Communication
With Families
Can Prevent
Suicide
Oregon Counseling
Association 2013
Conference
Jerry Gabay and
Stewart S. Newman MD
THE OCCAP
CHECKLIST
2
Mr. Gabay and Dr. Newman
have no financial interest in or
an affiliation with commercial
interests that might pose a
conflict of interest.
3
Suicide Prevention in Youth and Young Adults
Communicating With Families Saves Lives
A Checklist for Health Providers
and Mental Health Practitioners
Created by the Oregon Council of
Child and Adolescent Psychiatry
4
Legal Disclaimer: The material in this document
has been prepared for informational purposes only
and does not constitute legal advice. We provide
timely information, but make no claims, promises,
or guarantees about the accuracy, completeness,
or adequacy of the information contained in or
linked to this document or associated websites.
Legal advice must be tailored to the specific facts
and circumstances of a particular case. Nothing
reported herein should be used as a substitute for
the advice of competent counsel.
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Communication with
Families Can:
 Improve
the care provided
to patients
 Reduce risk of suicide and
self harm
 Improve outcomes through
use of community resources
11
We Believe
The perceptions of clinicians
of the restrictions on
communication with families
is often greater than the limits
imposed by laws or
regulations.
12
Preventing Suicide with
Communication
 Magnitude
of Suicide
 Therapeutic and Practical Value of
Communication
 Legal Argument for Communication
 Ethical Argument for
Communication
 How to Use the Checklist
13
Public Health Risks
HIV/AIDS
Homicide
Motor
Vehicle Deaths
Breast Cancer
Suicide
14
Epidemic:
1 : affecting or tending to affect a
disproportionately large number
of individuals within a population,
community, or region at the same
time
2 : excessively prevalent
15
In the US, someone
dies by suicide
EVERY 13.7
MINUTES
38,364 in the US in 2010
16
1,107,144
Years of Potential
Life Lost
SAMSHA 2010 data
17
Compared to Murder
US in 2010, per 100,000
12.4
14
12
10
8
6
4.8
4
2
0
Homicide Rate
Suicide Rate
18
Deaths in Oregon 2010
685
800
700
600
500
400
300
317
200
100
0
Car Crashes
Suicide
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In Oregon
701 deaths from
There were
suicide in 2012
Compared to 500 deaths from breast
cancer in 2011
22
Comparisons for Oregon
Overall
Suicide Rate
 16.9/100,000
Suicide
Among Males 20-24
 29.3/100,000
Breast
Cancer Death Rate
 12.9/100,000
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Clinicians Need Help
Thirty-five
percent of those who
took their lives were being
treated for mental illness at the
time of their deaths, and even
more saw a PCP within a
month of suicide.
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Preventing Suicide with
Communication
 Magnitude
of Suicide
 Therapeutic and Practical Value of
Communication
 Legal Argument for Communication
 Ethical Argument for
Communication
 How to Use the Checklist
26
90%
OF SUICIDE VICTIMS ARE
SUFFERING FROM ONE OR MORE
PSYCHIATRIC DISORDERS:
- Major Depressive Disorder
- Bipolar Disorder
- Schizophrenia or Psychotic disorder
- Post Traumatic Stress Disorder
- Personality Disorders such as Borderline PD
- Alcohol or Drug Abuse*
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Symptom Risk Factors
(Specific to depression)
- Desperation or Hopelessness
- Anxiety/agitation/panic attacks
- Aggressive or impulsive behaviors
- Preparations or rehearsal during a
previous episode
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Symptom Risk Factors
(Specific to depression)
- Recent
hospitalization
- Psychotic symptoms
- Improvement without justifiable
explanation
**Non-Suicidal Self Injury**
**Previous Suicide Attempt**
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Symptom Risk Factors
- Serious physical illness,
especially recent
- Chronic pain syndrome
- History of childhood trauma or
abuse
- History of being bullied
- Family history of death by suicide
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Protective Factors






