520 - To treat or not to treat…managing patients who refuse to answer suicide screening questions

Publication Number: 520.6969

Kristen Volz, Connecticut Children's Medical Center, Hartford, CT, United States; Shane J. Sacco, University of Connecticut School of Medicine, Farmington, CT, United States; Steven C.. Rogers, Connecticut Children's Medical Center, Hartford, CT, United States

Background: The Joint Commission requires healthcare systems to screen for suicide risk and recommend using evidence-based suicide screening tools. Tool kits that correspond to the screeners provide clinicians with guidance on how to conduct suicide risk screenings for youth. Suicide risk is determined based on the patient responses to multiple questions. The guidelines suggest that patients who refuse to answer one or more questions should be considered a positive screen and treated as at-risk for suicide. However, there is limited literature to support managing “refusals” as positives and the characteristics of these patients.

Objective: To determine if there are the unique characteristics of patients who refuse to answer suicide-screening questions.

Design/Methods: We conducted a retrospective chart review of 10-18 year old patients approached for suicide risk screening in a large urban pediatric emergency department from 2019-2022. Using Fisher’s exact test and logistic regression, we evaluated associations between demographics, encounter details, patient types, and risk screening results.

Results: We reviewed 22,185 patient charts and 98 patients refused to answer one or more of the screening questions (0.4%); 50 refused all questions (51%) and 48 refused some questions (49%). Compared to patients that answered all questions, those that refused any questions (all or some) were more likely to have a mental/behavioral health complaint and a parent in the room, ps < 0.001 (figure 1). Compared to patients who only refused some questions, those that refused all questions were more likely younger, Black or African American, and to have a parent in the room, ps < 0.01 (figure 2). When comparing the rates of mental/behavioral complaints, patients who answered with negative results displayed the lowest rates (7.9%), then full refusers (30.0%), then partial refusers (56.2%), then those who answered with positive results (59.1%). Rates differed significantly between all groups (ps < 0.01), except between partial refusers and positives (p=0.77) (Figure 3).

Conclusion(s): Patients that partially refuse to answer screening questions are more likely to have a mental/behavioral chief complaint and have an association with positive screen patients. Therefore it is appropriate to manage them as at-risk for suicide. Future studies should aim to identify a larger sample size to further explore how to manage a patient who refuses all screening questions.

Characteristics of those who answered all questions vs to those who refused any or all of the questions
Figure 1_refusal.pdf

Characteristics of those who refused some of the questions vs those who refused all of the questions
Figure 2_refusal.docx.pdf

Comparison amongst all groups
Figure 3_refusal.pdf