Thursday, January 10, 2008

Suicide, Malpractice, and Clinical Ethics

Ruth Farrell, a 41 year old librarian in Westport, Connecticut, was admitted to Silver Hill Hospital in mid January, 2002. On January 28, 2002, in between 15 minute checks on her status, she hanged herself, using her own spandex pants.

The executor of her estate, David Kervick, a 60 year old lawyer from New Jersey, who she had met in 2001 when they were both inpatients, sued the hospital and Ms. Farrell’s psychiatrist, Dr. Ellyn Shander, for not preventing her death. On January 3, 2008, a Superior Court jury in Stamford, Connecticut, ruled in favor of the hospital and Dr. Shander.

The New York Times articles from November 23, 2007 and January 4, 2008, tell a painful story. Ms. Farrell was named for a grandmother who had died by suicide. She began cutting herself in high school. During college she was hospitalized for a year for depression. Her pastor said “I have no idea how she lasted as long as she did.” Ms. Farrell’s final admission to Silver Hill was her seventeenth.

Given that suicidal risk was so obvious, how could the jury find for the hospital and psychiatrist?

From my reading of the two New York Times articles, the answer is (1) clinical ethics and (2) a realistic view of the limits of what medicine can accomplish.

After the trial, a juror commented that she was “impressed that when Ms. Farrell could not afford the fees, the doctor often accepted homemade treats in lieu of payment…Ellyn [the psychiatrist] would take cookies, and a lot of doctors won’t do that.” The jury concluded that Dr. Shander cared deeply about Ms. Farrell, stretched herself to be available, and was not mercenary.

The juror conveyed a realistic view of psychiatry as helpful, but finite in its capacity, not omnipotent. “With Ms. Farrell’s history of suicidal thoughts and deeds…she could have done it at home, and the hospital and the doctor helped her all these years.” The jury saw the suicide as the end of a tragic life story, not as the fault of Silver Hill or Dr. Shander. Remarkably, the jury has planned a reunion for January 28, the anniversary of Ms. Farrell’s death, and invited the defense team to participate.

Some decades ago I was briefly involved in the treatment of a young person who committed suicide, elsewhere in the country, a few months after our last contact. I met at length with the family after the death – one of the most painful meetings in my career. The family expressed great grief and anger. They challenged me as to whether, in retrospect, I would have done anything differently. I told them that if I could turn back the clock I would indeed have taken a different course of action, and explained why I had not done so at the time.

Several years later a lawyer called about my late patient. I returned the call with great trepidation. The lawyer told me that the family was bringing suit against the facility where my patient had died, but had “said to get information from you, but to make sure that you were not part of the malpractice suit.”

Apparently the family had concluded that although I had not done what, in retrospect, we all agreed would have been the best thing to do, I cared about their family member and provided well thought out, though ultimately ineffective, treatment.

Health professional students are taught about the importance of genuine caring. The importance of loving one’s patients can’t be overemphasized. It is harder to conceptualize what it means for organizations to be loving, but I believe it can be done. This will be a topic in future postings.


Anonymous said...

I would not be happy wedged in the claustrophobic crack between a suicidal patient and a litigious society.

But then, the position of a suicidal patient is hardly better. A suicidal patient's misery might be compounded by thoughts of self-immolation or, paradoxically, might be relieved by it but, either way, if he should deliver himself into the hands of a psychiatrist intent only on protecting himself from lawsuits, will soon have another good reason to kill himself.

When I think about my own experience of visiting my psychiatrist soon after attempting suicide, and the humiliation I suffered at her hands, I can only marvel at my naivety.

Did my psychiatrist do wrong? Surely not, according to the standards of clinical ethics. She suggested I be placed in a hospital. I said I couldn't; I would lose my job. When I asked for benzodiazepines, she stormed at me, "That would be unethical." I was, of course, manipulating her. An alcoholic and sometime drug abuser like me can't be trusted. It doesn't matter that I've seldom taken benzos. Just follow the rules and, above all, preserve the power relations.

Besides, who would respect a patient such as me? All the fine essays of an Irvin Yalom can't hide the fact that you can have any problem, any problem you like, as long as you don't drink or otherwise self-medicate.

