Response to Patient Suicide 

---

Suicide Risk Assessment and Response is a four-hour didactic course for R-1 psychiatry residents.   It involves interactive case discussion, a lecture on suicide risk assessment, and a panel discussion of psychiatrists who have lost patients to suicide.

​

Goals and Objectives for the course include:

​

• Developing a beginning understanding of how to structure a suicide risk assessment.

• Increasing familiarity with suicide risk factors and protective factors.

• Understanding that some patients will die from suicide as a result of their illness. 

• Understanding that we cannot accurately predict suicide risk for any individual patient.

• Understanding that clinical failures are not personal failures.

• Developing an awareness of post-suicide reactions.

• Developing an awareness with resources for support after a suicide. 

• Familiarity with University of Colorado Department of Psychiatry residency guidelines for response to patient suicide. 

Patient suicide guidelines for RESIDENTS

This document is to serve as a guideline for residents and faculty and should not take the place of sound clinical judgment.  Each event should be evaluated on a case by case basis.  The particular sequence of actions taken should be tailored to the specific patient, resident(s) and attending involved with the case. 

In the event of suicide, or news of suicide event, during regular work hours: 

• Contact chief resident and attending on service.

• Discuss with chief resident and attending how contact with the family of the patient will be handled.

• If unable to complete clinical duties that day, let your chief resident and attending know what work needs to be done so they can ensure the completion of this work.

• If time off is needed, contact chief resident and attending for assistance in making arrangements.

• Team debriefing including all involved residents, attendings, medical students, and other staff should occur within 72 hours of event.

• Notify residency director, Dr. Robert Davies, of event.

• Meet with Dr. Rachel Davis, the designated support person for patient suicide, within 72 hours of the event.

   Rachel Davis, MD              (W) 303-724-8244, (C) 303-579-5748

              Rachel.Davis@CUAnschutz.edu

• Follow up meetings with Dr. Davis as needed for the first month and arrange a second meeting 8 weeks following the event for follow-up – this is not intended to be therapy.   However, a determination of whether additional therapy is needed should be made and if appropriate, a referral can be placed.

• Participate in a quality assurance and M&M presentation of the case.  For the M&M case the attending and chief resident involved in the case should also be in attendance.  Attendings and residents should present portions of the case and should all be involved in the preparation of the presentation per hospital policy.

*If you have switched to night float or another service when the debriefing or M&M is to take place, contact the training    office for assistance in getting time off to attend this event. 

In the event of a suicide event during on-call hours:

• Contact the on-call attending to relay information about the event.

• Contact chief resident and patient’s service attending.

• Option to sign out to jeopardy if needed, to be discussed with chief resident and on-call attending.

• Otherwise follow resident protocol above.

Patient suicide guidelines for CHIEF RESIDENTS

This document is to serve as a guideline for residents and faculty and should not take the place of sound clinical judgment.  Each event should be evaluated on a case by case basis.  The particular sequence of actions taken should be tailored to the specific patient, resident(s) and attending involved with the case. 

In the event of suicide, or news of suicide event, during regular work hours:

• Make contact with residents who cared for patient – both resident on service and residents who previously cared for patient, if applicable.
  
• Contact attending on service if not already done.
  
• Discuss with resident and attending how contact with the family of the patient will be handled.
  
• Meet with resident for immediate check-in and to determine how to help the resident if they are unable to complete their clinical duties that day.
  
• When immediate responsibilities are taken care, discuss need for time off with affected resident and attending.  Involve training director as needed.
  
• Meet with involved medical students for a check-in and to assess need for additional support.
  
• Contact medical student educational coordinator.
  
• Team debriefing including all involved residents, attendings, medical students, and other staff should occur within 72 hours of event.
  
• Participate in a quality assurance and M&M presentation of the case. For the M&M case the attending and chief resident involved in the case should also be in attendance.  Attending and resident should present portions of the case and should all be involved in the preparation of the presentation per hospital policy.
  
• Consider optional meeting with Dr. Rachel Davis, the designated support person for patient suicide.

Rachel Davis, MD              (W) 303-724-8244, (C) 303-579-5748

           Rachel.Davis@CUAnschutz.edu

In the event of a suicide event during on-call hours:

• Check-in with on-call resident about event by phone and provide support as indicated.
  
