To Detain or Not to Detain (Grand Rounds thread maybe?)

[Ceke2002]

So a while back I'm sure someone mentioned something about tossing about the idea of doing some sort of 'Grand Rounds' thread on here (it might have even be me, I can't remember off the top of my head). Anyway I thought I'd take the initiative and start a thread off and see what happens - if it turns out to be something people are interested in participating in, or continuing, then perhaps it could become a sort of semi regular, maybe monthly or bi-monthly type event with people taking turns to present their own 'Grand Rounds Case'.

From what I understand of Grand Rounds type posts they are based on either a case that is available within the public sphere of record, or they are a specific patient case, or an amalgam of cases - but in all variations no information that could reasonably identify an individual is given. If I'm wrong on this, please feel free to correct me.

The 'case' I'm going to present is a matter of public record; however, I am still going to change certain details so as not to make the case searchable (that would be cheating) and to protect the identity of certain individuals involved.

I really hope I've written this up properly as well, or as close to how a Grand Rounds case should be written up at least.

EDITED TO ADD: Case Outcome posted below with further discussion points on ethics and patient safety versus rights to personal freedoms.

~~~~~~~~~

NB: All names given are pseudonyms that bear no resemblance to any person's actual name or identity.

Case Presentation #1

The patient is a 23 year old college student, who despite dealing with a congenital loss of hearing, which will eventually leave her completely deaf, has managed to excel academically, even travelling overseas on a scholarship to study with a prestigious institute as part of a 12 month exchange program where she also performed volunteer work with four different charity groups. Her parents divorced when she was 6 years old and she initially lived with her mother, until starting college where she moved in with her father to be closer to campus grounds.

Her congenital loss of hearing was discovered in high school, and since then it has been reasonably well managed; with surgical intervention assisting in slowing the progression of the disease. The patient is aware her disease is not curable, and that the eventual outcome will be a total loss of hearing. Concerned with the level of hearing loss she is already experiencing she decided to make an appointment with one of the college's course advisers to see what assistance is available in terms of students with disabilities. During this meeting she casually mentions that she might be feeling a little depressed about her situation. The course adviser refers her to one of the campus counsellors, Mr Stuart Brooklyn, for further assessment. During her counselling session she reports a significant degree of stress regarding her condition, and a discussion of the possibility of clinical depression as a reaction to this stress is raised. At the end of the session the patient is referred to the College's On Campus Family Medicine Practitioner, Dr Marigold Boston. Subsequently she is examined by Doctor Boston, who determines she may be suffering a reactive form of Depression and starts her on Lexapro. A week later she returns to Doctor Boston complaining of headaches, broken sleep and anxiety. Her dosage of Lexapro is increased. During this time she is also continuing regular counselling sessions with Mr Brooklyn.

After a further week on medication the patient again returns to Doctor Boston saying she is still having continued disruption of sleep, and experiencing difficulty with concentration, focus, and low motivation. She further describes experiencing episodes of disconnection, but also reports a significant decrease in depressive symptoms. Dr Boston then explains that antidepressant medication takes 4-6 weeks for full effects to be seen, and for the first time the patient spontaneously broaches the topic of suicide. She states that she has been having thoughts of suicide on and off since the age of 15, but has never made any attempt to act on them. She also mentions the idea of one day travelling to a country that allows assisted suicide. Seeing as there is no clear plan in place, and any theoretical plans are set for a date well into the future and involve possible international travel, Dr Boston is satisfied that no immediate danger is present at this time. She recommends that she see the patient on a monthly basis, and that the patient also continues her counselling sessions with the Mr Brooklyn.

The following day the patient attends another counselling session with Mr Brooklyn, where he notes a decrease in anxiety, and they discuss plans for future stress management. Two weeks later the patient presents for a further appointment with Mr Brooklyn; however, Mr Brooklyn is away and she agrees to be seen by the Head of the Campus Counselling Department instead, Dr Rose Georgia. At this appointment she again mentions that she has been experiencing suicidal thoughts since the age of 15 and produces a 3000 word document outlining her reasons for wishing to commit suicide and stating her belief that she would be able to do so in a painless and effective manner. In this document, which is detailed and concisely written, she talks about her congenital hearing loss, the knowledge that it is an incurable condition, the periods of disassociation she has been experiencing, and her recent struggles with depression. Despite these issues she says she feels she is currently at a very good time in her life. She then states that she wishes to commit suicide at what she terms an optimal point in life, which she believes to be between the ages of 40 and 45; however, she also concedes that she has recently begun to consider that she may be at an optimal point to end her life sooner. She writes that she is confident that she can achieve a successful act of suicide, and that the planning required will allow time for reconsideration. When questioned further on the contents of the document, and if she has a set date in mind for her intended suicide, she states that she has no planned date or day in which to carry out out the act , but that she would do it in her own time. At this point Dr Georgia, believing the patient is adamant about taking her own life and therefore poses an immediate risk to herself, contacts the local area's Mental Health Crisis Intervention and Assessment Unit with an urgent referral request.

A 20 minute phone call between Dr Georgia and a Mental Health Triage worker attached to the Crisis Intervention and Assessment Unit is conducted where detailed notes are taken on the presenting situation. Following this the patient is deemed to be a Category B Risk Level - non emergent, but must be seen within 72 hours. The patient is then contacted the following day by one of the Crisis Intervention and Assessment Unit workers, Ms Fern Delaware. Due to the college environment, and background noise, Ms Delaware, having first established the patient's safety, informs her that someone will call later to arrange a face to face meeting. That evening, in order to accommodate the patient's college schedule, a home appointment is arranged for the next Saturday afternoon. At this day and time the patient is seen by two Crisis Intervention and Assessment Unit workers: Ms Delaware, who is an Advanced Social Worker, and Ms Lily Vermont, a Senior Psychiatric Nurse. During the assessment the patient is observed to be well groomed, shows clarity of thought and behaviour, and is orientated to time, place and person, although she exhibits a flat affect. She denies any psychotic symptoms, and also denies any acts or thoughts of self harm. She is open and honest in regards to her suicidal ideation, mentioning consistent passive thoughts and intent; however, she further states that she feels herself to be at no immediate risk as she is looking forward to taking her course exams in 6 weeks time. Towards the end of the interview she again reiterates that she feels herself to be in no immediate danger and that she did not intend to commit suicide at that time. Both Ms Delaware and Ms Vermont also make note of an appointment the patient attended two days prior with Doctor Boston, the Doctor who had initially prescribed her Lexapro. Upon follow up Doctor Boston reports that the patient had expressed certain strongly held beliefs that she interpreted as being inconsistent with a desire to live; however, the patient had also spoken of her upcoming exams, stated that she felt happy at present, and had discussed a planned interstate trip once her exams were over. Because of these clearly stated future plans, Doctor Boston says she did not feel the patient was in any imminent danger of carrying out a suicidal act at that time, and that she felt the patient would benefit from a course of Psychotherapy, and they had discussed this recommendation.

Five days after the in home assessment an appointment is made for the patient to see one of the Crisis Intervention and Assessment Unit's Attending Physicians. Unfortunately due to a clerical error there is a mismatch between the date and day of the appointment, and the patient arrives for her appointment on the wrong day. The Attending Physician asks the staff to pass on their sincerest apologies and to request that the patient please attend the correct appointment date the following day where a 2 hour block of time has been allotted for them. A phone call is made by clinic staff the following morning reconfirming the corrected appointment time with the patient; however, the patient states that she is unable to attend on that day due to course commitments at College. The next day another phone call is placed to the patient's home, and mobile number. The calls go unanswered and a recorded message is left offering a new appointment with the Attending Physician. The following day the clinic is able to make contact with the patient, who declines their offer of a new appointment from the previous day, indicating that she is willing to wait until after exams, and that everything is currently okay.

