1. Communication With Families Can Prevent Suicide Oregon Counseling Association 2013 Conference Jerry Gabay and Stewart S. Newman MD THE OCCAP CHECKLIST

2. 2 Mr. Gabay and Dr. Newman have no financial interest in or an affiliation with commercial interests that might pose a conflict of interest.

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4. 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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10. Communication with Families Can:  Improve the care provided to patients  Reduce risk of suicide and self harm  Improve outcomes through use of community resources 10

11. We Believe 11 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 12

13. Public Health Risks  HIV/AIDS  Homicide  Motor Vehicle Deaths  Breast Cancer  Suicide 13

14. Epidemic: 14 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 15 38,364 in the US in 2010

16. 1,107,144 Years of Potential Life Lost 16 SAMSHA 2010 data

17. Compared to Murder 17

18. Deaths in Oregon 2010 18

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21. 21 In Oregon There were 701 deaths from 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 22

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24. 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. 24

25. 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 25

26. - Major Depressive Disorder - Bipolar Disorder - Schizophrenia or Psychotic disorder - Post Traumatic Stress Disorder - Personality Disorders such as Borderline PD - Alcohol or Drug Abuse* 26 90% OF SUICIDE VICTIMS ARE SUFFERING FROM ONE OR MORE PSYCHIATRIC DISORDERS :

27. Symptom Risk Factors (Specific to depression) - Desperation or Hopelessness - Anxiety/agitation/panic attacks - Aggressive or impulsive behaviors - Preparations or rehearsal during a previous episode 27

28. Symptom Risk Factors (Specific to depression) - Recent hospitalization - Psychotic symptoms - Improvement without justifiable explanation **Non-Suicidal Self Injury** **Previous Suicide Attempt** 28

29. 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 29

30. 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 30

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32. Suicide Communications Are Made To Others 32 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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34. Only Needed Information  Not disclosing psychotherapy content  Focus on diagnoses, risk assessment, warning signs, treatment recommendations, safety planning and relevant community resources 34

35. 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 35

36. 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 36

37. 37 PSYCHIATRIC SERVICES, 2003 VOL. 54 (12) 1622-1628.

38. 90% OF CLINICIANS WERE CONFUSED ABOUT THE TYPES OF INFORMATION THAT ARE CONFIDENTIAL 38 OF CLINICIANS INTERPRETED CONFIDENTIALITY POLICIES CONSERVATIVELY 54%

39. 68% OF FAMILIES BELIEVED THAT THE RIGHT TO PRIVACY MADE IT DIFFICULT FOR PROVIDERS TO SHARE INFORMATION WITH THEM 39 OF CLINICIANS BELIEVED THAT CONFIDENTIALITY POLICIES MADE IT DIFFICULT TO PROVIDE INFORMATION TO FAMILIES 31%

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41. Health Insurance Portability and Accountability Act of 1996 41 HIPAA

42. "Medical professionals can talk freely to family and friends, unless the patient objects. No signed authorization is necessary." 42 -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

43. We Believe 43 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]) 44

45. 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]) 45

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… 46

47. 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 47

48. 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.” 48 United Educators. (2005). Students with mental health problems: When should parents be notified? Retrieved from http://webhost.bridgew.edu/tesposito/asatt/United%20Educators.doc http://webhost.bridgew.edu/tesposito/asatt/United%20Educators.doc

49. 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. “ 49

50. 50 - Skip Simpson, JD, Texas attorney who specializes in malpractice in suicide and other mental health cases. “If a clinician followed this check list I would not accept a case against that clinician.”

51. 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 51

52. 52 Confidentiality Fundamental to therapeutic relationship Not absolute Safety of the patient overrides duty of confidentiality

53. Ethical Standards 53 American Psychiatric Association’s The Principles Of Medical Ethics With Annotations Especially Applicable to Psychiatry, 2009 Edition Revised Section 4 Confidentiality

54. Ethical Standards 54 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.

55. Ethical Standards 55 American Psychological Association’s Ethical Principles Of Psychologists and Code of Conduct Standard 4: Privacy and Confidentiality

56. Ethical Standards 56 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…

57. American Nurses Assoc.  Provision 3.2 Confidentiality:  Duties of confidentiality, however, are not absolute and may need to be modified in order to protect the patient... 57

58. 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.” 58

59. 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. 59

60. ACA Code of Ethics  B.2.a. Danger and Legal Requirements  The 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. 60

61. 61 “(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

62. Practice Parameters 62 - 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)

63. 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 63

64. 64 Who’s the Checklist For? Family physicians General practitioners Pediatricians Physician assistants Nurses Social workers Nurse Practitioners Psychiatric Nurse Practitioners Counselors Psychologists Psychiatrists

65. 65 “Family” = significant people in patient’s life.

66. The OCCAP Checklist 66 Two sections: Gathering information to inform risk Sharing risk information and treatment resources with those close to the patient

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68. The OCCAP Checklist 68 Top Section Complete comprehensive risk assessment **or** Refer for immediate evaluation

69. The OCCAP Checklist 69 Risk Assessment Information: Patient Family members Previous treatment records

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71. The OCCAP Checklist 71 Be assertive to obtain authorization to disclose information No authorization needed for family members to share info

72. The OCCAP Checklist 72 Request records from previous providers promptly Remember to review records you do receive thoroughly

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74. The OCCAP Checklist 74 Bottom Section: Sharing Information With Family With signed authorization Minor patients at some risk (most patients) Patients identified at high risk

75. The OCCAP Checklist 75 Communicate to Families: Diagnosis Treatment recommendations Safety Planning

76. The OCCAP Checklist 76 Explicit Discussion of: Safety planning, suicide warning signs, risk reduction strategies Community resources and support services

77. The OCCAP Checklist 77 Changes In Level of Care are Highlighted Involve the Family Assure follow-up Accepting provider informed Confirm patient attended appt.

78. The OCCAP Checklist 78 Nonproprietary Free for distribution Modifiable for your clinical setting Feedback welcomed and encouraged drstew@mindmatterspc.com

79. The OCCAP Checklist 79 Where do I Get It? http://www.aacap.org/AACAP/ Regional_Organizations/OCCAP/ Suicide_Prevention_Communication_Checklist.aspx Google: Oregon Suicide Prevention Checklist

80. Use your BEST judgment 80 Duty to Confidentiality still exists and must be honored Best interests of the patient always applies to decision making Disclosures are weighed against risk

81. Key Points 81 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

82. 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? 82

83. 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. 83

84. ACA Code of Ethics  B.2.a. Danger and Legal Requirements  The 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 84