To be introspective and shy, to be full of self-doubt (and sometimes self-pity), to "enjoy" years of untreated depression, to gradually turn to drink to muffle the pain. For these high crimes you can expect:

A trash-can diagnosis of personality disorder.

A direct order to be taken into care if you should try to kill yourself.

A humiliation if you refuse.

Jim Sabin said...

Hello Martin -

Thank you for these thoughtful and pain-laden comments. You raise a number of issues that are very important for ethics and psychiatry.

1. You are right - "the claustrophobic crack between a suicidal patient and a litigious society" (great phrase!) is a tough place to be. This kind of difficulty is part of what medical education is supposed to help physicians understand and deal with. In other specialties the risk of mortality isn't from suicide, but the "claustrophobic crack" is similar. In my first year of medical school my preceptor, then in his 70s, an internist who had won a Nobel prize, described how his teachers had helped him come to grips with the domain. Litigation wasn't a fear in his era, but there is a "claustrophobic crack" between mortality and the physician's wish to help that is built into the medical profession.

2. A "psychiatrist only intent on protecting himself from lawsuits" is at greater risk for lawsuits. The best protection is providing good care and fostering a good relationship. That's why I wrote this posting.

3. I'm sorry you experienced humiliation on top of whatever went into a suicide attempt. Deciding whether hospitalization is the right course is difficult. It is possible to make mistakes in both directions - unnecessary hospitalization and failure of protection.

4. Managing benzodiazepines, even without a history of alcoholism and drug abuse, can also be tough. They can be overused and underused. But ideally the decision will be worked at collaboratively, in an atmosphere of respect. Years ago, in a discussion of this kind with a patient who was honorable but had severe chemical dependencies, I tossed my wallet to him and said "I trust you with my wallet, but we can't trust your self-management and self-reporting when it comes to drugs and alcohol." I never used the term "alcoholic," but rather "you have alcoholism." Alcoholism is a severe problem, not a type of person.

5. Personality Disorder diagnoses can indeed by used as a "trashcan" form of stigmatization, but they can also be useful (to the patient and significant others as well as to the treatment team) if the area is approached thoughtfully and with respect. I liked to give patients the diagnostic manual and ask for their help and advice in using it.

Again, thanks for the thoughtful comments!



Anonymous said...

Thank you, Jim, for graciously replying. I am moved by the quality of your reply, especially the comment concerning alcoholism as something one has.

I now feel chastened about what must have seemed like an attack (which is what it was, and by a lay person, no less). Understand that I did it because the ethical spirit informing your post is in such marked contrast to my experience.

Suicide Malpractice said...

This anecdote illustrates that all suicide malpractice suits are expressions of animus by vengeful, hate filled, scapegoating families. They cannot face the likelihood that their genetics, combined with their relationship problems with the suicider are the predominant cause of the suicide.

These families and their lawyers should be resisted in every instance to the Supreme Court. Cross claims should be filed against each plaintiff to highlight the contribution of the plaintiff to the suicide.

Nikki said...

This particular patient, Ruth Farrell, was a friend of mine. Her relationship with the psychiatric community, and those treating her, was not all grace and large-heartedness. Her story ran much deeper, but that will never be written in the paper. Ruth had Dissociative Identity Disorder. This was not just due to the abuse from her sadistic father (and mother). She continued to be "handled" throughout her adulthood, which ultimately ended in her death. She was one of the most gracious and courageous people I have ever met.

Jim Sabin said...

Dear Nikki

Thank you for your comment. When I reread my post I remembered that January 28 is the anniversary of Ruth Farrell's death. The jury must have seen Ruth as you describe her - "gracious and courageous." Their plan to have a reunion on the anniversary of her death showed that they had become attached to her only from hearing about her.

Many years ago I had a patient from France who (a) had a severe psychiatric ailment and (b) felt very attached to a previous psychiatrist in France. I asked what the psychiatrist would say at the end of the appointment. "Courage" was one of the two phrases he would use. Your comment about Ruth's courage brought that back to mind. The phrase felt right, and over the years I used it a lot.

"Gracious and courageous" is a wonderful way to be remembered. Thank you for telling us about your friend!