Most doctors aren’t trained to expect suicide in a patient, so they often think of it as a personal failure, and even, perhaps, question their own abilities – but experts say these kinds of tragedies “don’t make you a failure as a physician”.
“Suicide can be traumatic for anyone who encounters it,” says Julie Cerel, professor at the University of Kentucky College of Social Work and director of UK’s Suicide Prevention and Exposure Lab, who has also researched the impact of suicide on police, firefighters and paramedics. “They have trouble shaking those scenes.”
“This is especially true for physicians, most of whom replay, constantly, the last sessions or encounters with the patient who committed suicide, thinking, ‘What might I have missed? What could I have done differently?’ Even if they can’t think of anything they should have done differently, they keep second-guessing themselves.”
Dr Michael Myers, professor of clinical psychiatry, SUNY Downstate Health Sciences University, New York, is familiar with that sense of self-blame, writes Batya Swift Yasgur in Medscape.
Myers lost two patients to suicide during his residency – one when he was training in internal medicine and one when he was training in emergency medicine.
“I thought maybe if I trained as a psychiatrist, I could help people not to die by suicide,” he said.
Myers, co-author of The Physician as Patient: A Clinical Handbook for Mental Health Professionals, now treats other physicians, many of whom have lost patients to suicide. He says self-blame and guilt are natural responses, but it’s not always possible to stop a suicide.
Suicide is “a humbling act” because, “no matter how much we do, we can’t necessarily transfer our life force and will to live to someone else whose life may be filled with trauma, abuse, chronic illness – medical or psychiatric”, he said. “We’re dealing with someone else’s pain, and we may be powerless to relieve that.”
But physicians are accustomed to believing their role is to prevent patient death at all costs, so suicide is what Chicago psychiatrist Dr Elena Tuskenis calls a “rupture of expectation”.
“Any kind of death, in the context of medical care, may be seen by the physician as a failure; and with suicide, it’s particularly difficult to wrap your head around it,” she said. “But the tragedy of a patient suicide does not mean you’ve failed as a physician.”
Sorrow
Even when physicians “come to accept that they did the best they could, they still experience a sense of sorrow”, said Myers.
“We’re expected to just keep going without attending to our own emotions, but that’s not realistic or healthy," said Tuskenis, who experienced patient suicide as an outpatient clinician. The death was a shock to both her and the patient’s primary care doctor, whom the patient had most recently seen.
“Although we were both grieving the loss, as a psychiatrist, I was expected to provide support for the primary care physician,” Tuskenis said. “We could have ideally been a mutual support to one another, but the organisation at the time did not structure our interaction in that way. And I did not prioritise managing my own personal response to the loss.”
A common reaction after a patient’s suicide is to isolate and shut down. But experts encourage clinicians to find someone to talk to.
Relating to family
Many clinicians wonder how to relate to the family of their former patient after a suicide. Should they reach out? Attend a memorial or funeral?
Tuskenis approaches the question not only as a physician but also as someone who lost a brother to suicide when she was at medical school.
“He was in psychiatric treatment. He had an appointment with his psychiatrist, then drove to a motel and took his life.”
Within days, the psychiatrist invited the family to a meeting. Tuskenis recalls he “reassured us that, at the last appointment, my brother was calm, stable, did not appear anxious, and expressed no thoughts of wanting to kill himself”.
The psychiatrist shared his handwritten notes, which Tuskenis saw as a “gesture of compassion”.
She now thinks the psychiatrist probably also wanted “to show us he had …not been in error in anyway”.
“This was an excellent example of the complexity in the doctor–patient relationship and, by extension the family, when a tragedy like this happens.”
She said none of her family ever thought to blame the physician. “But we were all traumatised that my brother decided to do what he did right after his appointment. I’m sure the physician was startled as well.”
Skip Simpson, a Texas attorney specialising in suicide malpractice, also encourages physicians to contact the family.
“It’s a very human thing to do,” Simpson told Medscape. “Families recognise that the professional really does care about them and the person who died, and acts like a normal human being instead of going into a ‘hide-the-ball’' situation. They’re also less likely to sue if you just act normally.”
Going to a memorial service or funeral can be tricky but also healing, both to the physician and the family. “Make sure you’re invited and welcome, so you’re not seen as an intruder in an intimate family setting,” Myers said.
Trauma after trauma
Sometimes, families might decide to sue the physician, facility, or organisation for a patient’s suicide, described Tuskenis as “trauma on top of another trauma” – an outcome that may complicate grief and reinforce a sense of failure and shame.
Simpson and Myers urge physicians to follow their organisations’ protocols, since many healthcare systems have (or should have) procedures in place if this happens.
Residents should speak to their supervisors. And physicians in private practice should contact their malpractice insurance carrier immediately after a suicide.
“Most families don’t sue the physician after a patient’s suicide… but in case it happens, the insurer will want to know immediately,” said Myers, who advised holding on to the patient’s medical record but not altering anything.
“It’s okay to make additions, like an addendum in case the file is subpoenaed, which can be written after the patient’s death. But never go back and make any changes to what you’ve already written.”
Evolving practices
Although a patient’s suicide can be shattering to a physician’s career, it can also have a beneficial impact, Cerel says. For example, some are motivated to document their interactions with patients more thoroughly. Some take additional classes to deepen their knowledge of suicide prevention.
Keeping abreast of research and approaches is particularly important, and “relatively new approaches, like safety planning, can be helpful”.
If you decide to hospitalise a suicidal patient, don’t implement a “15-minute check” protocol, warned Simpson, formerly a member of the American Association of Suicidology’s Task Force on Improving the Competency Within Mental Health Regarding Suicide Assessment and Treatment. “Most cases I take are families suing professionals or institutions for patients who committed suicide while in an inpatient unit, often on a 15-minute observation schedule.”
He said suicidal patients should be watched on a one-on-one basis or be in the line of sight of a nursing station. “Although the 15-minute protocol is common, it’s not reliable. A patient who’s intent on self-harm can do so within six or seven minutes, right in the hospital room. And irreversible brain damage can occur within two minutes if a person hangs himself, for example.”
Batya Swift Yasgur has a counselling practice in New Jersey.
Medscape article – Handling Your Grief After a Patient’s Suicide (Open access)
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