~~~~~~~~~

Consider And Present Your Findings:

You are the Attending Physician in this case. Whilst you are waiting for the patient in question to attend an appointment, it is your job to review the patient's case notes (which consists of all the information given above), and to present an initial formulation of the case, along with any recommendations you see fit, to the Clinic Director.

• What diagnoses are you leaning towards in the first instance?
• What differential diagnoses are on your radar if any?
• What treatment, or combination of treatment, might you be considering during this review phase?
• Based solely on the information that is contained within the notes you have on hand, do you feel this case warrants the patient being detained under any mental health act or law?
• On a scale of risk assessment where would you place this patient with the information provided to you thus far - low, moderate, or high?

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[psych md jd]

• Based solely on the information that is contained within the notes you have on hand, do you feel this case warrants the patient being detained under the mental health act?

Which "mental health act" are you referring to?

Involuntary commitment laws vary from nation to nation and state to state.

Some jurisdictions use the dangerousness standard. Others, like France, use the "need for treatment" standard. See: Law & Psychiatry: The Evolution of Laws Regulating Psychiatric Commitment in France at http://ps.psychiatryonline.org/doi/abs/10.1176/appi.ps.201300174

 

[birchswing]

As a patient who had mental illness on a college campus, I have never heard of nor could I imagine the level of intervention described here.

But accepting all this intervention as fact and as a patient playing a doctor, my assessment, based on the very limited information, is that the patient is having existential anxiety about life. For the first time in her life she is considering accommodations for her hearing loss. That seems to be what triggered her into admitting to thoughts of suicide that she's had for so many years. If she needs accommodations at 23, what will she need at 45? The solution to uncertainty is the certainty of death. The Lexapro seems to have had an activating effect. She is sleeping less and is more obsessed than before on the future, such as writing her 3,000 word treatise on suicide. Before she seemed to force her anxieties into perfectionism or at least being high achieving--not only excelling in school but working for four charities abroad. Now her rumination is about the future. Did Lexapro lift some veil that allowed for that? I don't know. The other big change in her life is that she has gone from having no outside help to having what sounds like practically an army of help from every direction. Her thoughts about the future are too hard to hold and so rather than trusting herself with her own thoughts, she literally hands over them to others in paper form (her suicide treatise). That reminds me of my own OCD where I am checking with other people about something that they would have no more idea about than I would myself. If I were a psychologist, my question wouldn't be whether she is at risk but what she is looking for in presenting the risk? Does she want reassurance? Does she want meaning in life? I don't think that she wants to die in any case based on what is presented. She seems afraid of death and life.

I'm sure some of my own projections are in there.

EDIT:

I realized I didn't answer the actual questions:

• What diagnoses are you leaning towards in the first instance?

Existential anxiety; the human condition; seeking of love and reassurance

• What differential diagnoses are on your radar if any?

Anxiety disorder; OCD; depression

• What treatment, or combination of treatment, might you be considering during this review phase?

Talk therapy, assessment of nutritional and sleep needs

• Based solely on the information that is contained within the notes you have on hand, do you feel this case warrants the patient being detained under the mental health act?

No

• On a scale of risk assessment where would you place this patient with the information provided to you thus far - low, moderate, or high?

Low

 

[Ceke2002]

Which "mental health act" are you referring to?

Involuntary commitment laws vary from nation to nation and state to state.

Some jurisdictions use the dangerousness standard. Others, like France, use the "need for treatment" standard. See: Law & Psychiatry: The Evolution of Laws Regulating Psychiatric Commitment in France at http://ps.psychiatryonline.org/doi/abs/10.1176/appi.ps.201300174

I tried to word it as non specific so people could use whatever act or laws they operate under per state or country. So, basically just go with whatever law you would normally use.

edited to add: On second thoughts, I've reworded the original post to hopefully make this section a little clearer. Thanks for pointing this out to me, much appreciated.

 

[Ceke2002]

As a patient who had mental illness on a college campus, I have never heard of nor could I imagine the level of intervention described here.

But accepting all this intervention as fact and as a patient playing a doctor, my assessment, based on the very limited information, is that the patient is having existential anxiety about life. For the first time in her life she is considering accommodations for her hearing loss. That seems to be what triggered her into admitting to thoughts of suicide that she's had for so many years. If she needs accommodations at 23, what will she need at 45? The solution to uncertainty is the certainty of death. The Lexapro seems to have had an activating effect. She is sleeping less and is more obsessed than before on the future, such as writing her 3,000 word treatise on suicide. Before she seemed to force her anxieties into perfectionism or at least being high achieving--not only excelling in school but working for four charities abroad. Now her rumination is about the future. Did Lexapro lift some veil that allowed for that? I don't know. The other big change in her life is that she has gone from having no outside help to having what sounds like practically an army of help from every direction. Her thoughts about the future are too hard to hold and so rather than trusting herself with her own thoughts, she literally hands over them to others in paper form (her suicide treatise). That reminds me of my own OCD where I am checking with other people about something that they would have no more idea about than I would myself. If I were a psychologist, my question wouldn't be whether she is at risk but what she is looking for in presenting the risk? Does she want reassurance? Does she want meaning in life? I don't think that she wants to die in any case based on what is presented. She seems afraid of death and life.

I'm sure some of my own projections are in there.

EDIT:

I realized I didn't answer the actual questions:

• What diagnoses are you leaning towards in the first instance?

Existential anxiety; the human condition; seeking of love and reassurance

• What differential diagnoses are on your radar if any?

Anxiety disorder; OCD; depression

• What treatment, or combination of treatment, might you be considering during this review phase?

Talk therapy, assessment of nutritional and sleep needs

• Based solely on the information that is contained within the notes you have on hand, do you feel this case warrants the patient being detained under the mental health act?

No

• On a scale of risk assessment where would you place this patient with the information provided to you thus far - low, moderate, or high?

Low

I can assure you this is an actual case, and yes all of the appointments mentioned did take place. I'm going to wait a week, see if anyone else responds, and then I'll reveal the actual outcome of the case.

 

[DrBacchi]

How do you know this case?

 

[Ceke2002]

How do you know this case?

As I said the case is a matter of public record, I merely read the facts of the case as they were presented in publicly accessible documents, and then changed certain details, including using pseudonyms for the medical professionals involved, so as to prevent people from simply looking the case up themselves. The case has absolutely nothing to do with me or any of my past or present treatment.

 

[Ceke2002]

Okay, seeing as I have a sneaking suspicion people might be reluctant to respond to this, because it was started by a self acknowledged patient, and there is always the chance that someone could use an idea such as a Grand Rounds thread to try and circumvent the TOS in regards to asking for medical advice, let me state for the record that I just really liked the idea of possibly having a Grand Rounds type thread on here and there is no other motivation to this thread apart from the hope of perhaps kicking off a regular 'Grand Rounds' type post for the forum. I have always enjoyed reading Grand Rounds posts on a number of different blogs (not just limited to Psychiatric blogs either), I find the different case evaluations, thoughts, ideas, conclusions given and ensuing discussions to be of great interest. In terms of how I picked the particular case in question - I read a lot of different reports, studies, publications, press releases, and so on, within the field of mental health, so all I did was pick one of those reports, make some minor changes to prevent the case simply being looked up, and replace certain given names with pseudonyms. There really isn't anything more to it than that.

