When Elena Tuskenis, MD, was in her first year of residency, she heard about the suicide of a patient she had seen briefly on an inpatient unit. The deceased patient had been treated at the hospital’s outpatient clinic by a fellow resident.
Tuskenis, a Chicago-based psychiatrist, approached the resident to express empathy and support. She was shocked by the response: “I’m not going to talk about this,” the resident said. “Please never mention it again.”
Her colleague’s reaction “illustrates the issues we have as physicians or physicians-in-training that lead us to avoid discussing patient suicide” Tuskenis told Medscape. “It’s terrifying, it’s painful, and it may evoke grief, stigma, and shame.”
Julie Cerel, PhD, professor at the University of Kentucky College of Social Work and director of UK’s Suicide Prevention and Exposure Lab, added that most physicians “aren’t trained to expect suicide in a patient and they often think of it as a personal failure. This may even make some clinicians question their ability to be an effective provider.”
Replaying and Second-Guessing
“Suicide can be traumatic for anyone who encounters it,” said Cerel, 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 the last sessions or encounters with the patient who died by suicide over and over. ‘What might I have missed? What could I have done differently?’ Even if they can’t think of anything they could or should have done differently, they continue to second-guess themselves,” said Cerel, co-editor of a collection of 14 first-person stories entitled Seeking Hope: Stories of the Suicide Bereaved.
Michael F. Myers, MD, professor of clinical psychiatry, SUNY Downstate Health Sciences University, Brooklyn, New York, is familiar with that sense of self-blame. He 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 that self-blame and guilt are natural responses, but we don’t always have the power 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,” Myers said. “We can’t be arrogant about that because we’re dealing with someone else’s pain, and we may be powerless to relieve that.”
But physicians are accustomed to believing that their role is to prevent patient death at all costs, so suicide is what 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,” Tuskenis said. “But the tragedy of a patient suicide does not make you a ‘failure’ as a physician.”
Even when physicians “come to accept that they did the best they could, they still experience a sense of sorrow,” said Myers.
Vanessa McGann, PhD, a New York City-based psychologist, calls this “disenfranchised grief” because “you’ve had a relationship with the patient, but you’re not the patient’s family or community member and there’s no formal space or context for your grieving.”
Moreover, physicians sometimes sense an implicit message that it’s not okay to grieve. “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 came as a shock to both Tuskenis 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 organization at the time did not structure our interaction in that way. In this situation, I did not prioritize managing my own personal response to the loss.”
A common reaction following the suicide of a patient is to isolate and shut down. But experts encourage clinicians to find someone to talk to — a close friend, family member, colleague, supervisor, therapist, or support forum.
“Find or create safe anonymous spaces for support,” Tuskenis advises.
McGann is a past co-chair of the American Association of Suicidology’s Clinician Survivor Task Force. In 2021, she co-founded the Coalition of Clinician-Survivors (CCS) of which she is a co-chair today. The organization serves not only clinicians who have lost patients to suicide but also clinicians who have lost family members and loved ones to suicide.
McGann herself lost a sister to suicide and found that “there was no space or any kind of support system for clinicians who had sustained that type of loss and are struggling with grief, stigma, and other associated emotions.”
The organization is designed to create that “safe space” clinicians can turn to. The website includes educational materials, testimonials, a list-serve for discussion, and a names of clinicians who have lost patients to suicide and make themselves available to offer support and guidance to others.
Relating to the Surviving Family
Many clinicians wonder how to relate to the family of the deceased patient in the aftermath of a suicide. Should they reach out? Should they attend a memorial or funeral?
Tuskenis approaches the question not only as a physician but also as a family member who herself lost a brother to suicide when she was in medical school. “He was 40 years old and in psychiatric treatment. He had an appointment with his psychiatrist, then immediately drove to a motel, checked in, and took his life.”
Within a few days after that occurrence, the psychiatrist invited the family to a meeting in his office. Tuskenis recalls that the psychiatrist “reassured us that, at the time of the last appointment, my brother was calm, his mood was stable, he did not appear anxious, and did not express any thoughts of wanting to end his life.”
The psychiatrist showed the family his own handwritten notes, which Tuskenis saw as a “gesture of compassion.” She now thinks the psychiatrist likely also wanted “to show us he had dotted all the i’s and crossed all the t’s and had not been in error in some way.”
To Tuskenis, “this is an excellent example of the complexity in the doctor–patient relationship and, by extension the family, when a tragedy like this happens.”
She noted that none of her family members ever thought to blame the physician. “But we were all traumatized by the fact that my brother decided to do what he did right after his appointment. I don’t have a doubt that the physician was very much startled as well.”
Skip Simpson, JD, a Texas-based attorney specializing in suicide malpractice, also encourages physicians to reach out to the family.
“This is a very human thing to do,” Simpson told Medscape. “Families recognize that the professional really does care about them and cares about the loved one who died and acts like a normal human being instead of going into a ‘hide-the-ball’ situation. They’re much less likely to sue if you just act normally.”
