A Cry for Help: A Case Report of Suicidal Ideation in a Physician-mediated Forum
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A Case Report of Suicidal Ideation in a Physician-mediated Forum. Objective: To present a clinical case of a suicidal-valediction patient.To review service provider and clinicians’ ethical expectations in similar situations.
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A Cry for Help: A Case Report of Suicidal Ideation in a Physician-mediated Forum
- 1. A Cry for Help: A Case Report ofA Cry for Help: A Case Report of Suicidal Ideation in a Physician-Suicidal Ideation in a Physician- mediated Forummediated Forum Immaculada GRAU, Francisco J. GRAJALES III, Juan Miguel Garrido,Enrique BUISAN, Antonio Delgado Medicine 2.0 | Maastricht, NL | November 28th, 2010
- 2. • Forumclínic Background • Study Objective • Case Presentation • Review of the literature • Discussion • Future directions • Conclusions OverviewOverview
- 3. MIE2009 Sarajevo ForumclínicForumclínic’s Mission’s Mission To improve the quality of care through increased access to culturally sensitive evidence-based information for Chronic Diseases in Spanish and Catalan audiences.
- 7. MIE2009 Sarajevo Ischemia Diabetes Chronic Obstructive Pulmonary Disease Schizophrenia Breast Cancer Depression Heart Disease Arthritis and Osteoarthritis Obesity Bipolar Disorder HIV/AIDS + Anorexia / Bulimia Conditions Targeted
- 12. MIE2009 Sarajevo
- 16. MIE2009 Sarajevo ObjectiveObjective To present a clinical case of a suicidal- valediction patient. To review service provider and clinicians’ ethical expectations in similar situations.
- 17. MIE2009 Sarajevo Case ReportCase Report • 29 year old Hispanic male c reported Dx of schizophrenia • Self-reported a Hx of failed suicide attempts • Requested advice on how to commit suicide with OTC or Rx medication
- 18. MIE2009 Sarajevo Case ReportCase Report Failed Suicide Juanito 2010/11/27 “Yesterday, 2010/11/26, I was supposed to have died. Unfortunately, my family found me unconscious and called an ambulance. They took me to the hospital and suctioned my stomach. I didn’t die this time, but I will not give up trying.
- 19. MIE2009 Sarajevo Case ReportCase Report …I know that I must die and I will succeed even if I have to try a new method. My thing is taking pills, and I believe this is how I should die. I want to make it clear to everyone in this forum that Schitzophrenia is not a mental condition, we are just passer bys in this world.
- 20. MIE2009 Sarajevo Case ReportCase Report …I would like to tell you a lot of things, but I think its silly now so I would like to say my final goodbye. If I post here again it is because I have not died yet, but that I am still trying to say goodbye”
- 21. MIE2009 Sarajevo Information AvailableInformation Available • First and last name (optional) • Gender & DOB • Occupation • Last level of completed education • Email • User type (Pt, Fm, Clinician, Other) • Country, city, and approx. population • Number of people in home • + Postings (variable)
- 22. MIE2009 Sarajevo Forumclinic PolicyForumclinic Policy • We provide information not medical advice • The forum moderator must intervene • Forum evaluations every 48 hours • Inform patients upon registration and (inappropriate) posts • Comprehensive use of disclaimers
- 23. MIE2009 Sarajevo What HappenedWhat Happened • Nine postings prior to the clinician intervening • Information provided by the community was comprehensive • BIG QUESTION: How should we deal with this?
- 24. MIE2009 Sarajevo ReviewReview Objective: What evidence, guidance, or recommendations does the literature provide for similar situations? Sources: 1) Peer-review Literature 2) Ethics and Professional Codes 3) Broad web-search 4) Snowballed information
- 25. MIE2009 Sarajevo ReviewReview Findings: 1.Literature base is tiny 2.Most does not apply to our case 3.Those that do, come from telemedicine and email
- 26. MIE2009 Sarajevo Ferguson and EysenbachFerguson and Eysenbach Patient-clinician interactions can be classified in two types: • Type A or Type I interactions occur in the Absence of a pre-existing patient- clinician relationship. • Type B or type II interactions occur when there is a pre-existing (Bona fide) patient-clinician relationship.
- 29. MIE2009 Sarajevo Question?Question? Do professionally mediated forums, which are virtual communities establish a bona-fide patient- clinician relationship?
- 30. MIE2009 Sarajevo • New platform using SAAS • Automatic (semantic) recognition of suicidal and similar messages using crawlers • JMIR case report and review paper Future Directions
- 31. MIE2009 Sarajevo • QALY, costing, and ROI analyses • Guidelines for new physicians • Ethical guidelines for grey areas • Multivariate analyses of moderator interaction dynamics Future Research
- 32. MIE2009 Sarajevo • Clinician-moderated forums are legitimate and challenging spaces for patient engagement. • The case presented reveals some of the many ethical and legal challenges that may arise in physician-specialist moderated forums on an ongoing basis. • The Forumclínic approach has proven useful in cases of suicidal valediction. Conclusions
- 33. MIE2009 Sarajevo • The peer-review evidence-base for clinical guidance in moderated forums is very small. • At present, the resilience of the current approach will be tested as litigation arises. • Further research is required in order to establish a series of best-practice guidelines for similar situations. Conclusions
- 34. MIE2009 Sarajevo Spain • Hospital Clínic de Barcelona • Funación BBVA • Fundació Clínic per la Recerca Biomedica Canada • Western Regional Training Centre for Health Services Research • Dean Giustini - @giustini Acknowledgments
- 36. Questions?