 

[st2205]

Without getting into any nuance, no, I would not commit this woman. I would hope few would. There's nothing to be accomplished and would be more evidence of a delusional disorder on the provider's part if they thought so.

 

[Ceke2002]

Without getting into any nuance, no, I would not commit this woman. I would hope few would. There's nothing to be accomplished and would be more evidence of a delusional disorder on the provider's part if they thought so.

I agree, and in this particular case there are those who do believe the situation was serious enough, based on the document that was produced by the patient, to warrant the patient being detained. Just from reading the notes of this case I've always had the impression that detaining the patient was more coming from the ideals of a saviour complex of sorts, rather than someone looking at the actual facts of the case as they were presented at the time and making a medically sound judgement.

 

[Ceke2002]

And seeing as @birchswing has responded to this in the role of a patient putting themselves into the shoes of a Physician, so to speak, I'll do the same - why not, Grand Rounds threads always seem to attract a variety of expertise and view points.

Of course bearing in mind that I am not a Doctor, and my education in respect to mental illness is somewhat limited in that respect...

What diagnoses are you leaning towards in the first instance?

Dysthymia, Major Depressive Episode possibly either precipitated and/or complicated by a some sort of pathological grief reaction

What differential diagnoses are on your radar if any?

Cluster B traits, Generalised Anxiety Disorder, 'sucky life' syndrome.

What treatment, or combination of treatment, might you be considering during this review phase?

Continue Lexapro, engage patient in long term Psychotherapy to build resilience.

Based solely on the information that is contained within the notes you have on hand, do you feel this case warrants the patient being detained under any mental health act or law?

No

On a scale of risk assessment where would you place this patient with the information provided to you thus far - low, moderate, or high?

Moderate risk, monitor closely, but still no need for detention.

 

[Ceke2002]

So anyone else wanna have a crack at this? Yes, no, maybe, perhaps?

Seeing as there doesn't appear to be much interest in a Grand Rounds type thread on here (meh, oh well, cest la vie and all that), let's see it's 4 pm on a Saturday afternoon where I am, so I might give it another few hours or so and then just reveal the outcome of the case.

 

[birchswing]

I am curious. When you offered your assessment had you seen the outcome yet? I'm not sure how these normally work. Part of me thinks it's going to be something really esoteric—like that there was a brain tumor pressing on a certain part of her brain causing these symptoms and also causing the hearing loss. I've never heard of Grand Rounds before, so I'll be curious to see what the outcome is.

 

[splik]

I am curious. When you offered your assessment had you seen the outcome yet? I'm not sure how these normally work. Part of me thinks it's going to be something really esoteric—like that there was a brain tumor pressing on a certain part of her brain causing these symptoms and also causing the hearing loss. I've never heard of Grand Rounds before, so I'll be curious to see what the outcome is.

well we've been told the hearing loss is congenital so it's not going to be related to a brain tumor. but a tumor of the cerebellopontine angle would cause hearing loss and potentially neuropsychiatric disturbance.

 

[Ceke2002]

I am curious. When you offered your assessment had you seen the outcome yet? I'm not sure how these normally work. Part of me thinks it's going to be something really esoteric—like that there was a brain tumor pressing on a certain part of her brain causing these symptoms and also causing the hearing loss. I've never heard of Grand Rounds before, so I'll be curious to see what the outcome is.

Well this is my first attempt at trying to do a Grand Rounds type thread, so I'm kind of just going off what I've seen on other blog sites and the like. Generally speaking a case gets posted, and people discuss and comment on it. From what I can ascertain the cases are either historical cases with identifying details changed, or an amalgam of cases/patients put together into one case. In this instance I thought it would be just easier to go with a case I was familiar with that was part of the public record. I did choose this case because of the discussions recently regarding ability to predict suicide and suicide prevention versus a patient's rights to not have their freedom or liberties curtailed.

 

[splik]

So anyone else wanna have a crack at this? Yes, no, maybe, perhaps?

Seeing as there doesn't appear to be much interest in a Grand Rounds type thread on here (meh, oh well, cest la vie and all that), let's see it's 4 pm on a Saturday afternoon where I am, so I might give it another few hours or so and then just reveal the outcome of the case.

i would be interested in a grand rounds thread its just this case (so far anyway) is rather dull. it's not really grand rounds worthy. you want some sort of diagnostic conundrum or treatment issue, or ethical quagmire to sort through. potentially could have generated more interesting discussion by asking different questions such as "when, if ever, do patients have a right to commit suicide" and "when, if ever, would you allow a patient to commit suicide?" etc. but the diagnostic, treatment, and risk assessment bits of the case are a total snooze fest.

 

[Ceke2002]

well we've been told the hearing loss is congenital so it's not going to be related to a brain tumor. but a tumor of the cerebellopontine angle would cause hearing loss and potentially neuropsychiatric disturbance.

The hearing loss is one of the items in the original case that I did change. I didn't realise by changing it from an eye condition with no related underlying brain conditions to congenital hearing loss, that I'd be opening up the possibility of discussion of neuropsychiatric disturbance. Guess my first attempt at doing a Grand Rounds thread hasn't been too crash hot. The physical condition the patient presents with is basically just to indicate a potential reason for her depression - ie that the depression is some sort of reactive type.

 

[splik]

The hearing loss is one of the items in the original case that I did change. I didn't realise by changing it from an eye condition with no related underlying brain conditions to congenital hearing loss, that I'd be opening up the possibility of discussion of neuropsychiatric disturbance. Guess my first attempt at doing a Grand Rounds thread hasn't been too crash hot. The physical condition the patient presents with is basically just to indicate a potential reason for her depression - ie that the depression is some sort of reactive type.

no don't worry, i was just explaining that it was possible to have a lesion causing hearing loss and neuropsychiatric symptoms. as you said it was congenital that would mean that the hearing loss was something the patient was born with and so birchswing's musings would not be of concern.

but you do have to be careful about changing even minor details of cases unfortunately as it can have huge implications!

 

[Ceke2002]

i would be interested in a grand rounds thread its just this case (so far anyway) is rather dull. it's not really grand rounds worthy. you want some sort of diagnostic conundrum or treatment issue, or ethical quagmire to sort through. potentially could have generated more interesting discussion by asking different questions such as "when, if ever, do patients have a right to commit suicide" and "when, if ever, would you allow a patient to commit suicide?" etc. but the diagnostic, treatment, and risk assessment bits of the case are a total snooze fest.

Ah, gotcha, I guess because I know the outcome of the case I was interested to see how others would have approached the idea of detaining this patient, if they even would have. Maybe I should have asked something more along the lines of 'If the risk is not clear cut, do you believe a patient's right to liberty trumps their right to safety, or do you err on the side of caution'? or 'At what point would you detain a patient when the risk to themselves wasn't cut and dried'?

I probably could have revealed the outcome of the case, because it is somewhat of an ethical quagmire, and then used that as a jumping off point for discussion, which probably would have been the better thing to do, I just didn't know/think whether a Grand Rounds type thread would do that - reveal the case outcome before discussion had ensued that is.

In the words of Homer Simpson..."It's my first day'.

 

[splik]

well it doesnt have to end with revealing the outcome. perhaps you will get more interesting discussion when you post the outcome?

 

[Ceke2002]

no don't worry, i was just explaining that it was possible to have a lesion causing hearing loss and neuropsychiatric symptoms. as you said it was congenital that would mean that the hearing loss was something the patient was born with and so birchswing's musings would not be of concern.

but you do have to be careful about changing even minor details of cases unfortunately as it can have huge implications!

