September 27, 2006

How to Write A Suicide Note

I'll write this for the ER psychiatrist seeing acute cases, but the strategy applies to all types of psychiatry.  Always keep in mind what is the purpose of the note, and who will actually be reading it.


1.  Write so the reader doesn't have to guess what you were thinking. 

The overall biggest mistake in medical note writing is spending too much time/too many words on the "Objective" or narrative portion of the note, and not enough on the "Assessement."    

Who is going to read this note?  Insurance companies read the objective and bill based on it.  But no one else will care about this.  The only part that other doctors, lawyers, and juries care about is the assessment and plan (assuming its more than two lines.) 

And so you must write your assessment and plan in a way that makes it completely obvious why you did what you did. 

For example, a common error is trying to convince the reader that the person was not suicidal by listing occurrences or patient statements.   "Patient was denying suicidal ideations...had good affect and was joking with staff... etc etc."  You are forcing the reader to make an inference, to have to connect the dots himself.  This is bad, because what if they come up with a different conclusion?  Make the train of thought obvious.  "I was able to conclude that he wasn't suicidal because not only was he denying suicidality, but his good affect and joking with staff indicated to me he felt better."

Did the person shave himself this morning, with attention to detail?  If yes, that's a good clue he wants to live.  But write it down in the note.  Don't write it as, "Appearance: clean" because it's more important than that.  Put it in sentence form in the body of the note.  Here's an example of a suicidal surgical patient I was saw in consultation.  "I noted that he was cleanly shaved with attention to the margins along his goatee; I asked him if he had done it (or a nurse) and he said he did it, he was trying to look good."  That's gold.   He may be suicidal, but he was hopeful enough to want to look good.  Now link it explicitly: "This supported my assessment that he was still interested in life, and that he wanted to live."

2.  Prime real estate should be valued. 

The maxim "if it wasn't written, it wasn't done" is idiotic, and false.  But if it is written, it shows it carried more importance to you relative to other parts of the note.  Writing about a patient's future plans in the objective  shows it mattered more to you than did, say, checking a box near "Appearance: Clean."  Or, the reverse: not writing about his future plans makes it look like it mattered LESS to you than his appearance.

Don't waste space with SIGECAPS and the like; no one cares.  I know this contradicts everything you've been taught, but it's true.   It's important in making the diagnosis of depression, but the actual readers of the note (other doctors, lawyers, and juries) only care what your diagnosis was, and what you did about it. 

3.  Your note should be timeless. 

Certainly you need to assess suicidality, and explain why you think he isn't right now.   But keep in mind that your assessment will last more than 24 hours.  If he kills himself next week, lawyers are still going to come looking for you-- and documenting that he wasn't suicidal at that precise instant isn't necessarily going to be enough.  You need to evaluate his future and what should be done about it.  For example, you have a person who has had multiple suicide attempts (but is not  malingering) in the ER.  You're convinced he's not suicidal now.  But what about next week?

"Currently he is not suicidal, feels fairly hopeful about the future and has made some specific future plans like XXX..." [list them!]

Note that hopelessness/pessimism about future-- not depression, psychosis, etc,--  is the best predictor of suicide.  So note it explicitly. 

Okay, in the near term he is not likely to be suicidal.  Or is he?  He's had nine attempts before, after all.  What about that?

"...However, given his history of [impulsiveness/poor judgment/poor frustration tolerance/drugs], it is probable that he will attempt suicide again at some point in his life.  Unfortunately, this is a function of his future acute stressors-- over which I have no current control-- not how he feels right now.  He feels fine now, but on the drive home something bad could happen (e.g. girlfriend leaves him, loses his job, etc) which will activate his suicidal impulses..."

That's key, because it sets up the problem: he is going to attempt it again-- let's just get that out into the open-- but that has nothing to do with how he feels today.  And it explains how you can't be held responsible now for it then.  So now you explain why you didn't do the "obvious" thing, which is hospitalize:


Hospitalization and/or medication now is not going to alter that future eventuality, and thus are not indicated today.  In fact, hospitalization may be detrimental because it sets up a pattern of dependency.  Rather than finding better ways to deal with distress, he learns to run to the hospital whenever he is faced with frustration.  He does not learn how to cope with stress.  The main risk is thus that if he can't get to an ER, or the distress is particularly severe, he will not be able to cope and will have an even greater risk of suicide.  In essence, hospitalizing him now puts him at greater risk for suicide later..."


