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Book Forum: Suicide   |    
Risk Management With Suicidal Patients
Am J Psychiatry 1999;156:653a-654.
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edited by Bruce Bongar, Alan L. Berman, Ronald W. Maris, Morton M. Silverman, Eric A. Harris, Wendy L. Packman. New York, Guilford Publications, 1998, 197pp., $30.00.

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This book, readers should be forewarned, is both a superb treatise and a potentially dangerous resource. To begin with the positive: the book is an absolutely invaluable reference book for all clinicians and hospital administrators (both general and psychiatric hospitals) as well as a practical guide (perhaps too practical) for those involved in suicide malpractice litigation (as expert witnesses, defendants, plaintiffs, and attorneys). Although the book is short, consisting of only seven chapters, three of which are reprinted from the journal Suicide and Life-Threatening Behavior, the new material is very useful. Furthermore, the advantages of having all of the chapters together and hard-bound make this volume an extraordinarily worthwhile addition to all mental health professionals’ libraries.

Chapters 1 (by Bongar, Maris, Berman, and Litman) and 2 (by Slaby) deal with outpatient standards of care and outpatient management of suicidal patients. Chapters 3 and 4 (by the authors of chapter 1 plus Silverman) focus on inpatient standards of care—general clinical formulations and legal considerations in the former and integration with clinical risk management in the latter. Chapter 5 consists of a very brief, but nonetheless excellent, overview of psychopharmacological treatment of suicidal inpatients by Goldblatt, Silverman, and Schatzberg. "Clinical Psychopharmacotherapy With Hospitalized Patients: A Forensic Perspective," by Silverman, is the sixth chapter, and the seventh, "Legal Issues and Risk Management in Suicidal Patients," by Packman and Harris, provides the view of two attorneys on suicide malpractice litigation. This final chapter is a wonderfully concise overview of a complex area of law and is especially useful in that it provides a perspective of how attorneys view these cases; the section on risk management in a managed care environment provides a caveat for us all.

The problematic aspect of this work relates to the setting of standards of care. Chapters 4 and 6, in particular, although otherwise excellent, set forth what the authors term "the first attempt to clarify the minimal standards of care for the treatment of inpatient suicidal patients." However, they posit comprehensive, exhaustive lists of do’s and don’ts that can hardly be considered minimal. There is a potential for considerable harm to be done to the profession if malpractice attorneys were to use these so-called standards as minimal. As an expert witness, I have reviewed dozens of cases, both for plaintiffs and defense attorneys, and as an administrator, I have had to appeal numerous Medicaid disallowances, and I am convinced that there is virtually no such thing as a perfect medical record—one can always find something. Worse, to call superlative standards "minimal" provides ammunition to those seeking to find fault. Standards should be established by treatment guidelines developed by professional associations of experts, such as APA, with careful, balanced consideration of what constitutes a reasonable standard of care. Data-based standards would be optimal, but no one, including these authors, has these. For an individual or a small group of individuals (even a highly distinguished group of experts like these authors) to promulgate standards on their own, and, worse, to define their stringent standards as minimal, borders on the irresponsible. The authors acknowledge that "in truth, the standard of care, that level of care provided by the mythical ‘average’ practitioner operating in a reasonable and prudent manner, is defined by the opinions [their italics] of experts called upon as consultants in a tort action." Surely, a plaintiff’s experts would be delighted to use the putative standards cited in this work to bolster their views. In a brief postscript, Bob Litman comments that

Dr. Silverman succeeded in his effort to provide standards of "good clinical practice" (see Chapter 4), but in my opinion he lost sight of the original concept of "minimal standards." His proposed "remedies" for "alleged failures" embody ideal performance.

Silverman responds to Litman in his own postscript, explaining that these standards are, for him "a starting point. In my own clinical work, I attempt to adhere to these standards. I would hope that anyone assessing or treating a suicidal individual would attempt to do likewise." I agree with Litman, and I certainly agree with Silverman that one should "attempt" to adhere to these standards—but "attempt" is the critical word. They are laudable standards and goals, and we should all do the best we can, in an imperfect world, to match them. To posit that they are minimal, however, sets most of us up to be viewed as failing to meet them. Clearly, when standards are promulgated, authors become concerned about incompleteness. Consequently, they may create comprehensive checklists that, although excellent as such, may prove unreasonable, in toto, for the clinician. Note, too, that in his introductory chapter, Bongar states, in contrast to Silverman (cited above), that "we are not positing a standard of care (his italics) in this volume. Rather, we are presenting principles of care giving that might be considered optimal (his italics), impossible to achieve in their entirety but worthy of consideration." Well, whom are we to believe—Bongar or Silverman? And whom will attorneys cite?

Aside from a few misquoted statistics—e.g., "From 0.5% to 1% of the population dies by suicide annually" (I assume they mean 1% of annual deaths are by suicide)—and an occasional surprising viewpoint—e.g., "Although most suicides are mentally disordered at the time of their suicides, we must not rule out the possibility that proper care may help individuals see clearly and rationally that their future is relatively hopeless and devoid of sufficient quality of life to be reasonably continued" (p. 9) (what kind of "proper care" is that?)—the book is well edited and indexed, and the chapter bibliographies are fairly extensive.




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