Thanks, if I decide to try anything like this again (probably not seeing as I appear to not be very good at it ) I'll keep things like that in mind.

The details of the case I did change were the patient's medical condition (it was eye related not hearing related), the patient's age (she is a few years younger in the actual case), the age of onset of suicidal thoughts (in the actual case the age of onset is younger, but the time period the thoughts are experienced over is the same), the word count of the document the patient handed over (it was less than 3000 words in the actual case, but the content remains the same) and some minor details regarding timing of certain appointments (but nothing that changes the actual content of the notes from those appointments).

 

[birchswing]

Ah, gotcha, I guess because I know the outcome of the case I was interested to see how others would have approached the idea of detaining this patient, if they even would have. Maybe I should have asked something more along the lines of 'If the risk is not clear cut, do you believe a patient's right to liberty trumps their right to safety, or do you err on the side of caution'? or 'At what point would you detain a patient when the risk to themselves wasn't cut and dried'?

I probably could have revealed the outcome of the case, because it is somewhat of an ethical quagmire, and then used that as a jumping off point for discussion, which probably would have been the better thing to do, I just didn't know/think whether a Grand Rounds type thread would do that - reveal the case outcome before discussion had ensued that is.

In the words of Homer Simpson..."It's my first day'.

He says that? "D'oh!" comes to mind as his catchphrase. When I was in second grade I had a Bart Simpson shirt that said, "Don't have a cow, man."

 

[Ceke2002]

well it doesnt have to end with revealing the outcome. perhaps you will get more interesting discussion when you post the outcome?

Maybe I'm not too fussed though, I mean this is my first attempt at anything like this, I'm not a Doctor, and of course I have to factor into consideration that as a patient on here some people might be wary of responding to a thread like this incase it's a situation of someone trying to circumvent the TOS. If a discussion ensues all well and good, if not then that's cool too. I just thought I'd give it a go either way.

I'm about to get tea on so I'll reveal the outcome of the case, and some of the ethical considerations surrounding it, after that.

Cheers for the tips and advice as well.

 

[Ceke2002]

Case Outcome:

This particular case comes from the public record of Coronial Inquests (Yes I read Coronial Inquests, a tad morbid perhaps, but I find them interesting). I cannot, or rather I will not link to the actual record of inquest seeing as my Psychiatrist is named in it. That's not the reason I chose this particular case to try and do a Grand Rounds type discussion point, like I said previously I chose it because of the recent discussions surrounding being able to predict patient suicide along with discussions on patient safety versus right to individual freedom.

Obviously seeing as this is a coroner's case, the patient in question obviously did end up committing suicide approximately 9 days after refusing a second offer of an appointment with the attending physician. My psychiatrist was the attending physician the patient was supposed to see in this case, but who following the first clerical mix up refused offers of further appointments with the added caveat that she felt able to wait, she had exams coming up, and everything was fine at that moment. My psychiatrist was also the attending physician who reviewed the patient's notes and felt that whilst there was certainly a plan in place, it was a future risk and that the Crisis Intervention Unit had time to work with the patient in question. He also noted the need for the patient to work with an experienced therapist in the long term. At no point did he feel the patient met the criteria for detention under the mental health act of South Australia. He did not believe there was an imminent threat as to justify detention.

Four days, and then one day prior to the patient completing an act of suicide, she had been contacted again by the same case workers who had initially handled and assessed her situation, with yet another offer of an appointment with Dr Name Redacted. On both occasions the patient refused, citing that they wished to engage with a Psychiatrist closer to her University campus. An appointment was eventually arranged with a Psychiatrist situated at a more suitable location for the patient to attend, which she indicated she was willing to accept and to also engage with a nearby hospital service as an outpatient. Again she reiterated that she was continuing medication as prescribed and did not feel depressed for the main part. In this final contact she also stated that her thoughts of suicide were consistently present, but that certain protective factors she had put into place to protect harm to others were having an effect of reducing the intensity of her suicidal thoughts.

The following day she took her own life.

