Therapeutic risk management of clinical-legal dilemmas: should it be a core competency?

Therapeutic risk management of clinical-legal dilemmas achieves an optimal alignment between clinical competence and an understanding of legal concerns applicable to psychiatric practice. Understanding how psychiatry and law interact in frequently occurring clinical situations is essential for effective patient care. Successful management of clinical-legal dilemmas also avoids unnecessary, counterproductive defensive practices.

Behavioral risk assessment of the guarded suicidal patient.

Psychiatrists and other mental health professionals are trained to assess patients by direct observation and examination. Short inpatient length of stay, brief outpatient visits, emergency room evaluations, and other time-limited clinical settings require rapid assessment of suicide risk. Recognition of behavioral suicide risk factors can assist in the early identification of the guarded suicidal patient, thus avoiding total reliance on the patient's reporting.

Naked suicide.

Suicide attempts and completions by individuals while naked remain unexplored, both by clinicians and in the professional literature. Nakedness at the time of the incident conveys important information about an individual's mental state. Motivations for attempting or completing suicide while naked are discussed. Nakedness during a suicide attempt is presumptive evidence of high risk for suicide completion. Deliberate self-harm, without intent to die, is not usually inflicted while naked. The clinical and forensic implications of naked suicide are explored. In completed suicides, the state of dress, including partial undress and nakedness may provide important clues in a psychological autopsy. Forensic psychiatrists and treating clinicians who encounter naked suicides are afforded a unique opportunity to advance our knowledge. Letters to the editor and case reports would stimulate discourse about this little understood phenomenon.

Gun safety management with patients at risk for suicide.

Guns in the home are associated with a five-fold increase in suicide. All patients at risk for suicide must be asked if guns are available at home or easily accessible elsewhere, or if they have intent to buy or purchase a gun. Gun safety management requires a collaborative team approach including the clinician, patient, and designated person responsible for removing guns from the home. A call-back to the clinician from the designated person is required confirming that guns have been removed and secured according to plan. The principle of gun safety management applies to outpatients, inpatients, and emergency patients, although its implementation varies according to the clinical setting.

Authorship in forensic psychiatry: a perspective.

Authorship in forensic psychiatry is a life-long commitment to learning, creativity, and professional growth. Forensic psychiatrists are writers, by choice and by necessity. The key concepts to effective writing in forensic psychiatry are "process" and a "workman-like approach." The process of writing is not a dash to the finish line, but is more akin to a leisurely, enjoyable walk. A workman-like approach to writing ensures that the author's writing is a process, not an event. Effective writing enhances clarity of communications with attorneys, judges, and others in the legal system. Writing with clarity and precision is a core competency in forensic psychiatry.

Attorneys' requests for complete tax records from opposing expert witnesses: some approaches to the problem.

As part of an impeachment attempt on cross-examination of opposing expert witnesses in trial or deposition, the cross-examining attorney may request the complete tax records of the expert. It is widely believed that expert witnesses may be expected to express opinions that favor the parties who engage them and who pay their fees. Theoretically, the purpose of this request is an attempt to paint the expert as a "hired gun" whose major source of income is forensic work. The different issues, statutes, and case law citations that bear on requests for tax records are reviewed, and the strategies for coping with this tactic are suggested.

Imminent suicide: the illusion of short-term prediction.

The concept of imminent suicide is examined. A search of National Electronic Library for Mental Health, the Cochrane Library, PubMed, OVID and MD Consult databases was conducted using the terms "suicide, imminent." The term imminent frequently appears in the mental health literature, finding common usage among clinicians. It is also a legal term of art embedded in civil commitment statutes; duty to warn and protect statutes and case law, usually under the rubric of dangerousness; and in seclusion and restraint policies. Managed care admission protocols may contain imminence criteria for patients at risk for suicide before approving insurance benefits, yet no suicide risk factors exist for the short-term prediction of suicide.

Pejorative testimony about opposing experts and colleagues: "fouling one's own nest".

Circumstances sometimes require expert witnesses under oath to express opinions about opposing experts or professional colleagues who work within their own professional, geographic, or organizational circle. This requirement poses some common problems that have not been well discussed in the literature. This article addresses some of those problems and suggests some useful solutions.

Commentary: Medical errors, sentinel events, and malpractice.

Medical errors do not necessarily represent negligence. Even when a mental health professional deviates from the standard of care, minor injury to a patient is unlikely to result in a lawsuit. The standard of care is not the same as the quality of care. Quality of care refers to the total care a patient receives, the patient's health care decisions, and the available mental health services. As defined by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), "sentinel events," such as a patient's suicide, do not necessarily imply that a deviation in the standard of care occurred. Psychiatrists and hospital staff are held to an "ordinarily employed" standard of practice. The Institute of Medicine (IOM) guidelines recommend evidence-based care related to patient needs and values. Both JCAHO and IOM promote best practices. Experts err when they testify to a best practice standard in malpractice cases.

On sound and unsound mind: the role of suicide in tort and insurance litigation.

Suicide continues to be a recognized as a crime by common law in a few states. In those jurisdictions, the beneficiary of a claim must prove that the individual who attempted or committed suicide was of unsound mind, to avoid having the patient's act declared illegal, which would bar recovery of the claim. In malpractice and insurance cases, expert testimony is required regarding the mental state of the individual who attempted or committed suicide. Psychiatric testimony varies widely, depending on the legal definition of "unsound mind" and the highly subjective interpretation of legal definitions. Some experts equate suicide with an unsound mind, whereas others apply M'Naghten criteria. Some psychiatrists who disagree with criminalizing suicide refuse to participate in these proceedings. In suicide malpractice cases, the appropriate function of the expert witness is to provide testimony about the standard of care. When experts attempt to testify about "sound or unsound" mind, they must be mindful of the imperfect fit between psychiatry and the law.

Narcissistic dimensions of expert witness practice.

The authors review narcissism as it relates to expert witness practice. The review addresses stable versus unstable narcissism, normal confidence, perspective taking, the effect of flattery, the will to win, mirror transference, narcissistic excitement, narcissistic rage, narcissistic injury, and post-traumatic stress disorder (PTSD). The article closes with recommendations for resisting narcissistic pitfalls and achieving the egoless state.

Patients' rights and psychiatrists' duties: discharging patients against medical advice.

Every psychiatrist who treats voluntary inpatients has had or will have patients who leave the hospital against medical advice (AMA). Studies reveal that between 6 and 35 percent of voluntary psychiatric inpatients are discharged AMA. These patients often are acutely ill and have severe symptoms at discharge. They also, as a group, have high rehospitalization rates and worse outcomes than patients who do not leave AMA. When a mentally ill patient demands to leave the hospital AMA, a tension arises between the patient's rights and the psychiatrist's duties. These duties include those to the patient and, in many cases, to third parties. Patients discharged AMA may remain dangerous and can expose health care providers to a heightened liability risk. More importantly, because of such factors, decisions about handling the AMA discharge are more difficult than decisions about admission. This article analyzes the sources of increased liability risk posed by AMA discharges. It includes discussions of patients' rights, including the different types of voluntary admissions, and psychiatrists' duties. Malpractice litigation in this area is reviewed. The article concludes by suggesting risk-management techniques that can aid in protecting the psychiatrist while also respecting patients' rights and delivering good clinical care.