Medpage inclues an article on clarifying the duty to warn.

Here are some excerpts:

Amid rising gun violence and threats in North Carolina, including in the last few weeks alone, the state has taken important steps to protect against gun violence, the leading cause of death in children statewide. The recently launched NC S.A.F.E. (which stands for secure all firearms effectively) initiative aims to educate communities about firearm storage through social media, television, and radio advertising. Additionally, Gov. Roy Cooper (D) ordered the creation of the Office of Violence Prevention to coordinate and deploy evidence-based public health strategies to mitigate violence in the community.

Medical professionals have an important role to play in stemming the tide of violence. However, in North Carolina, we are disincentivized from reporting patients who appear at high risk of committing violent acts against others. No one can predict violence with certainty, and people with mental illness are more likely to be victims than perpetrators of violence. Nonetheless, with the proliferation of guns and ease of access, mental health professionals are positioned to see warning signs for violence and to act to protect their patients and the community -- and that's especially true when someone makes an explicit threat. But to do so, mental health providers need legislative or judicial support to breach confidentiality when they encounter a high-risk patient who discloses the intent to hurt someone.

By 1985, the Tarasoff rule was codified in California law, whereby a therapist could be held liable for failing to protect third parties from a patient's violent behavior "if the patient has communicated to the psychotherapist a serious threat of physical violence against a reasonably identifiable victim or victims..."

The setting (e.g., inpatient or outpatient) influences clinicians' decision on which action to take, but there are generally four mechanisms to discharge Tarasoff-like duties. 

• Involuntarily committing a patient may allow for treatment and mitigation of risk if the risk is originating from mental illness. Notably, in the absence of mental illness, a person cannot be held against their will for expressing serious homicidal thoughts. 
• Therefore, voluntary admission may be a reasonable option if the patient agrees, yet could become an issue if the patient no longer meets inpatient criteria or rescinds consent and has continued to express homicidal intent. 
• The other mechanisms include warning the potential victim and 
• informing the police.

However, all these decisions become ethically complex as the clinician must consider their duties of confidentiality to the patient and their responsibility to protect others by issuing a warning, while also weighing their legal liabilities in each scenario.

Policies related to clinicians' duty to warn and protect also vary by state. So called "mandatory reporting states" require medical professionals to break confidentiality and report threatening patients, while permissive states allow confidences to be broken in circumstances when a victim is identifiable and the threat appears imminent. 

Only four states (Nevada, Maine, North Dakota, and North Carolina) do not explicitly recognize some version of clinicians' duties to protect potential victims, thereby potentially leaving clinicians at legal risk should they violate patient confidentiality. 

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