Young patient commits suicide
Three GPs, including Dr Des Spence (pictured) share their approach to a practice problem
Three GPs, including Dr Des Spence (pictured) share their approach to a practice problem
Mr Brown comes to see you with his daughter, Lucy, who is 24 and lives alone. Mr Brown tells you they really wanted to see Lucy's usual GP. Lucy has been on antidepressants for several months but they ran out a few days ago; he is concerned that she seems to be getting low in mood again.
You find out that Lucy has been depressed on and off since she was a teenager, taking SSRIs periodically. This time she has been taking them for three months and says they have helped; she doesn't really know why she let herself run out. She still has some symptoms of depression including poor sleep but is managing to go to her office job and to go out socially. When specifically asked about suicidal ideation she says she has felt that way in the past, but not in recent weeks.
You give her a month's fresh supply with a reminder to book a review appointment with her usual GP before they run out. Next morning there is a call from A&E saying Lucy has been brought in dead, apparently from an aspirin overdose.
Dr Mabel Adhagiuno
'Have I failed in my duty of care towards Lucy?'
This is one of the worst possible scenarios for any GP. The dilemma for me would be: have I failed in my duty of care towards Lucy?
The sad fact is that a considerable number of suicide victims have visited their GPs in the weeks or possibly days before committing suicide. The average GP will have 10-15 of their patients commit suicide during their career. Lucy has some suicide risk factors but not many: she is single and lives alone and has had intermittent depression since she was a teenager. But there is no mention of any lack of or recent loss of social supports. She is managing to work and go out – she says – but what about boyfriends? Did a break-up throw her over the edge? Lucy was asked about suicidal ideation, but how directly? She should have been asked: Do you wish to live or die? What reasons do you have for living or dying? Have you ever attempted to take your own life? Have you thought about doing it recently? If so, what would stop you? How long have you had those thoughts for? If you tried to take your life, have you thought about how to do this? Have you made such plans in the past?
The next consideration is Lucy's family and the support they will need. They might apportion a large amount of blame to me. After all, Lucy had 'really wanted to see her usual GP'. There will be a lot of 'if onlys'. If only Lucy had seen her usual GP; if only I had sent her to hospital; if only... Her family will be grieving and might have no wish to see me – I should brace myself for hostility but still try to provide any support needed. I would admit that I too am struggling with what Lucy has done, particularly as she denied current suicidal ideation. I would contact my medical defence union in case this may be the subject of a complaint. Lastly the suicide should be discussed in a practice meeting looking at significant event analysis to see what lessons the whole team can learn.
Dr Des Spence
'Everything was done by the book and there is no fear of litigation. But...'
I would rationalise that any competent doctor would have acted in the same way. She was seen with a family member, the history of her depression was explored, appropriate prescription given, follow-up arranged and most importantly of all suicidal ideation discussed. Everything has been done by the book and there is no fear of litigation nor grounds for a GMC complaint – you are in the clear. But...
Pain, guilt, anger and self-doubt are the emotional firebrands of general practice, and such events live with you for the rest of your life. I am not ashamed to admit that I have been moved to tears at work and suffered periods of depression after significant professional events. My advice? Be honest – a brave face fools nobody. And don't delude yourself that viewing your life through the end of a bottle will help either. Talk to your colleagues – we've all been there, and frankly these are the experiences that bring a partnership together and in the end make you a better doctor.
You must contact the family. You could do this by letter but there is no substitute for a face-to-face approach – if you can't contemplate this then use the phone at the very least. The family may have questions or be angry and blame you but you have to tough this one out. Be open, honest and should you become upset then they will at least understand that you have feelings too – a very levelling experience. I would strongly suggest that you stay at work. In time the family will accept her death and may well see you as source of support over the long term. Your career is long and in time you will understand that patients have no interest in your qualifications nor intellect but only your humility and humanity.
Dr Alison Lennox
'All we can do is allow patients room to tell us how they feel'
It is always a shock to get news like this. Obviously, Lucy can't have been demonstrating many worrying non-verbal clues to how desperate she was during the consultation. The fact that she was 'brought in' by her father should be construed as significant. Here is a girl in her mid-20s who is living independently, so she must be behaving in a way that is worrying her family.
Closer questioning about the risk factors of suicide is very important, asking about depressed mood, anger or hostility, risk-taking behaviour such as taking drugs, unprotected sex, spending lots of money, feelings of hopelessness, isolation, withdrawal, sleeping too much, loss of appetite, preoccupation with death and so on. It is often difficult to really get a feel for this from someone that you haven't met before unless you take some time and attempt to interview them alone. This type of consultation is often a 'make or break' situation and it is necessary to really give the patient time to get around to talking about their needs.
The consultation did specifically ask about suicidal ideation and so theoretically gave her the chance to talk about this – but I think this question often needs to be asked several times in different ways to tease out how the patient is really feeling. Finally, I don't think that we can anticipate or prevent all cases of suicide – who knows what happened between the consultation and the poor girl's death? All we can do is try to allow patients enough room to tell us how they feel.
Number of suicides
- An average GP might expect one suicide every five years in patients on their own list. About 50% of these will have seen their GP within the previous month, many within a few days
- Most are associated with depression
- Men outnumber women 4:1 and more often are very old or adolescent
- Alcohol dependence, previous attempt, recent loss and isolation are all important risk factors
- Young people are less likely to have had a psychiatric diagnosis
Assessment of suicidal risk
- Failure to ask about suicidal ideation is a common reason for failure of registrars in summative assessment
- Questions must be asked in context to be of real value. Look for non-verbal cues then ask an opening question such as: 'When you're feeling low, have you ever thought that there is no hope or you will never get better?'
- Move on to focused questions to look for persisting thoughts, intent and presence of an organised plan to grade the risk. Consider other factors above
- The mnemonic SADPERSONS is useful: S for sex (male) A for age (adolescent or very old) D for depressed P for previous attempt E for ethanol abuse R for rational thinking (lack of in psychotic illness) S for social support (lack of) O for organised plan N for no spouse S for sickness (physical ill health) - One point for each; higher than seven suggests a need for hospitalisation, five or six consider admission, three or four close follow-up is required
Continuity of care
- A recent RCGP study showed that 62% to 75% of patients felt it was important to consult the same GP on each visit. Previous studies have suggested this leads to higher levels of satisfaction, better compliance with treatment and more appropriate use of resources including hospital admission
- Some patients do however perceive that the familiar doctor is more likely to miss a new diagnosis
Why do patients bring relatives and friends with them when consulting?
- Although some patients regard consulting as a group activity, the presence of a third person in the room should ring an alarm bell in your head
- Are they worried about the patient or wanting something that isn't being done? Try asking them why they came
Dealing with the relatives afterwards
- Early contact to offer support is important, however difficult
- Accept they might be very hostile
- Share your own feelings with them
- Offer continuing help and consider early referral for counselling
- Recognise that this event has a significant effect on you
- Make sure all the team are informed about what has happened
- Discuss the case in detail with a colleague as soon as possible
- Use significant event analysis to learn from what happened
Dr Richard Stokell is a GP trainer in Birkenhead, MerseysideDr Spence is a GP in Glasgow Dr Des Spence