• Decide with on-call resident who will contact back-up attending and attending on service.
  
• Discuss with on-call resident option of being relieved of call duties if needed.  If indicated, contact jeopardy call resident.
  
• Discuss with resident and service or on-call attending any contact or notification of family members which needs to occur and assist as needed.
  
• Otherwise follow chief resident protocol above.
  

This document is to serve as a guideline for residents and faculty and should not take the place of sound clinical judgment.  Each event should be evaluated on a case by case basis.  The particular sequence of actions taken should be tailored to the specific patient, resident(s) and attending involved with the case. 

In the event of suicide, or news of suicide event, during regular work hours:

• Make contact with resident who cared for patient and chief resident for immediate check-in.
  
• Discuss with resident and chief resident how contact with the family of the patient will be handled and assist residents with family interactions.
  
• Attending should notify the Medical and Service Directors, Training Director, Chair’s office of the event.
  
• Attending should determine if the Risk Management Office should be notified about the case.
  
• When immediate responsibilities are taken care, discuss need for time off with affected resident and chief resident.  Involve training director as needed.
  
• Team debriefing including all involved residents, attendings, medical students, and other staff should occur within 72 hours of event.
  
• Participate in a quality assurance and M&M presentation of the case.  For the M&M case the attending and chief resident involved in the case should also be in attendance.  Attending and resident should present portions of the case and should all be involved in the preparation of the presentation per hospital policy.
  
• Consider quarterly safety case conferences.
  

In the event of a suicide event during on-call hours:

On-Call Attending

• Check-in with involved on-call resident by phone or in person for support.
  
• If possible, come to hospital to evaluate and document regarding event.
  
• Notify chief resident and service attending if not already done.
  

Service Attending

• Notify resident who cared for patient of event and provide immediate check in.
  
• Otherwise follow attending protocol above.
  

General Questions 

• Should I talk with my colleagues?  
• How much should I reveal to them?
• Should I worry in my revelations to them or even the experience of losing future referrals, or their perception of me? 
• How should I begin to address the suicide for myself? 
• How is this going to affect my treatment with other patients? 
• Is it best to try not to think about it and pretend it didn’t happen? Or should I engage in an activity that would help me to learn from the experience? 
• Or would that be too painful in reliving it again? 
• Is it unrealistic to think that this will affect my career?
• What is the difference between a clinical case conference and an M&M? 
• Which will be employed and when? 
• How should I prepare? 

Questions about interacting w/ the family 

• Should I contact family? 
• If so what method should I use (phone, letters, even visit?)
• What should I say to the family (should I be supportive, explanatory?)
• What should I do if they accuse or blame me? 
• How much should I reveal to them about my thoughts on what went wrong?
• What do I do if the family member needs urgent crisis management after I break the news?
• How much of what I say and how I say it impacts the chances for litigation? 

[Adapted from the Columbia University Medical Center Packet for Resident Whose Patient Committed Suicide] 

Initial Reactions

• Disbelief
  Denial
• Depersonalization (numbness, sense of unreality, spaciness)
  
• Shock

Second-phase Reactions

• Grief (loss of patient, loss of hoped for goals with patient, loss of fantasies related to power, influence and the ability to make a difference)
• Shame
• Guilt
• Fear of blame
• Anger (feelings of betrayal, a waste of work together, for engendering guilt and shame, for inadequate support, to protect against guilt)
• Relief
• Finding of omens (identifying clues before the death may provide an illusory sense of control)
• Subsequent behavioral changes
• Conflicting feelings of specialness (isolation vs. rite of passage)
  

Other Symptoms

• Anxiety
• Depression
• Acute/post-traumatic stress disorder
• Sleep difficulties
• Suicidal thoughts
• Accident Proneness
• Intrusive thoughts
• Exaggerated Startle (especially to pagers/late night calls)
  

Predictors of Stress

• Younger Age
• Less Experience
• Intensity of Involvement
• Institutional Response
• Female
• Decreased flexibility/resilience
• Pre-existing depression or anxiety

Ways to Cope

Decrease isolation by talking to people

[Adapted from Chapter 24: Psychiatrist Reactions to Patient Suicide by Dr. Michael Gitlin in Simon, RI and Hales, RE. Textbook of Suicide Assessment and Management. 2006. American Psychiatric Publishing, Inc. Washington, DC. snd the Columbia University Medical Center Packet for Resident Whose Patient Committed Suicide]