Effective clinical care for mental, physical, and
substance abuse disorders
Easy access to a variety of clinical interventions
and support for help seeking
Family and community support (connectedness)
Support from ongoing medical and mental health
care relationships
Skills in problem solving, conflict resolution, and
nonviolent ways of handling disputes
Cultural and religious beliefs that discourage
suicide and support instincts for self-preservation
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Suicide Communications Are
Made To Others
IN ADOLESCENTS, 50%
COMMUNICATED THEIR INTENT TO
FAMILY MEMBERS
IN THE ELDERLY, 58%
COMMUNICATED THEIR INTENT TO
THEIR PRIMARY CARE DOCTOR
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Only Needed Information
Not
disclosing psychotherapy
content
Focus on diagnoses, risk
assessment, warning signs,
treatment recommendations,
safety planning and relevant
community resources
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Special Populations
 LGBT
patients- be cognizant of the
“out” status of the patient to family
members, the potential to
exacerbate the situation that may
be driving the current risk
 Disclosures should not be made to
family members accused of abuse
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Preventing Suicide with
Communication
 Magnitude
of Suicide
 Therapeutic and Practical Value of
Communication
 Legal Argument for Communication
 Ethical Argument for
Communication
 How to Use the Checklist
PSYCHIATRIC SERVICES, 2003
VOL. 54 (12) 1622-1628.
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90%
54%
OF CLINICIANS
INTERPRETED
CONFIDENTIALITY
POLICIES
CONSERVATIVELY
OF CLINICIANS WERE
CONFUSED ABOUT THE TYPES
OF INFORMATION THAT ARE
CONFIDENTIAL
39
68%
OF CLINICIANS BELIEVED THAT
CONFIDENTIALITY POLICIES MADE IT
DIFFICULT TO PROVIDE
INFORMATION TO FAMILIES
31%
OF FAMILIES BELIEVED THAT THE
RIGHT TO PRIVACY MADE IT
DIFFICULT FOR PROVIDERS TO
SHARE INFORMATION WITH THEM
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41
HIPAA
Health Insurance Portability
and Accountability Act of
1996
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"Medical professionals can
talk freely to family and
friends, unless the patient
objects. No signed
authorization is necessary."
-Susan McAndrew,
Deputy Director of Health Information Privacy,
U.S. Department of Health and Human Services
Gross, Jane. Keeping Patients’ details private, even from kin.
New York Times, July 3, 2007
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We Believe
The perceptions of clinicians
of the restrictions on
communication with families
is often greater than the limits
imposed by laws or
regulations.
44
Federal Law- HIPPA Exceptions

Federal law permits, but does not require, a
provider to disclose to family protected
health information relevant to the family
member’s involvement in the patient’s care
without a release if the provider provides an
opportunity for the patient to object and the
patient does not, or the provider “reasonably
infers from the circumstances, based [on] the
exercise of professional judgment, that the
[patient] does not object to the disclosure.”
(45 CFR 164.510 [b][2])
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Federal Law- HIPPA Exceptions

Providers may also disclose otherwise
protected information when “the opportunity
to agree or object to the use or disclosure
cannot practicably be provided because of
the individual’s incapacity or an emergency
circumstance, the [provider] may, in the
exercise of professional judgment, determine
whether the disclosure is in the best interests
of the individual . . .” (45 CFR 164.510 [b][3])
46
Exceptions to FERPA
 Parents'
Guide to the Family Educational
Rights and Privacy Act: Rights Regarding
Children’s Education Records, US Dept. of
Education (October 2007)
 The Dept. of Education stresses that an
institution is permitted to share information
from a student's educational records with
parents, without the student's consent, if
… a health or safety emergency involves
their child…
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Duty to Communicate

The Marquette Law Review, Vol. 91, Spring
2008; Suicide on Campus: The Appropriate
Legal Responsibility of College Personnel

