Client Suicidal Ideation and Privacy

BACKGROUND

Trixie, an occupational therapist (OT), received a referral for a home safety assessment for an 85-year-old client, Mr. Porter.  The referral came through the rehabilitation company she works for, which was contracted by the Local Health Integration Network (LHIN) to provide services in the region. Trixie met with Mr. Porter and completed an initial assessment in the presence of his companion of 10 years. Following her initial assessment, Trixie made several safety and equipment recommendations and planned a follow-up visit—once all the equipment was delivered—to provide education and make sure Mr. Porter was able to use the equipment safely.

Trixie was notified by the vendor that all the equipment had been delivered and installed, then called Mr. Porter to book the follow-up visit.  When she arrived at Mr. Porter’s home, he answered the door and seemed surprised to see her. Trixie noticed Mr. Porter appeared unkempt and dishevelled. Mr. Porter said he had forgotten about their meeting; however, he agreed to the follow-up visit.

Once inside, Trixie noted the home was in disarray with dishes piled high in the sink and clutter throughout the living room. During her follow-up assessment, Trixie learned that Mr. Porter’s companion had recently moved out. Mr. Porter shared with Trixie that he felt lost and at times contemplated ending his life. Mr. Porter explained to Trixie that yesterday he determined he no longer had any reason to live and showed her a bottle of prescription pain medication he had been carrying around in his pocket. Trixie told Mr. Porter she was very concerned about him and asked if she could refer him to someone who may be able to help. Mr. Porter declined Trixie’s offer of assistance and begged her not to tell anyone.  This was the first time Trixie encountered a client with suicidal thoughts. She wondered what she should do and what her obligations were in managing this situation. 

CONSIDERATIONS

  • What is Trixie’s duty to maintain privacy in this practice dilemma?
  • How does the principle of consent apply in this scenario?
  • Can personal health information be disclosed without consent in this situation?

Responding to the situation:

In deciding what to do, Trixie needs to consider all relevant information and legislation. Trixie knows she has a responsibility to protect Mr. Porter’s personal health information, but she is also concerned that if she does not tell anyone, Mr. Porter may harm himself. 

Trixie is worried Mr. Porter may seriously hurt himself and wants to report her concerns to an appropriate person (like a relative or family physician). She tries to obtain consent from Mr. Porter before sharing any confidential information that would be needed to assist him, but Mr. Porter refuses. Trixie knows she must respect Mr. Porter’s wishes. This does not mean Trixie does nothing: She discusses different courses of action with Mr. Porter—like contacting his family doctor, referring him to crisis support services, or contacting 911—and explains she is obligated to do something if she has concerns about his safety. 

Understanding Privacy Legislation (Duty to Warn) 

Ontario’s privacy laws protect how personal health information (PHI) may be collected, used or disclosed by health care practitioners. Health information custodians must obtain consent for the collection, use or disclosure of PHI except in limited circumstances where disclosure is permitted by law.

Under the Personal Health Information Protection Act, 2004 (PHIPA), OTs are permitted to disclose personal health information about an individual if they have reasonable grounds to believe disclosure is necessary to eliminate or reduce significant risk of serious bodily harm to a person or group of persons. This disclosure is sometimes referred to as a duty to warn. Although duty to warn is not a legislative term, it is a provision in the law. If the risk is sufficient, then the duty to warn serves as the legal authority to release the information. 

If Trixie decides to break privacy and share details about Mr. Porter’s PHI, she should be transparent and inform Mr. Porter about her intended actions and document the discussion and rationale for her decisions.

OUTCOME 

  • Using her clinical judgement, Trixie decided there was a marked difference in Mr. Porter’s behaviour and there was evidence he had identified a suicide method and plan. She determined there was an imminent risk if Mr. Porter did not receive immediate help.

  • Trixie first attempted to contact Mr. Porter’s family doctor to discuss her concerns, but the family doctor was not immediately available. She then contacted her manager, who notified Trixie of the organization’s procedures for working with clients at risk. Trixie was provided with the contact phone number for the community mental health crisis services. The community crisis service coordinated a nurse from the outreach team to visit Mr. Porter at home that day to assess his risk.

  • Trixie reflected on the situation and decided if the community crisis team was unavailable, her next option would be to contact emergency services (911) as she deemed Mr. Porter to be at imminent risk of harming himself. Trixie documented the actions she took and her rationale for breaching privacy in the client’s clinical record. Trixie also followed up with her organization to familiarize herself with the procedures pertaining to working with clients in the community who were at risk for suicide. 

DISCUSSION

Working with clients who verbalize suicidal ideation can be complex. The management of suicidal clients warrants a comprehensive approach, requiring the OT’s knowledge, skill and judgement to recognize when an individual is in distress and help the individual obtain the necessary services in a respectful and caring manner.  

OTs are encouraged to review any relevant legislation, regulations, and organizational policies and procedures that relate to clients who may be experiencing suicidal thoughts.  OTs must understand their professional and legal obligations and be aware of organizational procedures for how to manage clients with suicidal ideation. If no such procedures exist, OTs are encouraged to proactively develop a policy for their practice setting. 

REFERENCES

CONTACT

If you have any questions about this case, or have any ideas or requests for future cases, contact the Practice Resource Service: 1.800.890.6570/416.214.1177x240 or practice@coto.org

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