Expert testimony given at the inquest placed a great deal of criticism on the Crisis Intervention and Assessment Unit - including the fact that what the expert saw as a clear and imminent danger should have lead to an immediate appointment with a qualified Psychiatrist, not gone through a 20 minute phone call with a Mental Health Triage service, followed by placing the patient in question in a non emergent category, waiting for a home assessment to be completed, and then upon review of the notes by the attending physician the fact that detention was not recommended nor felt to be necessary. In this case it was the expert's belief (Professor Name Redacted) that the patient had presented with such clear pathology that he was not in agreement that the patient could wait and be trusted to keep herself alive. He likened her case to someone bleeding to death without assistance, which he based mainly on the document the patient had produced outlining her reasons for wanting to take her own life. On the strength of that document alone he felt the patient was presenting with severe enough pathology so as to warrant a much faster response time and that also necessitated detention under the mental health act.

~~~~~

So ethical quagmire - You're presented with a patient who on the one hand appears to be adamant about committing suicide, but in the same breath refers to the future plans, exams, holidays, etc, talks about harm reduction techniques that are lowering her suicidal urges, the majority of references to suicide are made in the longer and not the immediate term - she plans to commit suicide at some stage...after exams, maybe, after she returns from a planned holiday, maybe, when she's at an optimal time in life around age 40-45 (some 20 or so years into the future), maybe. And yet her ambiguity towards suicide lead the majority of those involved with her case to consider her a low risk in the immediate term at least, and instead they ended up faced with with a patient who's ambiguity turned into action sooner than was perhaps expected. So do you agree with the expert's testimony in this case that based on all information presented the patient was presenting with such an imminent risk so as to warrant immediate action with a recommendation that detention should have taken place, or is a recommendation of that sort after the fact based more off of a saviour type complex where people showing the slightest risk are treated against their will, when they still possess capacity, on the off chance that they may commit suicide sometime in their own stated future. How would you personally deal with a case where a risk was clearly present, but that risk wasn't entirely cut and dried - is it more ethical to detain a patient with capacity against their will in this case, or do you feel it is not only unethical, but unnecessary to detain a patient under the circumstances described because it sets a dangerous precedent of where exactly is the line then drawn between personal freedom and patient safety.

Thoughts, opinions, discussions, whatever else?

Edited to Add: If detaining the patient under a certain mental health act actually contravenes the principals of that act, is it still unethical if detention saves a patients life, or is it again a case of a Physician attempting to play saviour by going against the system when the facts of the case don't necessarily point to an urgent enough need to circumvent certain ideas and ideals that have been put in place to protect a patients right to individual freedom.

 

[smalltownpsych]

For me this case points to the problems with having people not competent in the treatment of suicidal patients in charge of providing mental health treatment. I am referring to the counselor and general practice doc at the clinic. How many hoops do we expect a suicidal patient to jump through before they become frustrated? This happens way too much unfortunately because everyone thinks they can be a "therapist" and then they dump the patient when they realize they are in over their head. Treating chronically suicidal patients without hospitalizing and knowing when to hospitalize is part of what I do and the myriad of mid-level counselor types who don't know how to handle this should not be working without doctoral supervision or oversight.

 

[Ceke2002]

For me this case points to the problems with having people not competent in the treatment of suicidal patients in charge of providing mental health treatment. I am referring to the counselor and general practice doc at the clinic. How many hoops do we expect a suicidal patient to jump through before they become frustrated? This happens way too much unfortunately because everyone thinks they can be a "therapist" and then they dump the patient when they realize they are in over their head. Treating chronically suicidal patients without hospitalizing and knowing when to hospitalize is part of what I do and the myriad of mid-level counselor types who don't know how to handle this should not be working without doctoral supervision or oversight.

Yes, that was one of the criticisms leveled at the way things were handled, the fact in order for the patient to even get to see a qualified therapist they had to go through a counsellor, a GP, another counsellor who I believe was actually a qualified therapist but still had to contact a mental health triage service in order to have the patient referred for emergency assessment after the patient handed them a detailed document basically saying 'I am going to kill myself at some point', and then the patient has to wait for an in home assessment by crisis intervention workers after they've been deemed a non emergent risk, and all that before their file even lands on the attending physicians desk (in this case my Psychiatrist).

I do personally agree with the findings that the system needed to be a lot more streamlined to fast track cases like this and to sit up a better risk assessment/risk management scenario (I believe this was actually implemented). I don't agree though that at any stage, with the facts that were at hand, that my Psychiatrist or any other Psychiatrist who may have assessed the case, should have had this girl detained under the mental health act. I mean how long exactly were they planning to keep her detained, considering apart from one single comment in the document she wrote where she still later stated the required planning would give her ample time to reconsider, all of her talk of suicide was in the future tense - after exams are over, after I've come back from a planned trip, when I'm 40 something and I might travel overseas to euthanasia clinic, I'm going to kill myself sometime between who knows when and next year, maybe. I mean how do experts like this expect their fellow Psychiatrists to detain a patient under these circumstances and still have enough beds available for all the other patients who need emergency hospitalisation at the same time.

Edited to add: And of course being the Lead Clinician/Attending Physician in this case it was my Psychiatrist's name that ended up being splashed all over the news. I've never spoken to him about the case, but I've always wondered how it affects somebody's work or practice when the finger of blame is pointed squarely at you, despite their being numerous prior failures before a case even lands on your desk, and the patient is continuously refusing offers of help as it is.

 

[doctorpilgrim]

There are some larger issues also like, suicide can happen without mental illness, or even if mental illness is present what is the contribution to suicide. What is the role of detention after assessment and formulation of treatment plan and crisis resolution. There are patients with chronically high suicide risk with severe and persistent mental illness living in the community.

 

[splik]

So ethical quagmire - You're presented with a patient who on the one hand appears to be adamant about committing suicide, but in the same breath refers to the future plans, exams, holidays, etc, talks about harm reduction techniques that are lowering her suicidal urges, the majority of references to suicide are made in the longer and not the immediate term - she plans to commit suicide at some stage...after exams, maybe, after she returns from a planned holiday, maybe, when she's at an optimal time in life around age 40-45 (some 20 or so years into the future), maybe.

The absence of future orientation should be of particular concern to the psychiatrist. However the presence of future orientation does not mitigate the risk and may provide false reassurance.

 

[splik]

Edited to Add: If detaining the patient under a certain mental health act actually contravenes the principals of that act, is it still unethical if detention saves a patients life, or is it again a case of a Physician attempting to play saviour by going against the system when the facts of the case don't necessarily point to an urgent enough need to circumvent certain ideas and ideals that have been put in place to protect a patients right to individual freedom.

well this is where it is important to weigh up the risks and benefits of psychiatric hospitalization when formulating a management plan. Hospitalization has not been shown to be an effective intervention for suicide prevention. Where it has its place is in removing someone from a stressful situation that is driving their suicidality, or for close observation where an appropriate level of observation is being provided. Hospitalization obviously has negative consequences - it can be traumatic, deprive someone of their liberties, cost money, take time out of someone's life that could cause them to lose their job or affect their studies, is stigmatizing, expose them to a counter-therapeutic environment, make them less likely to seek care in the future, have implications on their eligibility for particular kinds of employment, implications for their ability to have custody of their children etc etc.

From a medicolegal perspective however you are much more likely to end up in court for a patient suicide, than for wrongful commitment, and things are much less likely to go in your favor when there is a dead body involved.

 

[Ceke2002]

The absence of future orientation should be of particular concern to the psychiatrist. However the presence of future orientation does not mitigate the risk and may provide false reassurance.

Awareness of false reassurance being enough to warrant detention of the patient? If the presence of future orientation doesn't mitigate risk then how does one protect a suicidal patient under these circumstances, I'm assuming you can't just lock up everyone who says they're suicidal?

 

[Ceke2002]