where college personnel have actual
knowledge that an undergraduate student is
suicidal, they have a duty to take reasonable
steps to protect the student from self-harm,
including, but not limited to, notifying the
student's parents or guardian
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United Educators Insurance
“One
conclusion is clear: The
failure to notify family members
about a student’s precarious
situation increases the
likelihood of a lawsuit.”
United Educators. (2005). Students with mental health problems: When
should parents be notified? Retrieved from
http://webhost.bridgew.edu/tesposito/asatt/United%20Educators.doc
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American Physicians
Assurance Corporation
 “From
a liability risk standpoint,
suicide claims are considered to be
low frequency/high severity. The
overall number of suicide-related
malpractice cases is low; however,
those that are filed tend to result in
higher than average indemnity
payments. “
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“If a clinician followed this
check list I would not accept a
case against that clinician.”
- Skip Simpson, JD, Texas attorney who
specializes in malpractice in suicide and
other mental health cases.
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Preventing Suicide with
Communication
 Magnitude
of Suicide
 Therapeutic and Practical Value of
Communication
 Legal Argument for Communication
 Ethical Argument for
Communication
 How to Use the Checklist
52
Confidentiality
• Fundamental to therapeutic
relationship
• Not absolute
• Safety of the patient
overrides duty of
confidentiality
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Ethical Standards
American Psychiatric Association’s
The Principles Of Medical Ethics
With Annotations Especially Applicable to
Psychiatry, 2009 Edition Revised
• Section 4 Confidentiality
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Ethical Standards
Annotation 8:
When, in the clinical judgment of the
treating psychiatrist, the risk of
danger is deemed to be significant,
the psychiatrist may reveal
confidential information disclosed by
the patient.
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Ethical Standards
American Psychological Association’s
Ethical Principles Of Psychologists
and Code of Conduct
• Standard 4: Privacy and
Confidentiality
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Ethical Standards
4.05 Disclosures … (b) Psychologists disclose
confidential information without the
consent of the individual only as mandated
by law, or where permitted by law for a
valid purpose such as to… (3) protect
the client/patient, psychologist, or
others from harm…
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American Nurses Assoc.
Provision
Duties
3.2 Confidentiality:
of confidentiality,
however, are not absolute
and may need to be
modified in order to protect
the patient...
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NASW Code of Ethics
 Code
of Ethics Standard 1.07(c)
states that the general obligation to
maintain client confidentiality “does
not apply when disclosure is
necessary to prevent serious,
foreseeable, and imminent harm to
a client or other identifiable
person.”
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ACA Code of Ethics
B.1.c.
Respect for
Confidentiality
 Counselors
do not share
confidential information without
client consent or without sound
legal or ethical justification.
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ACA Code of Ethics
 B.2.a.
 The
Danger and Legal Requirements
general requirement that counselors
keep information confidential does not apply
when disclosure is required to protect clients
or identified others from serious and
foreseeable harm or when legal
requirements demand that confidential
information must be revealed.
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“(I)t is generally acceptable for
a psychiatrist to warn a patient’s
family or roommate when the
patient is very depressed and
has voiced suicidal thoughts.”
-Practice Management Handbook for Early
Career Psychiatrists, American Psychiatric
Association
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Practice Parameters
- American Academy of Child and
Adolescent Psychiatry Practice
Parameter on Depressive Disorders
(2007)
- American Psychiatric Association
Practice Guideline for the Assessment
and Treatment of Patients with Suicidal
Behaviors (2007)
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Preventing Suicide with
Communication
 Magnitude
of Suicide
 Therapeutic and Practical Value of
Communication
 Legal Argument for Communication
 Ethical Argument for
Communication
 How to Use the Checklist
64
Who’s the Checklist For?
• Family physicians •
• General
practitioners
•
• Pediatricians
• Physician
•
assistants
•
• Nurses
•
• Social workers
Nurse
Practitioners
Psychiatric Nurse
Practitioners
Counselors
Psychologists
Psychiatrists
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“Family” = significant
people in patient’s life.
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The OCCAP Checklist
Two sections:
• Gathering information to
inform risk
• Sharing risk information and
treatment resources with those
close to the patient
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The OCCAP Checklist
Top Section
• Complete comprehensive
risk assessment
**or**
• Refer for immediate
evaluation
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The OCCAP Checklist
Risk Assessment Information:
• Patient
• Family members
• Previous treatment records
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The OCCAP Checklist
• Be assertive to obtain
authorization to disclose
information
• No authorization needed for
family members to share info
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The OCCAP Checklist
• Request records from
previous providers promptly
• Remember to review records
you do receive thoroughly
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The OCCAP Checklist
Bottom Section: Sharing
Information With Family
With signed authorization
Minor patients at some risk
(most patients)
• Patients identified at high risk
•
•
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The OCCAP Checklist
Communicate to Families:
• Diagnosis
• Treatment recommendations
• Safety Planning
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The OCCAP Checklist
Explicit Discussion of:
• Safety planning, suicide
warning signs, risk reduction
strategies
• Community resources and
support services
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The OCCAP Checklist
Changes In Level of Care are
Highlighted
• Involve the Family
• Assure follow-up
• Accepting provider informed
• Confirm patient attended appt.
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The OCCAP Checklist
•
•
•
•
Nonproprietary
Free for distribution
Modifiable for your clinical
setting
Feedback welcomed and
encouraged
drstew@mindmatterspc.com
79
The OCCAP Checklist
Where do I Get It?
http://www.aacap.org/AACAP/
Regional_Organizations/OCCAP/
Suicide_Prevention_Communication_Checklist.aspx
Google: Oregon Suicide
Prevention Checklist
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Use your BEST judgment
•
•
•
Duty to Confidentiality still exists
and must be honored
Best interests of the patient
always applies to decision
making
Disclosures are weighed against
risk
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Key Points
•
•
If you are in doubt, violate
confidentiality to protect your
patient from harm.
Better to defend an
inappropriate disclosure than
defend a failure to disclose with
subsequent harm
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Now it’s up to YOU!
What concerns do you have about
using this checklist?
 Will you use this in your practice?
 How could we help you use it?
 How will this change your practice?

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Defining “Imminent”


Imminent : Impending; menacingly close at hand;
threatening.
Imminent peril, for example, is danger that is certain,
immediate, and impending, such as the type an
individual might be in as a result of a serious illness or
accident. The chance of the individual dying would
be highly probable in such situation, as opposed to
remote or contingent. For a gift causa mortis (Latin for
"in anticipation of death") to be effective, the donor
must be in imminent peril and must die as a result of it.

West's Encyclopedia of American Law, edition 2. Copyright 2008 The
Gale Group, Inc. All rights reserved.
84
ACA Code of Ethics
 B.2.a.
 The
Danger and Legal Requirements
general requirement that counselors
keep information confidential does not apply
when disclosure is required to protect clients
or identified others from serious and
foreseeable harm or when legal
requirements demand that confidential
information must be reveale