Suicide And Homicide Risk Management (Page 15 of 18) in pdf

Suicide and Homicide Risk Management

Defense Directive 6025.13 outlines the procedures for

several months after a risk assessment.

27–29

investigation of potential provider malpractice.

The military psychiatric community commonly

the surgeon general for the specific military branch

assumes that a duty to protect exists, despite the lack

makes a determination that an adverse privileging

of clear statutory guidance. The Feres doctrine would

action should be placed against a physician, then that

not exempt a military clinician from potential liability

finding will be entered into the National Practitioner

if an active duty patient hurt or killed an individual

Data Bank (NPDB).

The NPDB is a database that

not on active duty; in such a case, relevant state law

22,23(pA-3)

provides information concerning specific areas of a

would be applicable. Unless one is familiar with the

practitioner’s licensure, including professional society

laws of each state, the best practice in the military is

memberships, medical malpractice payment history,

to adhere to a Tarasoff-like standard of care. The use

record of clinical privileges, adverse licensure actions,

of unit watch to prevent an individual from carrying

withdrawal of clinical privileges, and other negative

out an act of homicide would be an added medicolegal

actions taken against an individual healthcare practi-

(and ethical) safeguard when a clinician is assessing

tioner. Such information is provided through legally

a soldier’s threats.

authorized queries to assist state licensing boards,

In the authors’ experience, a large proportion of

hospitals, and other healthcare entities in establish-

soldiers presenting with homicidal ideation toward

ing the qualifications of the healthcare practitioners

their chains of command have diagnoses of adjust-

they seek to license, hire, or privilege. These actions

ment disorder, personality disorder, or, sometimes,

are representative of the military’s ongoing efforts to

alcohol-abuse disorder. In the absence of a severe

ensure that military healthcare is comparable to civilian

mental disorder, these service members do not meet

standards. A survey of all military malpractice cases

criteria for hospitalization, but are often hospitalized

from 1978 to 1987 revealed that of 14 cases involving

because the clinician believes that it is necessary to

attempted or completed suicide, six cases resulted in

protect the potential victim. As an alternative measure,

monetary settlements totaling $754,000.

unit watch helps protect potential victims by limiting

The use of unit watch for management of homicide

access to lethal means and providing an observer to

risk is perhaps the easier case to make. The landmark

notify the chain of command or authorities if the po-

Tarasoff decision, although binding only within the state

tential perpetrator takes any confrontational action.

of California, gave clinicians the responsibility to take

As an adjunct to the unit watch, additional clinical

measures to protect the potential victim if the clinician

actions in the case of a potential homicide sometimes

believes there is a probability that the patient will com-

include a recommendation that the commander move

mit murder.

In the Tarasoff case, a patient told his

the soldier to another section of the unit (in the case of

25,26

psychiatrist that he planned to kill a female love inter-

homicidal ideation toward an immediate supervisor),

est. The murder was carried out, and the psychiatrist

that the commander warn the potential victim about

was found liable for not taking action such as alerting

the homicide threat, and that the commander give

the victim and committing the patient. Many states

both parties a direct order to avoid all contact except

now require Tarasoff-like duties to protect potential

as necessary in the performance of their daily duties. In

victims, either through case or statutory law. However,

many cases, these interventions may actually be more

there is no federal law regarding this issue (federal law

effective in minimizing risk than simply notifying the

applies to the military). Some states have ruled that

local police and the potential victim, in keeping with

psychiatrists are liable for violent acts by their patients

the civilian standard of care when the patient does

even when no specific victim can be identified, when

not meet commitment criteria because of the lack of

no specific threat was made, or when homicides occur

evidence of a severe mental disorder.

SUMMARY

with unit watch according to the guidelines discussed

Although there are no simple answers in the assess-

above would further validate this technique. A retro-

ment and management of suicide and homicide risk

spective or prospective study comparing various out-

in any setting, military clinicians practice in a unique

community that necessitates a uniquely military ap-

come measures for soldiers at a post where unit watch

is commonly used with outcomes for a control group

proach to the issue. The recommendations and infor-

of soldiers at a post where unit watch is not commonly

mation presented in this chapter may help validate and

used might also be possible. Optimization, validation,

standardize a military approach, and will hopefully

and eventually incorporation of this chapter’s recom-

stimulate research in this area. For example, publica-

tion of a case series of soldiers successfully managed

mendations into the curricula in military behavioral

437

Suicide And Homicide Risk Management Page 15

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