Friday, September 2, 2016

Liability for patient suicide

Florida's Supreme Court ruled August 25 that a physician could be sued for medical malpractice in the case of a patient's suicide.

The case originated in Sarasota County, Florida, after the October 2008 suicide of 55-year-old wife and mother Jacqueline Granicz, who hanged herself. Her husband, Robert, sued her family physician, Joseph S. Chirillo Jr, MD, of Englewood, Florida, who was treating her for depression, and Millennium Physician Group, for medical malpractice.

Jacqueline Granicz started taking the antidepressant venlafaxine (Effexor, Pfizer) in 2005, but stopped taking it in 2008, according to court records.

The records say she called Dr Chirillo's office the day before she died and told his medical assistant that she had stopped taking the drug because she thought it was causing side effects such as poor sleep and mental strain, and also causing her to cry easily and have gastrointestinal distress. She said she had not "felt right" since late June or July.

After reading the assistant's note, Dr Chirillo changed the patient's prescription from venlafaxine to a different antidepressant, escitalopram (Lexapro, Forest Laboratories), and didn't schedule an appointment but said she could pick up a sample of the drug and a prescription at his office. She picked up the items that day and hanged herself the following day.

Granicz's husband then sued the physician and his medical group, alleging the doctor had breached his duty and the suicide had resulted from that breach.

According to court documents, allegations of breach of duty including that he failed to recognize that she was experiencing a change in symptoms, was depressed, and was seeking medical intervention; that Dr Chirillo didn't speak with her directly; that he didn't refer her to a clinician trained in management of depression; and that he failed to properly evaluate escitalopram, an antidepressant known to cause suicidal ideation in some patients

The doctor and his group filed for summary judgment saying that, "Dr Chirillo owed no duty to prevent the decedent from committing an unforeseeable suicide while she was not in his control."
The summary judgement was granted by the First District Court of Appeal, but the decision was later reversed by the Second District Court of Appeal that ruled in favor of Granicz. The Florida Supreme Court ultimately ruled Thursday to confirm the decision of the Second District that the case should proceed to trial.

Justice Peggy Quince said, in writing the opinion for the court, "Although the inpatient duty to prevent suicide does not apply here, there still existed a statutory duty…to treat the decedent in accordance with the standard of care."

The Supreme Court ruled that the First District court in its decision and the petitioners "in their initial brief outlined testimony from the hearing on the motion for summary judgment which tended to show that the decedent's suicide was not foreseeable. However, Granicz 1) pointed out that Dr Chirillo knew that patients who stopped taking Effexor abruptly had an increased risk for suicide, and 2) ultimately opined that stopping Effexor was "a contributing factor" in the decedent's suicide. On this evidence, "we approve the Second District's finding that there is a genuine issue of material fact remaining as to proximate cause."…

Carolyn Stimel, PhD, executive director of the Florida Psychological Association, told Medscape Medical News, "There's a fine line between how you balance the standard of care with people's free will on an outpatient basis."

She said the ruling points up several things, including that the "vast majority of psychoactive medications at this point are being prescribed by non-mental health trained physicians. More people get antidepressants from their [general practitioner] than get it from their psychiatrist because we have a shortage of psychiatrists."

She also said that people with depression are also often not referred for therapy to psychologists.

"Presumably, if this person had been in therapy there would have been somebody monitoring what was going on with their mental state and also dealing with the issue that she had stopped taking her medications."

  Ultimately you can't shove pills down someone's throat. The thought of doctors being responsible for whether patients kill themselves or not — that's pretty chilling. 
She says doctors have a legitimate question in asking what you can do when a patient won't take medications.

The problem was quantified in a previous Medscape Medical News story that said that one in five patients prescribed antidepressants stop taking them without telling their doctor.

"Ultimately you can't shove pills down someone's throat," Dr Stimel said. "The thought of doctors being responsible for whether patients kill themselves or not — that's pretty chilling."

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