In all the years I have been practising medicine, there is one aspect of the doctor-patient relationship that arguably remains the most vexed. It is characterised by over-caution, lack of confidence, and misunderstanding of the laws that govern it. It is a looming presence, the fear of which can overwhelm the best of doctors and sometimes get in the way of acting in the best interests of their patient.
I am talking about patient confidentiality, in particular in the context of suicide prevention.
It arises when a clinician like myself sees someone whom we assess to be at risk of taking their own life. As a psychiatrist I know that often the best asset here is not myself, nor another mental health professional, but someone close to the person in crisis, such as their partner, parent, carer or close friend. But when I suggest that it would be good if I could talk to them the patient expresses unease and finally says no. Often, I am reasonably confident that this isn’t the best call, but I am also, like all doctors these days, trained to respect patient confidentiality at all costs.
There are no figures for how often health professionals err on the side of caution, and we will always hear more about instances where their decision not to share information may have contributed to the worst possible outcome for a patient who is severely depressed, rather than the occasions when their actions have prevented this. However, the painful experience of many parents who have lost their sons or daughters to suicide is sufficient testament to the need to improve practice in this area.
The death in 2015 of Edward Mallen is one such example. His father has spoken openly about his son’s death, and the fact that although Edward himself had not talked to his family about how depressed he was, he had given consent for medical professionals to speak to his parents about how he was feeling. Yet, even with permission, they did not.
This is important. Suicide is now the leading cause of death among men aged 15-49 in England and Wales; the Westminster Parliament’s Health Select Committee is currently holding an Inquiry into Suicide Prevention, and The Five Year Forward View for Mental Health has set an ambition to reduce the numbers of people in England taking their own lives by 10 per cent by 2020/21. To support this, every area in England must develop a multi-agency suicide prevention plan showing how they will be working to reduce suicide in high-risk locations and amongst high-risk groups.
When considering such strategies, families should be considered a potential source of information, advice and support: potential partners in suicide prevention.
In 2014, the Royal College of Psychiatrists was one of nine signatories to a Consensus Statement on Information sharing and suicide prevention prepared by the Department of Health. This is unambiguous that the duty of confidentiality is no justification for not listening to the views of family members and friends, who may offer insight into the individual’s state of mind. This can aid risk assessment, care and treatment, and good practice includes providing families with non-person specific information in their own right, such as how to access services in a crisis, and support services for carers.
It also clearly states that when a practitioner is satisfied that a suicidal patient lacks capacity to make a decision about sharing information about their suicide risk, they should use their professional judgement to determine what is in the person’s best interest.
Now, I am not stupid. I know what any professional reading this piece is thinking: what if I get this wrong, or, more accurately, what if someone thinks I have got it wrong? The spectre of the GMC, other regulatory bodies or the Courts looms large in their thinking, and I am not surprised. ‘Safety first’ becomes the agenda. Better not take any risks. But I think these concerns, although understandable, are overstated. In my experience, if doctors make well-justified, well-recorded decisions to share information in the best interest of a patient who is in suicidal crisis, consistent with their professional codes of practice, this will be understood, respected and upheld in courts of law. Courts are exceptionally reluctant to rule against doctors who have clearly acted in good faith in the interests of their patients.
My College will emphasise these approaches as we revise our guidance on suicide and self-harm. This will be an important contribution to changing culture and practice in this area. However, this responsibility must be shared, and be recognised as core to all suicide prevention work.
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