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Book Review   |    
Risk Management With Suicidal Patients
Douglas Jacobs, M.D.
Psychiatric Services 1999; doi:
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edited by Bruce Bongar, Ph.D., Alan L. Berman, Ph.D., Ronald W. Maris, Ph.D., Morton M. Silverman, M.D., Eric A. Harris, Ed.D., J.D., and Wendy L. Packman, J.D., Ph.D.; New York City, Guilford Press, 1998, 197 pages, $30

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According to its editors, Risk Management With Suicidal Patients is "a forum for the exploration of avoiding liability in working with the suicidal patient." It provides a useful overview of how professionals can integrate risk management strategies into their practices to protect themselves from liability in the case of a patient's suicide. Useful tables provide quick references for clinicians and hospital administrators on topics such as suicidal risk factors, management strategies, and responsibilities of the various clinicians involved in treating a suicidal patient. The chapter topics include outpatient management, inpatient management, drug treatment, and an overview of legal issues and risk management.

Notably, the patient does not get lost in the discussion of liability issues. The focus in each chapter remains on care given to an individual patient under individual circumstances. The contributors state numerous times that the best protection from liability is good clinical care that incorporates appropriate risk management backed up by documentation.

Many of the chapters deal with what is meant by acceptable standards of care. The first four chapters, on outpatient and inpatient standards of care, specifically attempt to guide professionals in managing suicidal patients. Dr. Andrew Slaby provides a comprehensive list of 13 essential elements of outpatient care of suicidal or at-risk patients. Dr. Morton Silverman and his associates offer a similarly helpful list for managing suicidal inpatients. The same chapter also includes tables indicating which professionals—clinicians, hospital staff, and hospital administrators—are responsible for what aspects of treatment of the inpatient.

Almost every chapter summarizes and discusses sample malpractice cases. By addressing the decisions in each case and the underlying clinical themes and legal theories used to decide them, the authors give the reader an overview of the current legal climate for suicide malpractice litigation. In addition, the summaries help demystify terms such as "foreseeability" and "causation" that are commonly used to decide cases but whose relationship to daily practice may not be clear to professionals.

I have only two reservations about the book. As the editors acknowledge, three chapters have been previously printed, and one is adapted almost in its entirety from another book. Although I found these reprints highly informative, the material has not been updated. The second, more substantive reservation has to do with the frequent use of the phrase "standard of care." Although it is indicated that standard of care is a legal definition, I do think this point gets lost throughout the book as the contributors make repeated references to the concept.

The American Psychiatric Association has developed a series of practice guidelines on various disorders, but they are prefaced by a statement that they should not be construed as a standard of care. I think the contributors to this book are suggesting that similar practice guidelines, but with a clear definition of the standard, should be developed for the suicidal patient. However, until such consensus has been reached, it seems premature for these contributors to proffer a standard of care. Perhaps their efforts will help stimulate APA to develop practice guidelines in this critical area of psychiatry.

In sum, this book provides a useful guide for professionals in integrating risk management strategies into their daily practices. It not only outlines treatment situations that can lead to litigation, but provides useful guidelines that can reduce the potential of litigation for clinicians and increase the likelihood of a positive outcome from litigation that results from a suicide. Most important, Risk Management With Suicidal Patients is a reminder to professionals that even in this world of managed care and increasing litigation, we must not allow fear of liability to affect our good clinical judgment when it comes to the treatment we provide to our patients.

Dr. Jacobs is associate clinical professor of psychiatry at Harvard Medical School in Boston.

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