Issue 22 / 14 June 2016

PATIENT suicide can cause significant emotional distress to doctors, who are being encouraged to seek out support after UK research found that many doctors experienced guilt and grief in the aftermath of these tragedies.

Professor Garry Walter AM, Foundation Medical Director of the Doctors’ Health Advisory Service (DHAS) in New South Wales, said that the suicide of a patient would always have an impact on treating doctors, only the extent of the impact would vary.

He said that the first step for clinicians was not to ignore the impact of the suicide of a patient.

“A combination of informal and formal networks will often be sought after a patient’s suicide. The former may include members of one’s own family and professional colleagues. Often, this will suffice, but if the suicide is totally unanticipated or not the only recent patient suicide or if the doctor is experiencing other stressors – family or work-related – these informal networks may prove insufficient,” Professor Walter said.

In these instances, he said, speaking to a service like the DHAS could be “crucial”.

“The DHAS may well have an important role by providing a forum in which the affected doctor can voice the effect of the suicide on them and, where necessary, by helping to arrange a referral to a health professional, such as a GP, psychologist or sometimes a psychiatrist.”

The UK researchers interviewed 198 GPs, and found that 131 GPs (66%) had been affected by patient suicide, reporting feelings of grief, guilt and self-scrutiny. About 54 GPs (27%) said that they sought out support informally from peers and colleagues.

Earlier this year, the Australian Bureau of Statistics reported that the suicide rate had increased to 12 deaths per 100 000 people in 2014 – the highest rate since 2001. It’s a statistic that is keenly felt in rural Australia, where the suicide rate is 66% higher than in urban areas.

Professor Walter said that the risks may be heightened for doctors working in isolated circumstances – whether that is in solo practices or in remote locations.

“Many doctors may have few informal networks and not have well established formal networks,” he said.

Dr Molly Shorthouse resigned from her position as a rural generalist in Nhulunbuy, Northern Territory, in the aftermath of a cluster of youth suicides in the remote community in 2011.

While none of the youths had been patients of Dr Shorthouse, she had looked after their grieving families and the cumulative stress of these consultations took a heavy emotional toll on her.

“I didn’t seek any help and I think that’s a big issue because nurses, doctors and ambulance officers all have this sense that we should be able to cope,” Dr Shorthouse told MJA InSight. “But it just adds up, piece by piece by piece, and you end up with an episode of trauma really, without quite realising it.”

At a breakfast meeting for federal politicians in Canberra earlier this year, Dr Shorthouse described the intensity of her experiences as a GP in the remote East Arnhem Land community.

She told the gathering that it was in part due to the release of the Black Dog Institute’s guidelines on post-traumatic stress in emergency workers, that she realised that her reaction after the suicides had been more than just burnout.

“I had underestimated the intensity of providing mental health services to rural and remote communities. You often hear things that no one else hears. In the case of childhood sexual abuse, it can be descriptions that are so distressing you need to open the door and stand outside when the patient leaves the room, trying to stop the waves of nausea,” she wrote in her notes for the meeting.

Associate Professor Morton Rawlin, Chair of the Victoria Faculty of the Royal Australian College of General Practitioners (RACGP), said that just as dealing with a patient suicide could take an emotional toll on a health practitioner, so too could other difficult situations, such as advising a patient of a life-threatening diagnosis.

“We need to encourage GPs and other health professionals to seek assistance and not to try to do it all on their own,” Professor Rawlin told MJA InSight. “It is appropriate to talk about how difficult work is and to have a formal or semi-formal mechanism in place so you can have those sorts of conversations. Some practices set that up within their practice, but mostly it’s up to the individual practitioner.”

Professor Rawlin said some GPs accessed formalised support networks like Balint groups or had regular contact with a GP or psychologist, while others might just confide in colleagues. He said GPs could also access support via the RACGP and the medical boards.

“It’s okay to say, ‘I actually need to talk to somebody about this so it doesn’t keep eating away at me’. It’s much better to deal with it earlier rather than later,” he said, adding that a clinician’s distress could also have an impact on their family.

After leaving her Nhulunbuy position, Dr Shorthouse spent several years in Hobart where she completed further training in emergency and child and adolescent psychiatry. In 2014, she returned to East Arnhem Land.

Dr Shorthouse said that the mental health training, as well as drawing on the knowledge of Aboriginal health workers and Elders, had helped her to be better prepared to deal with the community’s mental health needs and to feel more resilient.

She welcomed the recent launch of the NT Primary Health Network’s Professional Support Program that, in partnership with Sybella Mentoring, provides counselling support for health practitioners in remote Aboriginal health services and private clinics. 

However, Dr Shorthouse said that further support was needed and called for national funding for rural and remote doctors to do mental health upskilling and for more health professionals to be trained in recognising “vicarious trauma”.

“I have become really conscious of watching my colleagues and providing education at the hospital and teaching everyone how to recognise vicarious trauma,” she said, noting that the Blue Knot Foundation provides training for health professionals.


Poll

Doctors get adequate support when a patient suicides
  • Strongly disagree (43%, 28 Votes)
  • Disagree (29%, 19 Votes)
  • Neutral (18%, 12 Votes)
  • Strongly agree (6%, 4 Votes)
  • Agree (3%, 2 Votes)

Total Voters: 65

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2 thoughts on “Coping with patient suicide

  1. James Leyden says:

    The public hospitals are always incredibly busy. On top of the impossible workload we are expected to teach ever more students with less resources. There I was, standard brain death case, have to certify brain death to stop life support, have to teach class of uni students about brain death, as we go to see patient, i realise it is a patient i have long known, who  i did not know had committed suicide. The feeling was like a punch in the stomach, not only is there no support, but you have to keep going, immediately afterward the next emergency, no pause, no moment, just more scenes to revisit in sweat drenched sleep years later.

  2. Pauline Helen Cole says:

    The community gives the message that many, or even most, suicides are preventable and that clinicians have failed if a suicide death occurs. So no wonder having a patient die by suicide is a sentinal traumatic event for doctors. Risk prediction is fraught with difficulty asside from some high risk indicators that need to be noted and acted upon. There is no clear evidence that ‘tick box’ assessments perform better that clinical assessment but repeatedly we are asked to undertake these and make our decisions accordingly. Statistically there are more deaths from those who fall within the low risk cohort than those who rate in the high risk group.

    Dialectical Behaviour Therapy is an evidence-based treatment. It is not primarily aimed at being a suicide prevention service – its aim is to assist people to build a lives worth living. Life threatening behaviours are worked on and it does end up assisting many people to thrive rather than suicide. But here is the problem; there is far too little of this treatment available. To make its best impact public health physician need to find a way to roll it out in schools as a prevention and early intervention strategy. DBT shines a light on the need for a team to carry the load of managing risk rather than pointing it towards one clinician.

    Perhaps it is worth remembering that we cannot possibly know how many lives we save, however we do fall into the myth of trap of believing that it is us who have failed to save the life of someone who has died by suicide. The DBT principle is that we can show people the way but cannot do the work for them. 

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