague’s agreement helps demonstrate that “average practitioner” and “prudent practitioner” standards of care have been met with respect to clinical decision-making.

Disclosure

The authors report no financial relationships with any company whose products are mentioned in this article or with manufacturers of competing products.

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