Family input can make difference between life and suicide
Confidentiality can be breached to protect the life of the patient or others.
This article by Patricia Casey was published on the Irish Times on July 4th.
The issue of doctor-patient confidentiality is perhaps at its most polarised in the context of suicide prevention. When it was addressed recently in a session at the annual International Congress of the Royal College of Psychiatrists, it attracted my attention.
The linked topics of suicide and confidentiality are very close to my heart. The speakers dealt with the role of doctor-patient confidentiality in deaths by suicide that may otherwise have been preventable.
This is something which has been of concern in Ireland in recent years and one woman, who tragically lost her husband and two young in 2011 in a murder suicide, has been campaigning on the issue.
Una Butler has worked tirelessly to change the absolutist stance on doctor-patient confidentiality, speaking of the need for psychiatrists to involve family members in aspects of treatment of their loved ones, so that they can be appraised of risk but also so they can provide necessary background information and details of recent symptoms or changes in these. This is particularly relevant if the patient referral has been identified as urgent, or the person is regarded as being at high risk of suicide.
At the conference two bereaved people spoke movingly of their particular concerns regarding confidentiality. Both were convinced that their loved ones’ suicides could have been prevented had they been afforded the opportunity to meet with the professionals carrying out the suicide risk assessment.
The first speaker told how her husband had depression 12 years previously and made a complete recovery. It then recurred and within a few weeks he became suicidal but he never told her. Instead he confided in his sister that he made a suicide attempt by trying to inject himself with some substance.
She gave this information to his wife who arranged an urgent appointment with his GP. She saw him and in turn referred him to a psychiatrist but failed to mention the information from his wife about a suicide attempt.
His wife attended the psychiatrist with him but was not seen and was advised that this was because of confidentiality, even though her husband was agreeable for the doctor to see her too.
She trusted the psychiatrist and assumed that this was best practice. Her husband was prescribed antidepressants about which she was given no information and no treatment plan or safety net was outlined to her. A few days later, her husband took his life.
The second speaker was a parent of a young university student, a 23-year-old man who was depressed and anxious. He felt a failure and his parents tried to reassure him. An urgent appointment with the crisis team for a suicide risk assessment was made by the GP who deemed him to be at high risk because of the onset of suicidal thoughts, along with guilt and hopelessness.
He was seen by a specialist clinical nurse but his parents were not interviewed, because of the confidentiality imperative. His risk was assessed as low and he was discharged without follow-up. He died the following day. At the inquest, the assessment records noted he smiled and reacted appropriately, hence the low-risk categorisation.
In my opinion, it is likely that this husband and this son would be alive today had those who knew them been interviewed.
The wife of the first person would have told the psychiatrist of his suicide attempt, while the parents of the young man would have told the nurse of the onset of suicidal ideation and would have reminded her how articulate, intelligent young men can be deceptive in the presentation of their thoughts and feelings.
Both the General Medical Council in Britain and the Medical Council in Ireland explicitly state in their guidelines that confidentiality can be breached to protect the life of the patient or others.
What if the doctor believes the risk is low? Even in those circumstances, if relatives have concerns about suicidality, these should and can be listened to. If the patient refuses permission to provide information, telephone calls can always be taken and information acted upon. But the optimum approach is to interview the relevant family members and this ought to minimise the ethical struggle around confidentiality once the doctor becomes aware that the person is suicidal.
This, of course, assumes that the doctor understands the balancing of rights to protect the patient from fatal harm vis-a-vis their right to autonomy. No doctor wants to lose the trust of the patient and, handled sensitively, by taking time to explain the need for discussions with family and where possible, by negotiating what can and cannot be conveyed to the family, it should be possible to respect the patient’s wishes while also taking account of the family’s need to know.
If our ardour over confidentiality leads to the loss of life then we are breaking an important rule of medicine which is “first, do no harm”.