well this is where it is important to weigh up the risks and benefits of psychiatric hospitalization when formulating a management plan. Hospitalization has not been shown to be an effective intervention for suicide prevention. Where it has its place is in removing someone from a stressful situation that is driving their suicidality, or for close observation where an appropriate level of observation is being provided. Hospitalization obviously has negative consequences - it can be traumatic, deprive someone of their liberties, cost money, take time out of someone's life that could cause them to lose their job or affect their studies, is stigmatizing, expose them to a counter-therapeutic environment, make them less likely to seek care in the future, have implications on their eligibility for particular kinds of employment, implications for their ability to have custody of their children etc etc.

From a medicolegal perspective however you are much more likely to end up in court for a patient suicide, than for wrongful commitment, and things are much less likely to go in your favor when there is a dead body involved.

For the interests of discussion...

The standards for an inpatient involuntary treatment order as per the Mental Health Act of South Australia is subject to the following conditions:

This is the act the attending physician in this case (let's set aside the fact that it's my Psychiatrist as that isn't relevant) would be expected to adhere to.

Division 2—Level 1 inpatient treatment orders

21—Level 1 inpatient treatment orders

(1) A medical practitioner or authorised health professional may make an order that a
person receive treatment as an inpatient in a treatment centre (a level 1 inpatient
treatment order) if it appears to the medical practitioner or authorised health
professional, after examining the person, that—

(a) the person has a mental illness; and
(b) because of the mental illness, the person requires treatment for the person's
own protection from harm (including harm involved in the continuation or
deterioration of the person's condition) or for the protection of others from
harm; and
(c) there is no less restrictive means than an inpatient treatment order of ensuring
appropriate treatment of the person's illness.

(2) In considering whether there is no less restrictive means than an inpatient treatment
order of ensuring appropriate treatment of the person's illness, consideration must be
given, amongst other things, to the prospects of the person receiving all treatment of
the illness necessary for the protection of the person and others on a voluntary basis or
in compliance with a community treatment order.

(3) A level 1 inpatient treatment order must be made in writing in the form approved by
the Minister.

(4) A level 1 inpatient treatment order, unless earlier revoked, expires at a time fixed in
the order which must be 2 pm on a business day not later than 7 days after the day on
which it is made.

(5) On the making of a level 1 inpatient treatment order, the following provisions apply:

(a) the patient must be examined by a psychiatrist or authorised medical
practitioner, who must, if the order was made by a psychiatrist or authorised
medical practitioner, be a different psychiatrist or authorised medical
practitioner;
(b) the examination must occur within 24 hours of the making of the order;
(c) if it is not practicable for the examination to occur within that period, it must
occur as soon as practicable thereafter;
(d) after completion of the examination, the psychiatrist or authorised medical
practitioner may confirm the level 1 inpatient treatment order if satisfied that
the grounds referred to in subsection (1) exist for the making of a level 1
inpatient treatment order, but otherwise must revoke the order.

A medical practitioner or authorised health professional may form an opinion about a
person under subsection (1) or (5) based on his or her own observations and any other
available evidence that he or she considers reliable and relevant (which may include
evidence about matters occurring outside the State).

(7) A psychiatrist or authorised medical practitioner who has examined a patient to whom
a level 1 inpatient treatment order applies may revoke the order at any time.

Note—
A psychiatrist or authorised medical practitioner who revokes a level 1 inpatient
treatment order may, in substitution, make a level 1 community treatment order under
Part 4 Division 1.

(8) Confirmation or revocation of a level 1 inpatient treatment order must be effected by
written notice in the form approved by the Minister.

22—Chief Psychiatrist to be notified of level 1 orders or their revocation

(1) A psychiatrist or authorised medical practitioner making, confirming or revoking a
level 1 inpatient treatment order must ensure that the Chief Psychiatrist is sent or
given, within 1 business day, a written notice in the form approved by the Minister.

(2) The Chief Psychiatrist must, within 1 business day, by written notice sent or given to
the Tribunal, ensure that the Tribunal is given a copy of a notice received under
subsection (1).

(3) The Chief Psychiatrist must, within 1 business day, by written notice sent or given to
the psychiatrist or authorised medical practitioner, acknowledge receipt by the
Chief Psychiatrist of a notice under subsection (1).

23—Copies of level 1 orders, notices and statements of rights to be given to
patients etc

(1) A medical practitioner or authorised health professional making a level 1 inpatient
treatment order must ensure that the patient is given, as soon as practicable, a copy of
the order.

(2) A medical practitioner or authorised health professional making a level 1 inpatient
treatment order must ensure that the patient is given, as soon as practicable, a written
statement in the form approved by the Minister (a statement of rights)—

(a) informing the patient of his or her legal rights; and
(b) containing any other information prescribed by the regulations.

(3) If a patient is unable to read or otherwise comprehend the statement of rights, the
medical practitioner or authorised health professional must ensure that any steps that
are practicable in the circumstances are taken to convey the information contained in
the statement to the patient.

(4) Subject to subsection (6), the director of a treatment centre in which a patient is first
admitted as an inpatient under a level 1 inpatient treatment order must cause a copy of
the order and statement of rights to be sent or given to a guardian, medical agent,
relative, carer or friend of the patient as soon as practicable.

(5) If a level 1 inpatient treatment order is revoked, the director of the treatment centre in
which the patient is admitted as an inpatient must—

(a) ensure that the patient is given, as soon as practicable, a copy of the notice of
revocation of the order; and
(b) subject to subsection (6), cause a copy of the notice of revocation to be sent
or given to a guardian, medical agent, relative, carer or friend of the patient as
soon as practicable.

(6) The following provisions apply for the purposes of subsections (4) and (5)(b):

(a) the person to be sent or given a copy of the order and statement of rights, or
notice of revocation, must be—
(i) a guardian, medical agent, relative, carer or friend of the patient
nominated by the patient for the purpose; or
(ii) if that is not practicable or appropriate—a guardian, medical agent,
relative, carer or friend of the patient who appears to have or be
assuming responsibility for the care of the patient; or
(iii) if that is not practicable or appropriate—any other guardian, medical
agent, relative, carer or friend of the patient to whom it is practicable
and appropriate to send or give the copy of the order and statement,
or notice of revocation;
(b) the director is not required to send or give a copy of the order and statement,
or notice of revocation, to a person whose whereabouts are not known to or
readily ascertainable by the director;
(c) it is not appropriate for the director to send or give a copy of the order and
statement, or notice of revocation, to a particular person if the director has
reason to believe that it would be contrary to the patient's best interests to do
so.

24—Treatment of patients to whom level 1 orders apply

(1) A patient to whom a level 1 inpatient treatment order applies may be given treatment
for his or her mental illness or any other illness of a kind authorised by a medical
practitioner who has examined the patient.

(2) The treatment may be given despite the absence or refusal of consent to the treatment.

(3) Nothing prevents the treatment of a patient to whom a level 1 inpatient treatment order
applies before confirmation of the order under this Part.

(4) This section does not apply to prescribed psychiatric treatment, or to prescribed treatment within the meaning of the Guardianship and Administration Act 1993. (5) If a medical practitioner authorises treatment of a patient to whom a level 1 inpatient treatment order applies that is treatment of a kind prescribed by the regulations, the medical practitioner must ensure that the Chief Psychiatrist is sent or given, within 1 business day, a written notice in the form approved by the Minister.

 

[Ceke2002]

What is the role of detention after assessment and formulation of treatment plan and crisis resolution.

Yes, this is something I wonder about myself in regards to this case, exactly what role or purpose would detention have provided (apart from to keep the patient alive, but then it comes back to the question of 'well how long do you detain someone for their own protection if there's no clear cut answer to the level of imminent risk).

 

[splik]

I wonder what role turning up for an appt that was wrongly scheduled played here. I had a pt attempt suicide after turning up to the clinic for an appt when I was away on vacation. Pts can feel a great sense of shame and embarrassment for getting it wrong, as well as rejected, abandoned, or failed in some way. Once I overslept (I know I'm a terrible person!) and my patient's interpretation of waiting for me was "did I do something wrong?" Vulnerable people can take these occurrences in deeper ways. Clearly there was no immediate action here, but it could have been sufficiently narcissistically injuring to the patient (who we know does not deal well with narcissistic injury to her fragile sense of self-integrity given the suicidality generated by going blind) to increase her resolve to commit suicide.

 

[Ceke2002]

I wonder what role turning up for an appt that was wrongly scheduled played here. I had a pt attempt suicide after turning up to the clinic for an appt when I was away on vacation. Pts can feel a great sense of shame and embarrassment for getting it wrong, as well as rejected, abandoned, or failed in some way. Once I overslept (I know I'm a terrible person!) and my patient's interpretation of waiting for me was "did I do something wrong?" Vulnerable people can take these occurrences in deeper ways. Clearly there was no immediate action here, but it could have been sufficiently narcissistically injuring to the patient (who we know does not deal well with narcissistic injury to her fragile sense of self-integrity given the suicidality generated by going blind) to increase her resolve to commit suicide.

