PSYCHIATRIC MALPRACTICE – NURSING MALPRACTICE – FAILURE OF PSYCHIATRIST TO ASCERTAIN THAT TREATMENT AFFORDED TO SUICIDAL DEPRESSION PATIENT WAS INEFFECTUAL – NEGLIGENT FAILURE OF NURSES TO ADMINISTER PRESCRIBED DOSAGES OF MEDICATION – WRONGFUL DEATH OF HOUSEMOTHER.
This was a psychiatric malpractice action in which the plaintiff contended that the 33 year old decedent’s death from suicide was occasioned by the negligence of the defendant psychiatrist with privileges at a hospital with a psychiatric care unit, who discharged the decedent when she was obviously suicidal and who failed to take steps to ensure that the patient was being provided with the prescribed dosages of her medication.
The plaintiff further contended that the defendant psychiatrist failed to ascertain that the nurses were not providing the prescribed dosages of the medication. The plaintiff further contended that several defendant nurses in the employ of the defendant hospital negligently failed to administer the prescribed dosages of the medication and negligently failed to properly coordinate with the lab performing blood work on the plaintiff, thereby failing to ascertain that proper levels were not being administered.
Finally, the plaintiff contended that the defendant nurses improperly engaged in incitive rather than supportive psychotherapy, which is a type of therapy for which they were allegedly not trained or competent to engage in. The decedent committed suicide by hanging herself several hours after she was discharged. The decedent, who did not have a longstanding history of depression, had fallen into a depression shortly before she was admitted to the hospital and a diagnosis of acute psychotic depression was made shortly thereafter. The defendant psychiatrist prescribed the anti- depressant drug Desyrel and the plaintiff’s expert maintained that this particular medication was not the drug of choice for patients suffering from a psychotic depression. The expert indicated that although the initial use of the drug was not, in and of itself, a deviation, the defendant should have, based upon records which were replete with mentions of an absence of an improvement during the 6 week hospital stay, initially taken steps to ascertain whether the plaintiff was receiving therapeutic levels of the drug.
The plaintiff’s expert related that two blood tests taken in the hospital revealed that the plaintiff had only 1/10 of the level of Desyrel in her blood that would have been expected if the prescribed dosages had been administered and the expert contended that these results reflected that the plaintiff was receiving far less than the dosages prescribed which would be necessary for effective treatment. The expert maintained that although the medication prescribed was not the drug of choice, the proper amounts would have afforded the plaintiff some improvement and that the defendant deviated in failing to ascertain that the prescribed levels were not being administered by the co-defendant nurses. The expert alternatively maintained that when no improvement was evident, the defendant psychiatrist should have changed the drug to a Trygliceric anti-depressant medication which, according to the expert, is generally known to be more effective with deep depression in general, and psychotic depression in particular.
The plaintiff’s nursing expert maintained that based upon the levels of the medication in the blood, it was obvious that the nurses were not administering the prescribed dosages. The nursing expert further contended that a nurse should only become engaged in supportive type therapy, which would entail discussing subjects only after the patient brought the particular subject up, and not engage in affirmative incitive type therapy in which the nurses would bring up subjects for discussion in an attempt to ascertain and deal with the patient’s particular problems. The expert maintained that such therapy by any individual, trained or otherwise, was inappropriate for this patient because she had paranoid and psychotic thoughts and as such, was not medically ready for such therapy.
The defendant psychiatrist and her expert psychiatrist each maintained that the decedent had enjoyed significant improvement and that the decision to discharge her was proper. The plaintiff countered through the introduction of records indicating that the decedent was delusional and had suicidal ideation throughout her hospital stay and the plaintiff’s expert maintained that in view of the absence of any improvement, the decision to discharge the decedent was improper. The defendant’s expert contended that it is impossible to predict that an individual is planning suicide.
The plaintiff’s expert countered that the decedent exhibited clear indicators which should have led the defendant to realize that suicide was imminent. According to the expert, the records were replete with mentions of the decedent’s feelings of hopelessness and of suicidal thoughts and the expert contended that the records reflected an absence in improvement throughout the hospital stay. The expert further maintained that the two brothers of the decedent had committed suicide and that such an event is an additional indicator of suicide which should have prompted the defendant to ascertain that a discharge at that time would have been dangerous.
The defendant conceded during cross-examination that the hereditary factor must be considered in evaluating the course of treatment and that this type of patient requires “special treatment.” The plaintiff argued that since the defendant did not contend that such special treatment was afforded, it was obvious that the defendant had deviated. The plaintiff’s expert maintained that studies have established that a high percentage of patients such as the decedent, who were suffering from acute rather than chronic depression, enjoy a relatively complete cure if proper treatment and medication is afforded and the expert contended that if such proper care was provided, the decedent would probably have never committed suicide and probably would have recovered fully.
The decedent, who did not work outside of the home, left a husband and two children, aged 11 and 14 at the time of the suicide. The plaintiff contended that prior to the onset of the acute depression, the decedent provided significant guidance and advice and that if proper care would have been provided, she would have been able to resume providing these extensive services. The jury found against the defendant psychiatrist, found against 3 defendant nurses, exonerated the remaining two nurses, who according to the records, played a limited role only in the treatment of the decedent. The jury then awarded $500,000.
The plaintiff, who was confronted with the classical defense that suicide is impossible to predict, utilized a renowned psychiatric expert who has published widely in the field, who effectively utilized the defendants’ own records to detail certain indicators which, according to the expert, should have alerted the defendant psychiatrist to the imminent probability that the decedent would have committed the act if released. Specifically, the expert pointed to continuing feelings of hopelessness and suicidal ideation as mentioned in the records, as well as a close family history of suicide, which according to the plaintiff’s expert, would greatly assist in predicting the chances of the decedent’s committing suicide if the depression was not properly treated.
Additionally, the plaintiff elicited concessions from the defendant herself that the individuals with a family history of suicide require special treatment and that the illness of major depression is the leading cause of death in the field of psychiatry, enabling the plaintiff to argue that based upon this testimony, it was foreseeable that if the decedent was not properly treated, she would be likely to commit the act.
The plaintiff had further contended that the medication initially prescribed was not the drug of choice and that although the use of such medication did not, in and of itself, constitute a deviation, the defendant psychiatrist negligently failed to ascertain that the proper amounts of this medication were not actually being administered and that as a result, the medication had little if any effect.
The plaintiff’s expert utilized the results of the blood test which indicated that the decedent had approximately 1/10th of the level of the drug as she would have had if the prescribed amounts were administered to lend significant support for the plaintiff’s contention that the defendant psychiatrist failed to properly monitor the patient and that the nurses failed to properly administer the prescribed dosages. Regarding damages, the decedent was a housewife who did not work outside the home and the plaintiff was confronted with the practical burden of establishing that the severely depressed decedent would have provided extensive guidance and advice to her family if the defendants had not deviated. The plaintiff’s expert had maintained that patients suffering from acute, rather than longstanding depression, generally enjoy a substantial resolution of the depression if proper care is provided and the plaintiff offered substantial evidence of extensive guidance and advice provided by the decedent before she fell into the depression, effectively arguing that it was highly likely that if such satisfactory treatment had been afforded, the decedent would have resumed her productive role as homemaker.