Inadequate Assessment of Man With Depression
A 35-year-old Ohio man was arrested for DUI. Because he exhibited suicidal tendencies and signs of depression, he was transported to an emergency department, where he was evaluated by three emergency physicians. He was then discharged to a facility for individuals who need to sleep off the effects of alcohol after drinking too much. He was left at the facility without any paperwork or any indications that he was experiencing depression or suicidal ideation. Within minutes of his being dropped off, he hanged himself in a bathroom.
The plaintiff alleged negligence in the three emergency physicians’ assessment and treatment of the decedent’s depression, suicidal ideation, and comorbid conditions; according to the plaintiff, the defendants failed to provide proper dosing and monitoring of the effectiveness of the antidepressant medication they prescribed. Additionally, the plaintiff claimed that the defendants failed to obtain and document an adequate health history.
The defendants claimed that the decedent’s injuries were self-inflicted and that proper treatment was provided. The defendants contended that the decedent denied a desire to commit suicide and said he wanted to receive treatment for alcohol abuse.
OUTCOME
According to a published account, a defense verdict was returned.
COMMENT
Medical malpractice cases commonly arise from mental health treatment. If emergency diagnosis and treatment of mental health conditions is within your scope of practice, be cautious and proceed formally. There are a few steps clinicians can take to ensure that the patient is receiving optimal care while lowering malpractice risk.
Use diagnostic terms appropriately, accurately, and precisely. Referring to a patient who is having a bad day as depressed is sloppy; describing a withdrawn patient as antisocial is often incorrect.
Always show concern for patients, and let the record reflect your concern for the patient’s well-being. Avoid making disparaging remarks that may be overheard, repeated, and used as evidence at trial. Jurors confronted with such remarks will be invited to infer that the clinician did not care about the patient, did not respect the patient, made value judgments about the patient, or considered treating mental health problems a bother.
Perform a proper psychiatric exam. While time constraints will preclude a full psychiatric workup, we should obtain a history of present illness and previous history, including hospitalizations. In addition, we should perform a mental status examination. This includes an objective determination of:
• General appearance
• Attitude/rapport
• Speech
• Behavior
• Orientation
• Mood
• Affect
• Thought process and content
• Memory
• Ability to perform calculations
• Judgment, and
• Higher cortical functioning (eg, interpretation of complex ideas).
The mental status exam is important because it adds objective data to the patient’s subjective history of present illness and may be useful in defending the clinician’s decisions. If you rarely perform a mental status exam, use a template or checklist when you do to ensure completeness.
Address suicidality and homicidality forthrightly. These areas represent the lion’s share of mental health malpractice cases. Any cause for concern should be acted upon fully and formally, with documentation to support your rationale and actions.
Don’t reach for psychotropic agents too quickly or without adequate follow-up. A skilled plaintiff’s lawyer can develop an entire theory of the case around a clinician’s rash use of “a pill to solve the patient’s problems.” Therefore, it is generally recommended to start psychoactive medications in conjunction with a comprehensive plan to monitor the patient’s response and overall functioning.
In this case, a defense verdict was returned. It is probable that the emergency physicians’ records demonstrated appropriate concern for the patient, and the jurors determined that the patient’s suicide was unfortunate but unforeseeable. —DML
Antiviral Ordered, Administration Delayed
Early one afternoon, a 36-year-old Pennsylvania woman was brought to a hospital emergency department by her mother, who reported that her daughter had sounded confused in a phone conversation. The patient had been experiencing virus-like symptoms for several days.
CT was performed with normal findings; a lumbar puncture showed inflammation, which was interpreted as evidence of a viral condition. The defendant emergency physician consulted with an infectious disease specialist, who recommended administration of acyclovir, stat. The emergency physician wrote the order but without the stat notation.
An hour later, the infectious disease physician arrived to examine the patient and ordered acyclovir, stat. The medication was still not administered for another three hours, by which time the patient was comatose. She was then transferred emergently to another hospital, where she was placed in a drug-induced coma.
After three weeks’ hospitalization, the patient was transferred to an inpatient rehabilitation facility. She sustained severe short-term memory loss and requires 24-hour care.