Now this is one major criticism I have of the Crisis Intervention Unit/Community Mental Health Centre where this took place, and where I was also a patient until my Psychiatrist transferred me to his other clinical practice. They are absolutely hopeless at booking appointments on behalf of the Clinicians who work there, and half the time they're not even aware of who is available and who is booked up, away on holidays, rostered to do inpatient hospital rounds, and so on. Typically once you're already a patient then the clinician who is treating you takes care of their own appointments, but even then if you're too unwell to attend an appointment, and your treating clinician asks the desk staff to rebook an appointment on their behalf because at that moment they're busy running between meetings and appointments, well it's anyone's guess as to whether or not the appointment will have been done correctly, or whether you'll end up receiving a very apologetic phone call from your treating clinician because they've double booked you with someone else who already had that appointment time, or they forgot to check the roster, or they mixed up dates and times, *insert whatever other conundrum*.

The main reception desk ladies there were lovely, but that still doesn't mitigate the fact that it's annoying enough when such appointment mix ups can lead to potential medication issues, or interrupt the flow of therapy, etc etc, but when a mix up like that occurs with an already vulnerable patient I can see how you may have a potential disaster on hand.

At the time the patient in this case turned up for their wrongly scheduled appointment my Psychiatrist was already with another patient and couldn't just leave session. So not only do you have a situation of a wrong appointment booking, the patient also turns up to find out the Clinician they're supposed to be seeing is busy taking care of someone else - that someone else not being them. I can see how that would make a vulnerable and depressed person feel in regards to it being taken as a personal slight or injury.

 

[birchswing]

well this is where it is important to weigh up the risks and benefits of psychiatric hospitalization when formulating a management plan. Hospitalization has not been shown to be an effective intervention for suicide prevention. Where it has its place is in removing someone from a stressful situation that is driving their suicidality, or for close observation where an appropriate level of observation is being provided. Hospitalization obviously has negative consequences - it can be traumatic, deprive someone of their liberties, cost money, take time out of someone's life that could cause them to lose their job or affect their studies, is stigmatizing, expose them to a counter-therapeutic environment, make them less likely to seek care in the future, have implications on their eligibility for particular kinds of employment, implications for their ability to have custody of their children etc etc.

From a medicolegal perspective however you are much more likely to end up in court for a patient suicide, than for wrongful commitment, and things are much less likely to go in your favor when there is a dead body involved.

It's always been interesting to me how much mental health care providers talk about the unpleasantness of mental hospitals. I've never been to one. There were times I thought I needed to (not for suicidality), but I was encouraged not to. My therapist and I were once talking about how you decide if a patient needs hospitalization; I can't remember the context. He said something that surprised me. He said that it's the end of therapy. And I thought he meant that the therapist would discharge the patient if he had to hospitalize him. And he said, no, that it was that a patient wouldn't want to see a therapist if he forced him to be hospitalized. I said that I wasn't sure if I would feel that way, and he said, well you've never been to a psychiatric hospital against your will.

I wonder why the threshold between not being hospitalized and being hospitalized has to be this huge wall rather than, well, a threshold. It's like if you go to a mental hospital you're admitting some huge defeat and it carries this huge seriousness. I envision a reality (I talked about this in another thread) in which mental health support is more pervasive. You could just walk into an urgent care clinic to talk to a mental health care provider the same as seeing as any other urgent care provider. Or community service boards could open up in that way. Or hospitals could have evaluation centers beyond just the emergency room. As far as I know, if you want to walk into a hospital because you're concerned about your mental health, there's no choice but the ER. And good luck getting help from a community services board (in my experience--although I do live in the state where Creigh Deeds' son was failed by the same community services boards I've also found to either be incompetent or underfunded).

 

[Ceke2002]

It's always been interesting to me how much mental health care providers talk about the unpleasantness of mental hospitals. I've never been to one. There were times I thought I needed to (not for suicidality), but I was encouraged not to. My therapist and I were once talking about how you decide if a patient needs hospitalization; I can't remember the context. He said something that surprised me. He said that it's the end of therapy. And I thought he meant that the therapist would discharge the patient if he had to hospitalize him. And he said, no, that it was that a patient wouldn't want to see a therapist if he forced him to be hospitalized. I said that I wasn't sure if I would feel that way, and he said, well you've never been to a psychiatric hospital against your will.

I wonder why the threshold between not being hospitalized and being hospitalized has to be this huge wall rather than, well, a threshold. It's like if you go to a mental hospital you're admitting some huge defeat and it carries this huge seriousness. I envision a reality (I talked about this in another thread) in which mental health support is more pervasive. You could just walk into an urgent care clinic to talk to a mental health care provider the same as seeing as any other urgent care provider. Or community service boards could open up in that way. Or hospitals could have evaluation centers beyond just the emergency room. As far as I know, if you want to walk into a hospital because you're concerned about your mental health, there's no choice but the ER. And good luck getting help from a community services board (in my experience--although I do live in the state where Creigh Deeds' son was failed by the same community services boards I've also found to either be incompetent or underfunded).

I'm not sure if it was in direct response to this case, but the clinic involved has had a walk in crisis service available for several years now. My Psychiatrist would have been the Clinic Director at the time of this inquest, although the patient's death occurred a few years earlier, so I would imagine he would have implemented a number of the recommended changes. In terms of forced hospitalisation versus therapy, I think your therapist has something there when he talks about forcing hospitalisation on someone potentially damaging the chance of establishing a longer term therapeutic bond. In this particular case obviously the attending physician thought establishing a longer term therapeutic framework was more important than rushing to detain someone who didn't actually meet the criteria for detention as set out in the Mental Health Act of South Australia.

The system here though is still pretty screwed up in terms of what Psychiatrists are expected to achieve. On the one hand you have someone getting told they made a misjudgement by not placing a patient under an involuntary inpatient treatment order, and then the Government suits that hold the purse strings for the clinic turn around and demand to know why the same clinician hasn't just turfed certain patients out the door, because they should all be better now and you're wasting resources. But as Splik said, from a medicolegal point of view once there's a body involved you're pretty much screwed.

 

[DrBacchi]

Had to google coronial inquest. Interesting reads, but these seem to be more descriptive than analytical (in a medical sense).

Is this the one you quoted Ceke2002? http://www.courts.sa.gov.au/Coroner...ings/Attachments/584/MUNDY Michaela Jayne.pdf

 

[smalltownpsych]

I didn't really make it clear but this doesn't sound like a patient that I would not hospitalize involuntary. Of course, I don't have to go through a lot of hoops to make that happen which makes it easier to work with a suicidal patient. In other words, I can monitor the risk and if it escalates, then act to keep them safe. It might just mean an overnight stay at our hospital. Not exactly traumatic and patients often agree to getting a good nights sleep or two away from it all. I also have experience in another state working with patients who were at high risk for suicide but had no ability to hospitalize without going through a lot of hoops and traumatizing the patient. This was even when patient wanted to be kept safe. I actually think the voluntary/involuntary issue becomes too much of the focus much of the time. If we have a good safe treatment option that makes sense, then patients will want it and legal proceedings are probably not going to be needed for the non-psychotic. In fact, the depressed and suicidal patients tend to be pretty compliant. If we lock them up in a torturous place and go through an adversarial legal system, of course they will resist.

 

[Ceke2002]

Had to google coronial inquest. Interesting reads, but these seem to be more descriptive than analytical (in a medical sense).

Is this the one you quoted Ceke2002? http://www.courts.sa.gov.au/CoronersFindings/Lists/Coroners Findings/Attachments/584/MUNDY Michaela Jayne.pdf

No it's not. I've already said I wont say which inquest it was to protect the names of certain people (namely my Psychiatrist who is not on here as a member, and whose identity I've therefore chosen to keep confidential). And yeah some inquests are more interesting than others, the ones that aren't so clear cut, or that open up some questions for example, others are a tad pedestrian and of course the public records aren't going to have anything too juicy in way of detail.

 

[Ceke2002]

