Strategies to Support Patients at Risk — Suicide, Abuse and Mental Health Challenges

Things to Know

If a patient discloses abuse, self-harm, or suicidal thoughts, be prepared to stop your assessment or treatment and address the comments. You need to maintain confidentiality of capable patients unless there is a significant risk of harm to the patient or others. In that case, your duty to warn (keep others safe) may supercede your need to obtain consent.

As a physiotherapist, it’s important to notice red flags, offer information about resources and supports, and refer the patient to the appropriate professional. Consider downloading the following document to have available: Resources to Support Patients at Risk.

Remember:

• Mental health crisis lines are excellent resources and can provide guidance on how best to proceed if you are concerned about a patient.

• Document the relevant information and actions taken in the clinical record, including only the critical details. For example: “Patient commenting that they are contemplating suicide, phoned crisis line together with the patient, patient agrees to follow up with family physician today.” Be prepared to redact these details if a third party asks for a copy of the clinical record and the notes do not relate to an insured injury.
• Stay within your scope of practice as a healthcare professional by responding to concerning comments, asking a few probing questions, and then deciding on your course of action. Depending on the scenario, the course of action might be to offer resource information, contact a family member or physician, or even to call 911 in extreme cases.

Best Practices

• Don’t ignore concerning comments. Be human, empathetic, and indicate your concern. For example: “That sounds very stressful, and I’m really concerned about you.”You may be the only health professional the patient feels comfortable disclosing this information to. How you respond might open doors for the patient to seek supportive services.
• Ask your patient some probing questionsto get more information about the degree of danger present. If appropriate, consider asking if the patient has a suicide plan, or what motivates the cutting – is it a way to cope with stress, or is it an attempt at suicide? In an abusive scenario, you could ask if there are children witnessing the abuse, or whether there are guns in the home.
• If you are in the middle of a hands-on technique when a patient makes a disclosure that causes you concern, be aware of how touch can be impactful and be careful of the effect on your patient if you suddenly take your hands off them after the disclosure.
• Capable adults have the right to make their own choices, even if that means remaining in an abusive relationship. Offer your patient resources for support services if they are open to it.
• Involve your patient in your action planwhenever possible to foster trust. For example, say: “I’m really concerned about your safety, I’m going to get the number for the suicide hotline and we’ll call them together for some advice.”
• Suggest to your patient that you’d like to create a team to support them. Explain that in addition to having a physiotherapist involved, you think it would be beneficial for them to connect with a counsellor, physician, social worker, or psychologist to ensure all of their needs are addressed by the right professional with the right skills.
• Follow-up with patients who stop therapy mid-session, leave and cancel sessions. Physiotherapy has great restorative value for people who may not feel valued and might need an open-door reminder.

Patients Under 18

In 2018, the age of protection was raised to include youth up to 18-years-old. Youth who are 16 and 17-years-old are now eligible to receive protection services from Children’s Aid Societies. While reporting for 16 and 17-year-old children is not mandatory, please contact your local Children’s Aid Society if you have concerns about a youth.

When a Patient is Suicidal – Privacy Considerations and Your Obligations

All healthcare providers, including physiotherapists, must understand the importance of protecting a patient’s privacy. This includes getting patient consent for collection, use and disclosure of all personal health information.

Ontario’s privacy laws allow patients to have control over who has access to their personal health information. However, they do not to prevent healthcare providers from immediately disclosing personal health information in specific and limited circumstances, including when a patient has expressed suicidal thoughts.

If a physiotherapist has reasonable grounds to believe a patient may seriously harm themself, or others, the Personal Health Information Protection Act (PHIPA) permits this disclosure without getting the patient’s consent.

The physiotherapist is expected to use their professional judgement when assessing the situation to determine if there are reasonable grounds to believe serious harm will occur and if it is appropriate to disclose this information.

The courts have set out circumstances in which concern for public safety may warrant the disclosure of information by a healthcare provider to reduce or eliminate risk of harm. The factors for consideration are:

• There is a clear risk to an identifiable person or a group of persons
• There is a risk of serious bodily harm or death and
• The danger is imminent

There are no restrictions on the types of people this information can be disclosed to – the PT should use their best judgement to determine who would be the most appropriate person to contact.

Depending on the situation, a family member or the patient’s family doctor or mental healthcare provider would be appropriate. In some urgent cases, it may be more appropriate to call 911 for emergency services.

If the physiotherapist is uncertain as to whether disclosure should be made, they should contact a lawyer or the Information and Privacy Commissioner.

Important: All disclosures should be documented in the patient chart.

This Isn’t Easy – We Are Here if You Need Us

If these types of conversations make you uncomfortable, know you are not alone. It’s important to discuss these topics with colleagues and become more comfortable speaking about them so that if a situation arises, you can react professionally and appropriately and not miss an opportunity to build trust and to provide critical support to a patient.

For more information on this topic or to talk through your situation, please feel free to reach out to a Practice Advisor at 1-800-583-5885 or advice@collegept.org.

The College of Physiotherapists of Ontario would like to acknowledge the work of the College of Health and Care Professionals of BC as a source for some of the material on this page.

Crisis Resources

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