- 37. References [1] Jacobs, Douglas; Brewer, Margaret. APA Practice Guideline Provides Recommendations for Assessing and Treating Patients with Suicidal Behaviours. Psychiatric Annals, May 2004. http://www.webcitation.org/5uayCMcC2 [2] Eysenbach, Gunther. Towards ethical guidelines for dealing with unsolicited patient emails and giving teleadvice in the absence of a pre- existing patient-physician relationship systematic review and expert survey. J Med Internet Res (2000) vol. 2 (1) pp. E1. [3] Ferguson T. Digital doctoring--opportunities and challenges in electronic patient-physician communication [editorial] JAMA. 1998 Oct 21;280(15):1361–2 [4] Hrynaszkiewicz, Ian; Norton, Melissa; Vickers, Andrew; Altman, Douglas. Preparing raw clinical data for publication: guidance for journal editors, authors, and peer reviewers. BMJ (2010) vol. 340 pp. c181
Editor's Notes
- based on the WHO premise of Social Determinants of Health – increased health education and interaction leads to better health
- 300,000 DVDs 30K in each condition 27K in SPANISH 3 IN CATALAN
- ...and here for breast cancer.
- Forumclinic is a set of audiovisual material (DVDs and Website) in both Spanish and Catalan that was launched in January 2007 with the purpose of improving the quality of life of chronically ill patients. Based on the premise that by having a better understanding of their disease patients can become more autonomous, the project aims to encourage patient involvement in the clinical decision-making process along with the health care team. Priority has been given to diseases of higher prevalence and wider social impact.
- And - here we have the results of the applied selection criteria, these 10 conditions: 7 of which are up and running on our website, with 3 more ‘ in production ’ .
- ...and here for breast cancer.
- ...and here for breast cancer.
- ...and here for breast cancer.
- BOTTOM LINE = WE GIVE INFORMATION, NOT ADIVCE
- WE PROVIDE INFORMATION, NOT MEDICAL ADVICE
- 6 Month analysis
- After swallowing a number of pills, he was found by his family and transported to hospital. Upon discharge, he presented to the forum requesting advice on the most effective suicidal dose of easily accessible medication. The forum community immediately responded in an empathetic manner and coached the patient to seek medical attention. By the time the forum moderator was informed, the advice given by the Schizophrenia forum community was so comprehensive that the forum moderator had relatively little to add.
- Ayer 10 de mayo de 2010 se suponia ke tendria ke haber muerto. Lamentablemente llegaron mi familia y llamaron una ambulancia donde me limpiaron el estomago con una sonda, osea un fracaso de suicidio pero no me voy a dar porvencido. Se que tengo ke morir y lo voy a lograr aunke sea por otros medios pero lo mio son las pastillas y creo ke esa es la muerte que debo tener. Quiero dejar en claro a todos ke la esquizofrenia no es un enfermedad mental solo somos emisarios de este mundo. Me gustaria decirles muchas cosas que se pero creo ke no tendria sentido asi ke ahora me despido. Si vuelvo a escribir aqui es que aun no he muerto pero sino solo les puedo decir Adios pd. si alguien se apiada de mi ke me digan cuales son las dosis letales de pastillas para morir.
- Ayer 10 de mayo de 2010 se suponia ke tendria ke haber muerto. Lamentablemente llegaron mi familia y llamaron una ambulancia donde me limpiaron el estomago con una sonda, osea un fracaso de suicidio pero no me voy a dar porvencido. Se que tengo ke morir y lo voy a lograr aunke sea por otros medios pero lo mio son las pastillas y creo ke esa es la muerte que debo tener. Quiero dejar en claro a todos ke la esquizofrenia no es un enfermedad mental solo somos emisarios de este mundo. Me gustaria decirles muchas cosas que se pero creo ke no tendria sentido asi ke ahora me despido. Si vuelvo a escribir aqui es que aun no he muerto pero sino solo les puedo decir Adios pd. si alguien se apiada de mi ke me digan cuales son las dosis letales de pastillas para morir.
- Ayer 10 de mayo de 2010 se suponia ke tendria ke haber muerto. Lamentablemente llegaron mi familia y llamaron una ambulancia donde me limpiaron el estomago con una sonda, osea un fracaso de suicidio pero no me voy a dar porvencido. Se que tengo ke morir y lo voy a lograr aunke sea por otros medios pero lo mio son las pastillas y creo ke esa es la muerte que debo tener. Quiero dejar en claro a todos ke la esquizofrenia no es un enfermedad mental solo somos emisarios de este mundo. Me gustaria decirles muchas cosas que se pero creo ke no tendria sentido asi ke ahora me despido. Si vuelvo a escribir aqui es que aun no he muerto pero sino solo les puedo decir Adios pd. si alguien se apiada de mi ke me digan cuales son las dosis letales de pastillas para morir.
- What do you do?
- Review: According to Ferguson and Eysenbach, clinical interactions through electronic media are classified according to the absence or presence of a bona fide patient-physician relationship. Although it may be argued that forums can create legitimate patient-physician relationships, a comprehensive use of clinician and patient education, disclaimers, and police and patient contact have proven useful for Forumclinic in ethically- and legally-challenging situations.
- based on the WHO premise of Social Determinants of Health – increased health education and interaction leads to better health
- Not enough for a systematic review
- Not enough for a systematic review
- Towards ethical guidelines for dealing with unsolicited patient emails and giving teleadvice in the absence of a pre-existing patient-physician relationship
- based on the WHO premise of Social Determinants of Health – increased health education and interaction leads to better health
- based on the WHO premise of Social Determinants of Health – increased health education and interaction leads to better health
- based on the WHO premise of Social Determinants of Health – increased health education and interaction leads to better health
- Other Research: QALY, costing, and ROI analyses Guidelines for new physicians Ethical guidelines for grey areas Multivariate analyses of moderator interaction dynamics