But what makes you a good doctor (and saves you from the charge of negligence) is the next two sentences:


"Given the chronicity of his suicidality, I have to do something that will actually help him long-term.   I believe he is not suicidal now, so my responsibility is to help decrease his suicide risk, as best I can, forever.  The best way to help him is to refer him for [intensive therapy/day program/psychiatric visit, etc] for long term follow-up, so that he can have somewhere to go and someone to manage him as symptoms and stressors develop.  This is the best way to keep him alive.  So, we discussed a crisis plan for future suicidality: at the first sign of distress he will call X; if this is not sufficient he will Y, then Z; ultimately he will come to ER..."


That's what the note should say, in your own style and with the contents of your interview.  So that when the lawyer asks, "why the hell didn't you hospitalize him?" he and the jury already know the answer.

4. The note is a not a newspaper article, it is an op-ed. 

Also note the way I wrote my sentences.   They are personal and  informal.  "Best way to keep him alive." "...over which I have no control."  Etc.  The note is your educated opinion, not a scientific article.  You have to explain-- pretend it is to a jury, if that will help-- not just what you did, but why you did it-- and why not something else.  "His affect changed when I left the room and he was noted to be joking" does not powerfully (enough) convey what you saw and what it meant to you.  "With me, he was crying, but when I left the room and he thought the evaluation was over, I watched him joking and laughing with one of the nursing assistants."  See how that changes things? 

5.  You can be wrong, but you cannot be negligent. 

It should be obvious from the note exactly what you were thinking-- and, importantly, that you were thinking.   That you took time to ask questions, observe, assess, draw conclusions that were reasonable.  You might have been wrong, but you did a thorough job.  That's why the assessment matters.  Simply having volume to the Assessment shows that you gave due consideration to the case.

In other words: the note isn't written to help you win a lawsuit, it's to prevent one from being filed.  You want a potential plaintiff's attorney to look at your notes and say, "forget it, it's not worth it-- it's obvious he isn't negligent."

6. Call someone. 

Very important: get someone else's opinion, and document it.  It's one thing for you to say he is not suicidal; but it's tremendously helpful to have a family member tell you he isn't, or that this situation is common, or that this happens whenever he gets upset, etc.  If his girlfriend, etc, seems to think it is ok for him to come home, write that down! 

"Spoke with his wife, who expressed no reluctance in taking him home despite everything he had been saying."

or, better:

 "Spoke with his wife who was happy to take him home, and did not think he needed to be hospitalized."


See how telling that sentence is?  Sure, by itself it is meaningless, and the wife is no psychiatrist, etc.  But in combination with the other things you (will) write, it details what's going on and why you did what you did. 

(In the converse, you should be hesitant to go against a family member, because they know them better than you.  If the mom says he needs inpatient, you have to have a really good set of reasons why he doesn't.  If you can't convince mom, you'll never be able to convince a jury after they die.) 

If family and friends are not available (document that you tried-- that also shows effort and is above standard of care!) then get a second doctor, or nurse.  I don't mean atttending phone back-up, which is useless.  I mean another resident, or an ER doc, anyone, so that you can write this next sentence:

"Discussed the situation with X who also evaluated the patient, and X agreed with me that..."

Apart from giving you a valuable second opinion, it also helps establish "standard of care," loosely defined as how a "respectable minority" of docs in your situation would have proceeded.  Two docs is pretty much a respectable minority, as far as I'm concerned (and have testified to such.)


7.  If you discharge a suicidal patient, you must show that this is a better treatment than admssion. 

You read all this and say, "well what if they say they're still suicidal?"  Let's assume they are not malingering. (I'll get to that later.)  And let us assume you don't actually think they need hospitalization and should be better served somehow else. 

What's the key?  To explain to the reader why you kicked them out of the ER despite actually believing their suicidality.  (I say "kicked out" because that's how the lawyers are going to phrase it.)

First thing is to explain why you felt he would be alive next week despite his suicidality now.  What's keeping him alive for later until Thursday, when is he has his outpatient appointment?   Explicitly list all the reasons for hope for the future and his future plans. 

Second thing is to explain why hospitalizing him isn't going to help him.  Essentially, it's the same note as in #3. 