Matthew Turner, JD, a malpractice attorney based in the Detroit suburb of Southfield, agrees. “There may be a small risk of reaching out to the family — some might think that an expression of compassion can be construed as some type of admission of error — but my opinion is that the benefits of reaching out and showing caring and concern outweigh any potential risks,” he told Medscape.
Going to a memorial service, wake, or funeral can be tricky but can be healing, both to the physician and to the family. “Make sure you’re invited and welcome, so you’re not seen as an intruder in an intimate family setting,” Myers advised. “And remember that HIPAA concerns continue even after a person is deceased, so don’t reveal to other attendees that you were treating the patient, or any confidential information about the patient.”
Myers describes a patient he had been treating for a long period of time — a physician with severe depressive illness and alcohol use disorder — who took his life when Myers was away at a conference.
“I got back and found out he was in the ER. I was there when they put him on life support, which was very brief because his parents were clear they didn’t want him on extended life support because of his beliefs about quality of life,” said Myers, who was also present when the patient was removed from life support.
The family asked Myers to speak at the patient’s funeral. Many colleagues urged him to decline but he agreed to do so because it was the patient’s mother who requested it. “I also received a note from the patient that he penned just prior to taking his life thanking me for the care he received, apologizing that he felt he had no alternative but to end his life, and asking me to take care of his mother.”
The note “crystallized” Myers’ decision to speak as a way of honoring the patient’s last request and comforting his mother. “It also helped me to get through it,” he recalls.
“Trauma on Top of Trauma”
Sometimes, families decide to sue the physician, facility, or organization for a patient’s suicide. This may lead to what Tuskenis refers to as “trauma on top of another trauma” — an outcome that may certainly complicate grief and reinforce a sense of failure and shame.
Simpson and Myers urge physicians to follow their organization’s protocols, since many healthcare systems have (or should have) procedures in place if this event happens. Residents should speak to their supervisors. And physicians in private practice should contact their malpractice insurance carrier immediately after a patient’s suicide.
“I know that sounds very pragmatic and technical, and the vast majority of family members don’t sue the physician after a patient’s suicide; but just in case it happens, the insurer will want to know at the get-go that you’ve lost someone to suicide,” said Myers.
“But be aware that organizations are usually more concerned with litigation than with helping clinicians,” Cerel said.
Simpson noted that if litigation has started, the lawyer may not want you to talk to anyone about the suicide, which compounds the sense of isolation and stigma and removes potential sources of emotional support. But it’s okay to speak to a colleague or close friend or family member without disclosing details about the patient, and it’s permissible and healthy to speak to a therapist.
Myers advises holding onto 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. You can write, ‘Three weeks ago, I did such-and-such but did not enter it into the patient’s chart.’ But never go back and make any changes to what you’ve already written.”
Evolving Practices, Professional Growth
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 physicians are motivated to document their interactions with patients more thoroughly. Some take additional classes to deepen their knowledge of suicide prevention. This is true not only of psychiatrists and mental health professionals but also of physicians in different specialties, such as oncology, emergency medicine, and primary care.
“You have to recognize the signs and know when to refer a patient to a mental health practitioner,” Turner said. “Getting extra training can help with that.”
Cerel emphasizes that keeping current on the latest research and approaches is particularly important because some clinicians are still using “outdated practices” when dealing with patients who may be suicidal. “For example, I still hear about clinicians entering into ‘no-suicide contracts’ with patients, but this is not an evidence-based intervention, and isn’t recommended,” she said. Instead, there are relatively new approaches, such as safety planning, which can be helpful in suicide prevention.
And some physicians don’t thoroughly assess patients for potential suicidality. “Sometimes I’ll see a brief note in a chart that says, ‘Patient denied suicidality,’ but it’s unclear what questions the clinician asked to elicit that information,” said Cerel. “There are evidence-based, targeted screening tools to ascertain the degree of suicidality.”
If you decide to hospitalize 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. “The vast majority of cases I take are families suing professionals or institutions for patients who died by suicide while in an inpatient unit, often on a 15-minute observation schedule.”
He noted that suicidal patients should be watched on a 1-on-1 basis or be in the line of sight of a nursing station. “Although the 15-minute protocol is very common, it’s not reliable. A patient who’s intent on self-harm can do so within 6 or 7 minutes, right in the hospital room. And irreversible brain damage can occur within 2 minutes if a person hangs himself, for example.”
Simpson also encourages professionals to involve the family in the patient’s care as much as possible right from the beginning. “Have the patient agree that you can share some information with family members. That creates a sense that ‘we’re all on the same team’ and also means that you can reveal information with the family without violating confidentiality.” This is an important way to reduce the possibility of a future lawsuit, he explained, in the event that the patient dies by suicide.
Batya Swift Yasgur, MA, LSW, is a freelance writer with a counseling practice in Teaneck, New Jersey. She is a regular contributor to numerous medical publications, including Medscape and WebMD, and is the author of several consumer-oriented health books as well as Behind the Burqa: Our Lives in Afghanistan and How We Escaped to Freedom (the memoir of two brave Afghan sisters who told her their story).
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