I’d like to thank Walter Olson for inviting me to contribute to one of my favorite blogs, Overlawyered. As an attorney and psychologist, I’ve worked in a number of different hospitals across the country. Health care institutions are unique places to work for in many respects because the decisions made there can directly lead to serious or even fatal outcomes. Of course this is obvious, as should be the fact that despite the best intentions of everyone involved in a patient’s care, bad outcomes occur.
Alison Cowan has this article in last Friday’s New York Times highlighting a recent case involving the suicide of Ruth Farrell. By all accounts Farrell had been quite depressed for a very long time. As is the case with some people who struggle with chronic depression, Ms. Ferrell was admitted to the hospital for care and observation related to her depression and suicidal ideation. Sadly, Ms. Farell hanged herself with her own pants between the standard 15 minute “checks” performed by staff on psychiatric wards. In turn, her estate sued her doctors and the hospital claiming improper care.
At first blush, one may ask how could such a terrible outcome occur if Ms. Ferrell had received proper psychiatric care? After all, it was depression and her suicidal ideation for which she was seeking treatment. One would hope that inpatient psychiatric treatment would at the very least prevent someone like Ferrell from harming herself. As much as these sentiments are understandable, they simply are not practical nor do they account for drive for privacy that permeates our health care institutions these days.
Most patients who are admitted to inpatient psychiatric facilities these days arrive there because they are either suicidal or psychotic. Short stays are the norm, and thus hospital staff are given the difficult task of caring for numerous patients who are very sick. Indeed, caring for the very sick is what hospitals do; but assuring safety for patients who are actively intent on hurting or killing themselves has always been a difficult task. Patients who are chronically suicidal often spend a great deal of time contemplating the method of their demise and it takes very little time to accomplish this goal once the final decision is made. A century ago, state mental hospitals kept patients in dormitory-styled facilities for this very reason (one layout at Worcester State Hospital was designed in a circle with the nurses station at the middle of “spokes” to optimize observation of patients). Modern psychiatric hospitals now look much like regular hospitals with many offering individual patient rooms to maximize privacy. Such changes follow the trend of the past 30 years of reducing the stigma associated with mental illness. These changes are largely laudable, but all change comes with a cost.
It may be tempting to think that in Ms. Ferrell’s case that cost for these changes was very high indeed; perhaps if psychiatric care had been delivered as it was 50 years ago she would be alive today. But such conclusions are erroneous and have their own untoward consequences towards our health care system. No psychiatric system, no matter how elaborately conceived, can assure us that a desperately depressed patient driven by suicidal thoughts will not harm himself. By seeking to hold someone responsible for the unfortunate events like those that occurred with Ms. Ferrell, our legal system drives the health care industry to spend inordinate amounts of monies to reduce patient risk to as close as zero as possible. Such pursuits invariably raise costs and limit services within our health care system which operates within a finite fiscal reality of uneven private and Medicaid reimbursements. The likely upshot with the health care system involved with Ms. Ferrell’s care will be employee seminars, new procedures and forms, extensive auditing of the delivery of care by hospital attorneys, and an increase in the pervasive fear of litigation that imbues so much of our health care system these days. However, very little will change in terms of patient care and outcomes, because it cannot. The fact is that sometimes bad things happen in hospitals which are nobody’s fault.
2 Comments
If she didn’t want to commit suicide I suppose she would not have. True, many people unsuccessful at suicide later are grateful at the result. But does that justify us taking away their liberty of self determination?
If the courts properly relieved her of her personal liberty to self detmination by ordering an unwanted admission, then by all means she should be subject to zero privacy and continuous observation; and if she so much as flinches wrong should be restrained by whatever means necessary.
Unless this is not what we want as a society, but to protect even the legally committed with some privacy and autonomy; then however we should expect a few to kill themselves. Liberty costs.
“By seeking to hold someone responsible for the unfortunate events like those that occurred with Ms. Ferrell, our legal system drives the health care industry to spend inordinate amounts of monies to reduce patient risk to as close as zero as possible.”
One side effect of this is that there is less money with which to actually treat people. Fewer people may indeed die IN the institutions because of such things, but there will be fewer people treated because of it as well, and MORE will die outside the institution.
This is not a net gain in terms of outcomes.