"Given his history of multiple suicide attempts, what needs to be done is to get him through this acute situation, and then prepare him for the future.  Hospitalizing him will have no impact on his future suicidaliity as it is stressor dependent.   Obviously, his history of other hospitalizations, medications, and ER visits have done little to prevent him from being at this point again and in this ER now. Thus, hospitalizing him will only "ensure" his safety for the few days he is inpatient, and do nothing to keep him alive long term.  It delays, not treats his suicidality, and when another stressor comes this hospitalization will have done nothing to help keep him alive.

Given this, the best way to help him is to refer him for... [as above].

As for his suicidality now, the plan is to let him decompress and reorganize for an hour or two here in the ER.  We will give him some Ativan (etc) to help him.  I'll give him supportive therapy as well as try to give him some better coping techniques for the future, and have RN do the same, to reinforce it.  I was upfront with my opinion that hospitalization was not helpful here, and I explained my reasons, and while he was not happy with this and did not agree--he wanted to be inpatient-- he at least understood my perspective and was satisfied I was trying to help him.  Of course [note word choice "of course"],  I called his family/friend/etc who agreed to come pick him up and stay with him continuously, and would not let him out of their sight, and would bring him back if things worsened, etc.  I told them how and when to give ativan. etc.

This is tricky, so let me be clear: this note isn't to convince you he's not going to die.  You have to already be convinced, for yourself, that despite his suicidality he will be alive tomorrow.  Then, and only then, should you be writing a note supporting your decision. 

8.  Plan should match Assessment; You can be wrong, but not negligent. 

This again? Here I refer specifically to diagnosis and plan.  If the diagnosis is malingering, and you kick him out of the ER, don't write "Psychosis NOS; Plan: discharge."  Because the plan is not obvious for the diagnosis.   The diagnosis should be, "Malingering; Plan: discharge."  Because that fits. To the reader, it's obvious.

You may be wrong.  You need to work on not being wrong.  But for the purposes of negligence, an incorrect diagnosis with a reasonable plan for that diagnosis is better than the correct diagnosis with an unreasonable plan. 

The note should convey an obvious train of thought.  Obvious means that the person could guess what your plan will be based on the diagnosis, and vise versa.  A person comes in suicidal because they broke up with their boyfriend yesterday should not have a note that says, "Depression: discharge."  It should say, "Adjustment disorder: discharge."  Because that plan seems more obvious for that diagnosis to a reader. 

If you diagnose "depression" you are implying a longstanding problem that may exist in the absence of actual stressors.  You might not want to be implying this, but it does.  All you meant was that the guy was sad, but now you have to write a more detailed note explaining the future course or treatment.

This applies to personality disorder.  If a borderline has another self-cutting event, the diagnosis is not depression; it's borderline.  Writing, "Axis I: Depression; Axis II: Borderline" means, "oh my God, she was acutely depressed on top of an underlying borderline personality disorder!"  Which is worse.

9.  Write the note as if the patient died, but you have a chance to change your note.

First, an amusing anecdote about why doctors are idiots.  I did a malpractice case where the doctor received a subpoena for records, and sent them in.  Great. Except the plaintiff's attorney already had a copy of the records, which he used to show that doctor had altered his copy after receiving the subpoena.   Game over.  You lose.  I am told this is a common maneuver.

So don't change your note.  But imagine the patient kills himself-- and you have the ability to change your note.  What would you change?  If the guy shot himself, maybe you'll have wanted to write he had denied having a gun, or that you discussed removing the gun with the family.  Or if he was on drugs, you'll have wanted to document discussing abstinence, protecting against withdrawal, or at least noted there were no signs of intoxication.  Etc.  Well, write this all in the note now.  Pretend they're dead, and write the note from that perspective, in other words justifying how you could not have predicted this-- any reasonable person would have concluded they would live, not die-- and how extensively you attempted to prevent it. 

And this is purusant to #2.  If the patient suicided, your magnificent documentation of SIGECAPS and his Family Psychiatric History isn't going to be worth squat. It may even hurt you without a rigorous Assessment (#3).  This is a real quote: "Doc, you've documented pretty clearly the guy was depressed: low energy, poor appetite, poor sleep, lack of pleasure, lack of interest in sex, chronic lower back pain-- how the hell could you let this guy out of the ER?  Did it not occur to you he was going to hang himself?  Or did you think he was just going to catch a movie to cheer himself up?"

Obviously, you're not supposed to lie in the note.  I'm trying to get you to think proactively, to start asking the right questions (SIGECAPS is the wrong question) and assessing the right things.  And then documenting them.

Write what you will someday desperately wish you would have written.  Make the Assessment and Plan strong.

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