Wary of Malpractice Suits, Doctors Draft Suicide Risk Survey

A new position paper recently distributed among Israeli psychiatrists sets rules to evaluate suicidal patients.

The Israel Psychiatric Association has formulated for the first time a procedure to evaluate suicidal patients. The measure is intended to help psychiatrists protect themselves against malpractice suits in cases of patients under their care who commit suicide.

A new position paper recently distributed among Israeli psychiatrists sets rules to evaluate suicidal patients. The procedure requires every psychiatrist to carry out a risk evaluation regarding suicidal patients. After the evaluation the psychiatrist may rule there is no need for compulsory treatment.

If the patient eventually does commit suicide, the therapist will not necessarily be held responsible.

The procedure, drafted by Israel's most senior psychiatrists, was signed by Dr. Gadi Lubin, the director of Mental Health Services in the Health Ministry, Dr. Zeev Kaplan, chairman of the Psychiatry Association and director of Be'er Sheva's mental health services and Prof. Avi Bleich, director of the Lev Hasharon Mental Health Center.

Hundreds of suicides and thousands of calls to emergency rooms about suicide attempts are registered in Israel annually. Some who commit suicide are psychiatric patients and in recent years psychiatrists whose patients have committed suicide have been sued for malpractice, especially after suicides in hospitals.

In June 1999, the Supreme Court ordered Hadassah Hospital in a precedential verdict to pay compensation fees to the family of a suicidal patient aged 35 who jumped to his death from the hospital's eighth floor.

According to the new position paper, "A suicidal patient leaves among his loved ones a feeling of unnecessary loss, pain, frustration, anger and guilt. These are projected or displaced on any external person or body who can bear or at least share the guilt and perhaps should also be sued for financial compensation due to 'negligence'... This is a short step away from seeing the suicide as the therapist's failure."

The paper says that in general there are "no sweeping therapeutic solutions to the risk of suicide. Even the supposed absolute protection, psychiatric hospitalization, does not always prevent the act."

"It is almost impossible to predict which patient will hurt himself," Kaplan said. "It is widely assumed that if you hospitalize a person who threatens to take his own life and deny his freedom, you are helping him and preventing the act. But sometimes the process is reversed, and hospitalization or supervision without the patient's consent can reduce his responsibility and increase the suicide risk."

Psychiatrist will be required to give patients an examination to detect various manifestations of suicidal behavior such as thinking about it, intent, a plan or an attempt to commit suicide and assess risk factors such as past suicidal behavior, psychotic disorders or distressing events in the patient's life.

On the basis of the evaluation, psychiatrists will consider whether to hospitalize the patient, enlist support systems, administer medication, therapy and/or monitoring.

The psychiatrist is not necessarily responsible for a patient's suicide, the paper says.

"Placing sweeping responsibility on the psychotherapist and reducing the patient's responsibility could lead the therapist to practice defensive medicine and impair his judgment," it reads.

Defensive medicine considerations could lead to selective treatment of patients, over-hospitalization, cloudy diagnosis, over or under-medication and avoiding risks. "There is no doubt all these practices are potentially significantly damaging to the patient," the paper says. "Relieving the patient of personal responsibility contributes to further regression in his already damaged self image. It is therefore important to preserve the patient's personal, legal and moral responsibility over all his personal decisions, including his suicidal behavior."

Kaplan says though the paper seems like a defense mechanism for doctors, its goal is to return the power of judgment to medical practitioners.

"The paper doesn't make their life easier and requires psychotherapists to carry out a detailed risk evaluation and documentation and finally make a professional decision based on that evaluation regarding the required activity," he said. "The courts will be asked to refer to our professional position and we assume the judges will make decisions based on these criteria."

Kaplan says the paper is open to changes if new technologies and approaches for suicidal evaluation are introduced.

"At this stage it provides the best answer to the extent of responsibility and judgment that needs to be exercised in these cases," he said.

Health Ministry figures show 4,510 suicide attempts were reported in hospital emergency rooms in 2008, 4 percent more than in 2007 and a 19 percent rise within a decade.

The overall number of suicides in Israel has gone down 24 percent over the past two years. In 2007, 250 men and 56 women committed suicide. The highest suicide rate registered in 2005-2007 was in the Kinneret area - 10.2 per 100,000 people. The lowest rates were among Jewish residents of the West Bank - 4.3 per 100,000 people.