What is the immediate course of action for a 14-year-old patient in a primary care office who admits to having a plan for suicide and is threatening to act on it?

Immediate Action for Suicidal 14-Year-Old in Primary Care

You are not legally obligated to call 911 on the spot, but you must arrange immediate mental health evaluation during the current office visit—this can be accomplished through psychiatric hospitalization, emergency department transfer, or same-day mental health professional appointment, depending on risk stratification. 1, 2, 3

Risk Stratification Determines Transport Method

The decision to call 911 versus arranging alternative immediate evaluation depends on specific high-risk features present during your assessment:

Call 911 Immediately If:

• Active suicidal intent with specific plan AND access to lethal means (this represents imminent danger requiring emergency transport) 3
• Persistent desire to die with inability to engage in safety planning (cannot be safely managed in outpatient setting) 3
• Recent high-lethality attempt (gunshot, hanging, jumping) or attempt with clear expectation of death 3
• Severe hopelessness combined with psychotic symptoms (command hallucinations, paranoia, confusion) 3
• Patient refuses voluntary transport but meets criteria for involuntary hospitalization 3
• Severe agitation, behavioral dyscontrol, or altered mental status requiring medical evaluation 3
• Lack of adequate support systems to safely transport to emergency department 3

Alternative Immediate Evaluation (Not 911) May Be Appropriate If:

• Suicidal ideation with plan but no immediate intent to act AND responsive/supportive family present 1, 2
• Someone available to provide continuous 1:1 observation until psychiatric evaluation 1, 2
• Family willing and able to ensure safe transport to emergency department or same-day mental health appointment 1, 3
• No psychotic symptoms, severe agitation, or intoxication 1, 3

Critical Actions While Patient Remains in Your Office

Never leave the patient alone—maintain continuous 1:1 observation regardless of transport method chosen 3:

• Remove access to medical equipment, sharps, medications, and potential weapons from the examination room 3
• Search patient and belongings for potential means of harm 3
• Keep patient in safe environment until transport or psychiatric evaluation occurs 3

Mandatory Safety Interventions Before Any Discharge/Transfer

You must explicitly instruct parents to remove all firearms from the home, lock up all medications (prescription and over-the-counter), restrict access to alcohol/substances, and secure knives and other potential means 1, 2:

• Adolescents can still access locked guns stored in their home, so complete removal is necessary 1
• This conversation must occur even if patient is being hospitalized, as it applies to post-discharge 1

Common Pitfalls to Avoid

Do not rely on "no-suicide contracts"—they have not been proven effective in preventing suicide and provide false reassurance 1, 2, 3:

• Refusal to agree not to harm oneself is ominous and indicates higher risk, but agreement does not lower risk 1
• Instead, develop collaborative safety plan with specific coping strategies, identified supports, and professional contact information 2

Do not underestimate risk based on low medical lethality of method—intent matters more than actual lethality 2, 3:

• A patient who took 10 acetaminophen tablets believing they would die has higher risk than one who superficially cut wrists knowing it wouldn't be lethal 2

Do not accept family reassurance alone when high-risk features are present—families often underestimate risk and overestimate their supervision ability 3:

• Independent clinical judgment must guide disposition decisions 1, 3

Legal Considerations

Breaking confidentiality is justified when there are significant concerns about imminent harm to the patient 3:

• You can initiate psychiatric holds for brief periods when criteria are met (mental disorder plus imminent risk of harm to self) 3
• Involuntary hospitalization criteria vary by state but typically require both mental disorder and imminent danger 3

Documentation Requirements

Document your risk assessment including: specific suicidal ideation/plan/intent, mental status examination findings, previous attempts, psychiatric comorbidities, family support assessment, means restriction counseling provided, disposition decision rationale, and follow-up arrangements made 1:

• This documentation protects both patient safety and medicolegal interests 1, 4

Follow-Up Mandate

Maintain contact with the patient even after referral/hospitalization—collaborative care between pediatrician and mental health professionals results in greater reduction of depressive symptoms 1, 2:

• Greatest risk for reattempting suicide occurs in months immediately following initial attempt 2
• Schedule follow-up within days of emergency evaluation, not weeks 1, 2