Duties and responsibilities
Examining risk in psychiatric practice
Originally published June 2014
The CMPA reviewed 881 legal and medical regulatory authority (College) cases involving psychiatrists that closed between 2008 and 2013. The majority of these were College complaints. Notably, in more than half of the cases, the legal action was dismissed or the College, following investigation, supported the care provided by the psychiatrist. The most common criticisms related to issues of professionalism include inappropriate manner, boundary crossings, and confidentiality breaches. Deficient risk assessment and medication management were the most common clinical issues. Communication and documentation issues were recurring themes across the cases.
Allegations of inadequate assessment often arose when a patient committed suicide while under the care of a psychiatrist. Though rare, allegations also occurred in cases where a psychiatric patient committed a criminal act or an act of violence against someone.
Peer experts supported the care provided by the psychiatrist in the majority of cases involving patient suicide, self-harm, or violence.
The main areas of concern identified in unfavourable decisions were inadequate assessments, including not soliciting collateral or secondary information when appropriate; inadequate monitoring; or not reassessing a patient before extending privileges (e.g. allowing day passes) or before discharging from hospital.
Meanwhile, incomplete documentation of the assessment or treatment plan often made it difficult to evaluate the rationale behind care decisions.
Poor coordination of care was often a factor when suicide occurred in hospital (e.g. other healthcare providers not advising the psychiatrist of a change in the patient's condition). Inadequate monitoring protocols or unsafe environments (e.g. unsecure windows, too easy access to medications) were contributing factors in some cases.
In these types of cases, both the hospital and the psychiatrist(s) are often named and generally share liability.
It is widely recognized that suicide may be unpredictable and that appropriate care may not prevent an unfortunate outcome. A thorough assessment and relevant documentation in the patient record can help defend a complaint or legal action involving patient suicide.
Case 1: Inadequate documentation calls into question the risk assessment
A psychiatrist prescribes lorazepam for her patient's new complaints of anxiety. She has been seeing him regularly for the past 2 years for the treatment of schizoaffective disorder with frequent auditory hallucinations, as well as depression and compulsive behaviours. Despite the new symptoms, the psychiatrist notes that he appears more cheerful than usual. One week later, the patient dies from an intentional overdose of antidepressants that he is also taking. The patient's family files a College complaint alleging the psychiatrist mismanaged the patient's condition. While experts are not critical of the psychiatrist's overall treatment plan, the College finds the documentation in the medical record lacking in detail. A peer assessor is critical that the psychiatrist did not detail the nature of the patient's auditory hallucinations, noting that such information can uncover a heightened suicidal risk, as in the case of a patient who is having command hallucinations to end their life. The psychiatrist is required to attend the College for a verbal caution.
Case 2: Documentation of assessment supports care decisions
An on-call psychiatrist assesses a new patient who has presented to the emergency department with complaints of depression. He concludes that this patient shows symptoms of chronic social dysfunction and depression, but judges he is not actively suicidal. The psychiatrist changes the patient's antidepressant. He arranges for a follow-up appointment in 5 weeks, when he plans to evaluate the need for psychometric testing. Three weeks later, the patient commits suicide. The patient's family files a College complaint alleging the psychiatrist did not thoroughly assess the patient. Expert review of the medical record finds careful documentation of the patient encounter including details on the patient's family history of depression and the assessment of suicidal risk. The College concludes that the psychiatrist's judgment was reasonable, while acknowledging that the outcome was tragic for all involved.
Prescribing medication is a significant part of psychiatric practice. However, a documented medication issue made up a small portion of CMPA cases. While these cases represented a diverse range of issues, inadequate consent discussions with respect to drug side effects and, to a lesser extent, monitoring issues were recurring themes.
Many cases that involved medication issues were also criticized by experts for inadequate documentation, particularly in relation to the rationale for selecting or adjusting medications or the consent discussion.
Issues related to professional conduct emerged in a large number of cases. These usually involved breaches of confidentiality or criticism of the psychiatrist's manner. There were also instances of boundary transgression.
Boundary issues ranged from inappropriate self-disclosure and conducting therapy sessions in informal settings, to engaging in sexual relationships with patients. The Canadian Psychiatric Association has stated that "the unique nature of the psychiatrist-patient relationship has the potential for progression into boundary violations,"1 and cautions psychiatrists to remain vigilant to avoid this risk. Psychiatrists are encouraged to consult peer supervisors or resources available from their professional associations. Most Colleges provide information on their websites about boundary issues.
Patients receiving care for psychiatric conditions, and their families, may be especially sensitive to the physician's demeanour or communication style. This can lead to a complaint. Experts in these cases have reinforced the need for psychiatrists to be sensitive and respectful of patients and their families and to ensure the reasons for clinical decisions are understood.
Beyond boundary and communication issues, breaches of confidentiality were also common complaints. These mainly involved disclosing personal information to third parties without the patient's consent. For example, speaking to a member of the patient's family about the condition without the patient's consent or providing too much information in response to a third-party request. This commonly included providing personal information to an insurer or employer not considered relevant to the understanding of the patient's condition. The latter scenario was more common.
Given the importance of trust in the therapeutic relationship, and the sensitive nature of the information shared between patient and psychiatrist, understanding privacy legislation and duty of confidentiality is imperative to the profession. The landmark 1999 Supreme Court of Canada case, Smith v. Jones, articulated the factors for when it may be permissible to disclose patient information in the context of the duty to warn of a threat to public safety.2
Risk management considerations
Psychiatrists should consider the following suggestions, based on expert opinion in the cases reviewed:
- Be aware of potential boundary issues inherent in the psychiatrist-patient relationship.
- Consider the need for collateral information from the patient's family, when appropriate.
- Ensure that documentation reflects the assessment of the patient's condition, supports the diagnosis and the rationale for the treatment plan, and includes the risk of suicide when necessary.
- Before prescribing medication, conduct a consent discussion with the patient or substitute decision-maker that includes discussion of benefits, risks, side effects, and alternative choices.
- Carefully document consent discussions in the patient's record.
- When prescribing a medication, order baseline and ongoing laboratory investigations, as required.
- When reinstating a patient's privileges, adjusting medications or discharging a patient, document decisions in the patient's record.
- Provide only the information required on third-party forms.
- Ensure communication with patients and families remains sensitive and respectful at all times.
- Work collaboratively with all providers to reduce safety issues within the facility.
Members with specific concerns related to any of the issues discussed in this article should contact the CMPA for advice.
- Canadian Psychiatric Association, "Sexual relationships with patients," Position statement, 2011. Accessed March 2014 from: http://publications.cpa-apc.org/media.php?mid=192
- Chaimowitz G, Glancy G, Blackburn J., "The duty to warn and protect—impact on practice," Canadian Journal of Psychiatry (2000) Vol. 45 No. 10, p.899–904