• Immediately seek survivor-sensitive peer support and/or consultation
  

• Be knowledgeable about survivor symptoms that are role-specific to care givers
  

• Monitor personal activities of daily living as well as any increased hypervigilance, cognitive confusion or dissociation
  

• Be aware of any change in the incidence of hospitalization and/or referral of patients who present with issues or problems similar to those of the deceased patient (this could be projection)
  

• Be aware of any increased use of gallows humor, paranoia or inappropriate affect and content 

• Avoid distancing, withdrawal or isolation from supports
  
• Note any increased use of maladaptive behaviors (drinking, eating, drug use)
   

[Adapted from Table 23-2 from Chapter 23: Aftermath of Suicide: The Clinician’s Role in Simon, RI and Hales, RE. Textbook of Suicide Assessment and Management. 2006. American Psychiatric Publishing, Inc. Washington, DC.]

Support Contacts 

(CU residents, contact Rachel Davis for password)

Articles

Web Resources

Uniting for Suicide Postvention

American Association of Suicidology (AAS) Clinician Survivor Task Force Bibliography

• Clinical Section

American Psychiatric Association – Helping Residents Cope with a Patient Suicide

Survivors of Suicide

Physician Litigation Stress Resource Center

Impact of Suicide on Practitioners

​

Biermann B: When depression becomes terminal: the impact of patient suicide during residency. J Am Acad

Psychoanal Dyn Psychiatry 31:443-457, 2003.

Brown HN: Patient suicide during residency training, I: incidence, implications, and program response. J Psychiatr Educ 11:201-216, 1987b.

​

Chemtob CM, Hamada RS, Bauer G, Kinney B, Torigoe RY:  Patients' suicides: frequency and impact on psychiatrists.  Am J Psychiatry 1988; 145:224-8

​

Gitlin, MJ. A Psychiatrist’s Reaction to a Patient’s Suicide. American Journal of Psychiatry 156(10):1630-

1634, 1999.

​

Havens, LL. The Anatomy of Suicide. New England Journal of Medicine 272:401-406, 1965.

Hendin H, Haas AP, Maltsberger JT, et al: Factors contributing to therapists’ distress after the suicide of a

patient. Am J Psychiatry 161:1442-1446, 2004.

​

Hendin H, Ligpschitz A, Maltsberger JT, et al: Therapists’ reactions to patients’ suicides. Am J Psychiatry

157:2022-2027, 2000.

​

Hendin H, Haas AP, Maltsberger JT, Koestner B, Szanto K.  Problems in psychotherapy with suicidal patients.
Am J Psychiatry. 2006 Jan;163(1):67-72

​

Kaye NS, Soreff SM. The psychiatrist’s role, responses and responsibilities when a patient commits suicide.

Am Journal of Psychiatry 148(6): 739-743, 1991.

​

Litman RE: When patients commit suicide. Am J Psychother. 19:570-576, 1965.

​

Lomax JW: A proposed curriculum on suicide care for psychiatry residency. Suicide and Life-Threatening

Behavior. 16(1): 56-64, 1986

​

Misch, DA. When a Psychiatry Resident’s Patient Commits Suicide: Transference Trials and Tribulations.

Journal of the American Academy of Psychoanalysis and Dynamic Psychiatry 31(3):459-475, 2003.

​

Perr, HM. Suicide and the doctor-patient relationship. American Journal of Psychoanalysis 18:177-188,

1968.

​

Reeves, G. Terminal Mental Illness: Resident Experience of Patient Suicide. Journal of the American

Academy of Psychoanalysis and Dynamic Psychiatry 31(3):429-441, 2003.

​

Sacks MH, Kibel HD, Cohen AM, et al: Resident response to patient suicide. J Psychiatr Educ 11:217-226,

1987.

​

Simon, RI and Hales, RE. Textbook of Suicide Assessment and Management. American Psychiatric

Publishing, Inc. Washington, DC., 2006.

​

Books:

Myers M.  Touched By Suicide: Hope and Healing After Loss
Written with Carla Fine, author of the best-selling No Time to Say Goodbye: Surviving the Suicide of a Loved One (Broadway Books/ Doubleday 1999).