Suicide And Homicide Risk Management (Page 14 of 18) in pdf

Combat and Operational Behavioral Health

problem. Thus, his treating clinician decided that the

is a unique and cohesive community that often allows

appropriate treatment setting would be to ensure the

these interventions to effectively reduce suicide or ho-

patient’s safety via a 24-hour watch, long enough for

micide risk. However, because these interventions are

his immediate emotional crisis to resolve. An adequate

relatively unknown in the civilian sector, meticulous

nonstigmatizing safety environment was created for

documentation of suicide risk factors and the reason

the soldier, and the unit provided emotional support

that unit watch was considered a safe intervention

as well as safety. As expected, his emotional crisis

for the soldier are essential in each case. Documenta-

resolved within 2 weeks and his symptoms resolved

tion of discussions with command, education given

within 1 month as he gained understanding and ac-

to the command, and assurance that the command is

ceptance of his changing life situation.

capable of carrying out a proper unit watch are also

In a garrison or deployed setting, the clinician must

recommended. Finally, the widespread use of the

clearly document the suicide or homicide risk assess-

unit watch by military mental health providers, and

ment, giving a clear rationale that makes the case for

its inclusion in the American Psychiatric Association

the specific treatment setting (eg, buddy watch, 24-

practice guidelines, may help establish this as an

hour watch, basic precautions, patient hold) rather

appropriate, if not yet evidence-based, intervention

than hospitalization or evacuation. The military unit

within the military.

MEDICOLEGAL ISSUES

The legal implications of using a unit watch are of

Act. The doctrine stems from Feres v US,

which con-

concern to many clinicians. There is no exact equiva-

solidated three lawsuits concerning the injury or death

lent to the unit watch in the civilian sector, although

of three service members due to possible negligence

it is loosely analogous to sending a patient home with

on the part of the military. Two of the cases involved

parents or family members who promise to watch the

physician malpractice. The US Supreme Court ruled

patient and confiscate weapons or excess pills. Sui-

that there was no cause of action under the Tort Claims

cide watches in a prison may use similar procedures,

Act for wrongful death of or personal injury to a mem-

despite the obvious differences between a prison en-

ber of the armed forces if the injury or death was “in

vironment and an Army barracks. Although the need

the course of activity incident to their service in the

for collaboration with the legal community on these

Armed Forces.”

Many lawsuits alleging malpractice

issues is obvious, no literature specifically addresses

or seeking consortium for loss of finances have been

this aspect. The following brief summary lays out the

barred because of the Feres doctrine, including suits

basic medicolegal issues involved.

in which unit commanders were accused of failure

Mental health clinicians in the civilian community

to take appropriate actions when there was direct

have serious concerns about liability when a patient

evidence of a soldier’s suicidal intent. Legal action

completes a suicide or commits a homicide. Many

by both active duty members suing through military

malpractice lawsuits involve plaintiffs who complete

courts and civilian dependents suing through federal

suicide after a psychiatric assessment concluded that

courts have been barred.

hospitalization was not indicated. Factors in finding

The suicide of a soldier while that individual is

the mental health clinician liable for damages often

under unit watch could potentially call into ques-

include inadequate risk assessment or inadequate

tion whether the mental health clinician did not fully

response to that risk.

Inadequate documentation of

appreciate the suicide risk or did not ensure that an

the risk assessment is a frequent factor that leads to

adequate intervention was used. The commander

a verdict against the clinician. Failure to frequently

could also be questioned concerning the competence

reevaluate the suicide risk may also be a basis for a

of the unit to perform a unit watch. Another issue is

finding of malpractice. Prison staff and supervisors

that soldiers performing the watch may have little or

have been found liable in cases of completed suicides

no experience with the procedures involved in a unit

in civilian prisons because of their responsibility for

watch, and they may not fully appreciate that seri-

the health and well-being of their wards. Insufficient

ous adverse outcomes might result if the procedures

training of personnel or inadequate adherence to

are not strictly followed. Although lawsuits are often

standard operating procedures may result in findings

barred through the Feres doctrine, the military may

of negligence.

nonetheless take disciplinary action against physi-

Military commanders and clinicians have a unique

cians or commanders if an internal investigation un-

protection from liability in the form of the Feres doc-

covers fault or negligence. Monetary payments may

trine, which is an exception to the Federal Tort Claims

be given out for compensable events. Department of

436

Suicide And Homicide Risk Management Page 14

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