Enabling Clinicians to Petition for ERPOs Can Save Patients’ Lives

October 29, 2020

Katherine Hoops, MD, MPH

The health care environment is an important point of contact for at-risk individuals, in particular individuals at risk of suicide. Clinicians from a variety of backgrounds—physicians, advanced practice providers, clinical social workers—all have a role in the care of these patients and the prevention of death and injury. ERPO is an important tool that I think should be available to clinicians when it comes to protecting our patients. I think it is also a logical extension of clinicians’ counseling and guidance, and it is an important area in which clinicians can partner with families and help patients who are at risk of harm to themselves or others.

I’m a pediatric ICU physician. When caring for a patient with lung disease called acute respiratory distress syndrome, physicians in my field use a lung protective strategy for mechanical ventilation, because we know it is associated with improved outcomes and reduced risk of death. It is the standard of care. This lung protective strategy can prevent 1 death when the therapy is given to 10 patients; in medicine, we call that the number needed to treat, the number of patients to whom a therapy is given to prevent a certain outcome. ERPO also has a number needed to treat of 10. The best available evidence suggests that for every 10 to 20 ERPOs issued, 1 suicide death is prevented. That’s compelling evidence for me as a clinician that ERPO is an effective means of preventing death and should be used to help my patients when appropriate.

However, just including clinicians among eligible ERPO petitioners isn’t adequate. We do a tremendous amount of education and work to train law enforcement and eligible petitioners to use ERPO effectively to prevent firearm death and injury, and the same needs to happen for clinicians. The ideal scenario would be that clinicians would be included among petitioners in existing or new ERPO legislation, and that would be coupled with rigorous education on ERPO and how it can be applied in the clinical context.

Patient confidentiality is essential to our work as clinicians, but we must breach confidentiality when we know a patient is at risk of harm to themselves or others. That’s when we have to reach out for help, be that to law enforcement or colleagues or families of patients. With ERPO, we can, to a degree, maintain patient confidentiality if clinicians can directly petition for the ERPO based on their clinical judgment, rather than having to reach out to law enforcement or a family member to file the petition on their behalf.

I can see a scenario in which ERPO becomes an important part of the standard of care—when a patient is admitted for suicidal thoughts, receives in-patient therapy, and is stable for discharge but still at high risk, since we know the risk of suicide is extremely high for the first 30 days after hospital discharge. An ERPO could be an important part of discharge planning for a patient who owns guns or has access to guns in their homes.

For me, as a pediatrician, it’s important to note that, at least in Maryland, these laws are about access not ownership. Patients, including children, who are not gun owners can still be protected by ERPOs. We teach clinicians when we are doing education on this subject, as in the ongoing ERPO Teach-Out, that these laws can be applied to children who have access to firearms in their home or to non-gun-owning members of a gun-owning household.

Clinicians are an important point of contact for individuals at risk of violence. These are common scenarios that clinicians see. ERPO is a tool that should be available for clinicians more broadly to protect their patients.


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