Can you petition and certify patient in this circumstance?

[Cadet133]

Hypothetical scenario. Youre called by RN because pt in hospital states shes fed up and wants to end her life. You come in to evaluate pt and pt refuses to talk to you and would not say if shes suicidal. Based on the information given by RN can you petition and certify her?

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[motuza]

I imagine it varies by state and I would need more information from the nurse. Did she say that because she did not get medication? Did someone make her upset? Is she in pain/withdrawal/actue intoxication? Is she demanding to leave the hospital after she made this statement to the nurse? I would not immediately jump to certifying a patient without better understanding the circumstances surrounding her medical hospitalization and why she doesn’t want to talk.

All that to say it’s not enough information to certify without further engagement and risk assessment. It would be enough to perhaps recommend a sitter but not much else decision making can be done with what you’ve provided.

 

[ObsequiousAplomb]

Where I practice, you can't file a petition for involuntary hospitalization to a medical hospital. It has to be a certified involuntary psychiatric hospital or certified involuntary psychiatric unit in a medical hospital. The criteria is imminent risk of harm, and that is interpreted in this region as persistent suicidal or homicidal ideation with a plan within their means with reasonable suspicion that this is due to a treatable mental illness.

I don't know the laws where you practice and I recommend you read them for guidance.

That being said, I agree that this is enough to warrant further evaluation and monitoring. You could recommend the primary team place a sitter. You should probably attempt to get more information, as noted in the comment above mine.

 

[Cadet133]

But lets say based on the information you gathered from RN you feel this pt is truly suicidal and is refusing to talk because she feels she will risk being voluntarily admitted. Just based on information alone RN alone can you petition her?

 

[nexus73]

But lets say based on the information you gathered from RN you feel this pt is truly suicidal and is refusing to talk because she feels she will risk being voluntarily admitted. Just based on information alone RN alone can you petition her?

I think you can and you should. The bar for placing a psych hold (or petition, or whatever you call it) should be relatively low. You have a good faith concern from the RN, a licensed healthcare professional, who provides concerning collateral information the patient is at elevated risk. The patient not talking to you actually increases my level of concern and makes me more likely to place a hold than if they would talk to me and I could do an adequate risk assessment. We can’t let someone leave to kill themselves. And not talking to the doctor once their is legitimate safety concern is not some legal loophole that prevents the patient from being involuntarily held.

 

[michaelrack]

In Mississippi you could easily put on 72 hours hold. Laws vary by state

 

[allantois]

If they aren't talking they will be held for a looooong time here in FL.. YMMV

 

[Bartelby]

I agree with nexus and michaelrack. This situation seems straightforward. The patient has told an RN that she wants to kill herself and refuses to engage further in a discussion about safety. The patient is leaving you little choice in that scenario.

 

[FlowRate]

Agree with above. If the nurse told me "the patient said they were going to go home and inject all of their insulin at once to ensure they died as quickly as possible because they see no point in living anymore due to the severity of their depression" then sure, they bought themselves a hold.

But, just saying, nine out of ten times a situation along the lines of the original post came up, it was a patient passively saying something vaguely suicidal because they were frustrated with being sick/in the hospital/not getting something they wanted and was NOT a situation where sending them to an inpatient psych unit was going to have any utility.

 

[forchinet121]

This is a slam dunk that I experienced a few times in residency, yes you absolutely hold the patient until they talk, they don’t want to talk they don’t go anywhere period

 

[Bartelby]

But, just saying, nine out of ten times a situation along the lines of the original post came up, it was a patient passively saying something vaguely suicidal because they were frustrated with being sick/in the hospital/not getting something they wanted and was NOT a situation where sending them to an inpatient psych unit was going to have any utility.

In those rare cases when the patient refuses to talk with me and it seems like they just made a frustrated comment, I just level with them. I explain that it seems clear they don't want to talk to me and out of respect for that I will keep it to ten minutes of questions, but that based on what the team has told me if they refuse to talk with me that I will have to place a hold. Typically at that point they will engage for enough time to clarify what the comment was about, often avoiding the hold.

 

[mistafab]

In those rare cases when the patient refuses to talk with me and it seems like they just made a frustrated comment, I just level with them. I explain that it seems clear they don't want to talk to me and out of respect for that I will keep it to ten minutes of questions, but that based on what the team has told me if they refuse to talk with me that I will have to place a hold. Typically at that point they will engage for enough time to clarify what the comment was about, often avoiding the hold.

Yes, that is a good approach. I use it in the ED often in the reverse with suspected malingerers who get angry and just keep repeating “Im suicidal” and wont answer your history taking questions. Something like “I know you said you were suicidal, however…(yada yada yada) I have to make a decision based on the evidence I have. You might not like my decision so Im just giving you the chance to tell me whats going on.”

 

[Stagg737]

Agree with all the above. This is where the magical skill of decent bedside manner comes in. Most of the time when you explain the situation to the patient and act as an advocate they'll let you know what's actually going on and 99% of the time a hold won't be necessary. It's incredible what basic respect and minimal empathy can accomplish. For those who still refuse to talk after making suicidal statements, it's completely justified to hold them until you get more info and admit them to psych if necessary.

 

[smalltownpsych]

I was just talking to a student the other day about how to assess a client who wouldn’t participate in an interview. Collateral information, observations, other risk factors, protective factors, history, access to lethal means. Also, if a patient is struggling with a difficult illness, suicidal ideation is pretty common and the nicer patients nurses or other docs are comfortable talking them through it. We get called when they‘re a little more difficult.

 

[forchinet121]

I was just talking to a student the other day about how to assess a client who wouldn’t participate in an interview. Collateral information, observations, other risk factors, protective factors, history, access to lethal means. Also, if a patient is struggling with a difficult illness, suicidal ideation is pretty common and the nicer patients nurses or other docs are comfortable talking them through it. We get called when they‘re a little more difficult.

In terms of a binary decision between hold and discharge none of that really matters, if they made a comment and now won’t speak to you it doesn’t matter how many collaterals they have I wouldn’t discharg them so if you’re busy on a consult unit it’s really that simple

 

[comp1]

So in general I'd say it varies by state law. But it really seems unlikely to vary much in this case as pretty much every state authorizes involuntary holds for imminent risk to self. So...yes, you could.

 

[smalltownpsych]

In terms of a binary decision between hold and discharge none of that really matters, if they made a comment and now won’t speak to you it doesn’t matter how many collaterals they have I wouldn’t discharg them so if you’re busy on a consult unit it’s really that simple

I get that decision and have tended to make the same; however, I have usually been able to work through that resistance. It does vary by state law and the state where I had the most experience with this was very clear in the law that refusal to talk to a professional person could not be used as the determining factor or some language to that effect. That is why you would need collateral information. I have had to justify my decisions in court a number of times and wouldn’t want to look like I hadn’t done a thorough job in a case like this. I guess in some states that doesn’t happen, but in one state where I worked my boss who was a bit arrogant was actually threatened with being charged with wrongful imprisonment by the county attorney because of a really weak hold.