Calculated risks in the treatment of intractably suicidal patients.

PATIENTS who threaten suicide in all seasons, self-mutilate, and who from time to time make serious suicide attempts tax and challenge clinical workers. Every hospital has its legend about the exploits of such a patient. When these patients die of suicide, a wave of sorrow and guilt follows. Many therapists exclude them from their practices; keeping clinical balance in working with them is difficult. Intractably suicidal patients require much time and great energy from those responsible for their care. They draw forensic attention and excite hospital administrators to action. Much of the anxiety they arouse comes from the question of whether they should be admitted to the hospital and, once they have come into the hospital, from the reciprocal: whether they should go out again. The increasingly litigious climate in the United States makes the treatment of such persons extremely difficult. The purpose of this paper is to review the literature pertinent to the care of such patients, to outline the clinical principles necessary for their management and treatment, and to set forth the conditions that are necessary to minimize legal exposure in the event of suit in the wake of suicide.