I didn't really make it clear but this doesn't sound like a patient that I would not hospitalize involuntary. Of course, I don't have to go through a lot of hoops to make that happen which makes it easier to work with a suicidal patient. In other words, I can monitor the risk and if it escalates, then act to keep them safe. It might just mean an overnight stay at our hospital. Not exactly traumatic and patients often agree to getting a good nights sleep or two away from it all. I also have experience in another state working with patients who were at high risk for suicide but had no ability to hospitalize without going through a lot of hoops and traumatizing the patient. This was even when patient wanted to be kept safe. I actually think the voluntary/involuntary issue becomes too much of the focus much of the time. If we have a good safe treatment option that makes sense, then patients will want it and legal proceedings are probably not going to ben needed for the non-psychotic. In fact, the depressed and suicidal patients tend to be pretty compliant. If we lock them up in a torturous place and go through an adversarial legal system, of course they will resist.

The attending physician (I'm going to try to use that term a little more often than just saying 'my Psychiatrist', because whether it was my Psychiatrist or someone else doesn't change the facts of the case) wouldn't have had to jump through a lot of hoops, not in terms of actually making an order of detention, but they would have had to examine the patient. Had the attending physician actually been able to examine the patient they may have formed a different opinion. As it was the GP she saw, the one who initially alerted the Mental Health Triage service, could have made an interim order for detention, which then could have been revoked or upheld within 24 hours by a Psychiatrist. I believe this was before they gave extra mental health training to GPs though.

Obviously the attending physician in this case, having reviewed the patient's notes, felt that establishing a longer term therapeutic relationship was more necessary than detention at that time, although they did make sure to at least have the caseworkers assigned to the case make daily contact, or attempt to, presumably not just to try and rebook an appointment time, but to also establish continuing safety. I do still agree with the attending physician's decision not to detain based on the notes received alone; however, I will admit I'm probably a tad biased in this case, and that's not because it happens to be my Psychiatrist involved in the case. I didn't say this before, because it wasn't part of the actual inquest report, but although I didn't know the patient in question directly, I did know a number of her friends. Nobody who knew her expected her to commit suicide, and they were well aware of her state of mind because this was something she'd been doing for years. She had created this entire dying swan/ethereally glamourised view of suicide type routine that she carried out to the point that no one actually thought she would ever go through with it. I mean there's only so many times you can listen to someone telling you they're going to kill themselves next week, no wait next month, next year, 2 years from now, when I'm 64, before you end up going 'Yeah, sure, whatever'. To say her friends were shocked when she actually did carry out several years worth of threats that seemingly had no actual basis would be an understatement.

There's also the consideration that even if she had been examined and detained by the attending physician, by law all patients under the South Australian mental health act must be given a copy of their detention order, and they must have the reason for the detention clearly explained to them, and then they must be informed of their right to challenge the detention order. All she would have needed to do is go before the Guardianship board and state that she had no intention of harming herself at that time, she had family support in place, she was already utilising strategies to reduce her suicidal thoughts, and she was preparing to voluntarily undergo treatment with a Psychiatrist who was more convenient for her to travel to, and unless the attending physician managed to give some sort of ultimate grandstand performance, chances would have been more than likely that the detention order would have been overturned as it was and she still would have gone on to commit suicide regardless.

 

[Ceke2002]

Had to google coronial inquest. Interesting reads, but these seem to be more descriptive than analytical (in a medical sense).

Is this the one you quoted Ceke2002? http://www.courts.sa.gov.au/CoronersFindings/Lists/Coroners Findings/Attachments/584/MUNDY Michaela Jayne.pdf

I just had a quick look through that particular case, and I must say I'm not entirely surprised that the services provided by CAMHS (child adolescent mental health service) don't seem to have improved all that much since I first tried to access them as a teenager in the 1980s, which is actually a sad indictment on the state of affairs when it comes to child and adolescent mental health services in my state. Although I suppose in this case the service was slightly better than me turning up as a 16 year old, with an already 8 year history of anorexia nervosa, and being assigned to a social worker whose expertise was teenage pregnancy and difficulty with breast feeding. Ah yeah, okay.

 

[smalltownpsych]

The attending was right to assert that establishing a relationship with this patient would be essential for the treatment. I also agree that it would not make sense to detain someone based on notes as my patient/doctor relationship is not established until I have actually met the patient. I don't know if the law would even allow for it to happen and I could be found guilty of unlawful detention or something to that effect. I would hate to be in court trying to defend a decision to detain a patient I had never met.

 

[thoffen]

This is an interesting case and highlights how subjective psychiatric care can be. Reading the record gives you very little impression of the actual individual. Most of the relevant things I was thinking of have been pointed out already, but here are my various thoughts reading this:

First, I struggled to think of differential diagnosis. There is little here to support diagnostic criteria of anything specific, and it is even more impossible to examine personality structure from such a record. The same presentation with a few adjustments could support burgeoning psychotic disorder, MDD, OCD, adjustment, etc. etc. and many missing variables will never be known given the result of the case.

Second, I knew the outcome was either completed suicide or contested involuntary hospitalization given the "matter of public record". That tainted my lens of what happened.

Third, as has been pointed out, even if suicidality were predictable, there are many uncertainties regarding intervention and its efficacy.

Fourth, it is easily possible for people to be at imminent risk and to withhold or report information in such a way as to prevent involuntary commitment.

Fifth, changing from blindness to hearing is an enormous difference in this case. Aside from medical-psychiatric implications, impending loss of vision is likely to be perceived as much more devastating than loss of hearing.

Sixth, there is an interesting medical-legal question already posed RE: whether attending physician who has never seen the patient has a treatment relationship with her and what his responsibilities may be. In these instances, though, I like to think of the ethical implications of the relationship the physician has with the patient regardless of statutes and see if that changes things. Certainly, liability owing to improper involuntary commitment with earnest belief that the patient is at imminent risk would be weighed against the ethical charge of intervening if high imminent risk is judged.

Lastly, where is the family or other contacts in this story? Suicide risk is so often about lack of connection to others in meaningful sense and perception of burdensomeness. A wealth of actual useful diagnostic information could also be gotten from collateral contact. I don't see documented any of this or an exploration of this.

 

[Ceke2002]

This is an interesting case and highlights how subjective psychiatric care can be. Reading the record gives you very little impression of the actual individual. Most of the relevant things I was thinking of have been pointed out already, but here are my various thoughts reading this:

First, I struggled to think of differential diagnosis. There is little here to support diagnostic criteria of anything specific, and it is even more impossible to examine personality structure from such a record. The same presentation with a few adjustments could support burgeoning psychotic disorder, MDD, OCD, adjustment, etc. etc. and many missing variables will never be known given the result of the case.

Second, I knew the outcome was either completed suicide or contested involuntary hospitalization given the "matter of public record". That tainted my lens of what happened.

Third, as has been pointed out, even if suicidality were predictable, there are many uncertainties regarding intervention and its efficacy.

Fourth, it is easily possible for people to be at imminent risk and to withhold or report information in such a way as to prevent involuntary commitment.

Fifth, changing from blindness to hearing is an enormous difference in this case. Aside from medical-psychiatric implications, impending loss of vision is likely to be perceived as much more devastating than loss of hearing.

Sixth, there is an interesting medical-legal question already posed RE: whether attending physician who has never seen the patient has a treatment relationship with her and what his responsibilities may be. In these instances, though, I like to think of the ethical implications of the relationship the physician has with the patient regardless of statutes and see if that changes things. Certainly, liability owing to improper involuntary commitment with earnest belief that the patient is at imminent risk would be weighed against the ethical charge of intervening if high imminent risk is judged.

Lastly, where is the family or other contacts in this story? Suicide risk is so often about lack of connection to others in meaningful sense and perception of burdensomeness. A wealth of actual useful diagnostic information could also be gotten from collateral contact. I don't see documented any of this or an exploration of this.

Good point on the family, there's not a lot in the report specifically, the patient makes no mention in the document she wrote outlining her reasons and ability to commit suicide regarding feeling burdensome on her family, or feeling alone, or not having a good network of support. When she handed the document to the Doctor who made the initial contact with the Crisis Intervention Unit he did inform her that he also intended to contact her father to inform him of his concerns, and that he had contacted the Crisis Unit, and she was agreeable to this. During the home assessment interview with the case workers the patient's father did request to be present, but was eventually convinced to allow the workers to speak to his daughter alone, so it sounds as if he was concerned enough to want to know what was going on.

I must admit I changed the going blind portion of the report to deafness, because I was trying to think what would be an equally debilitating and distressing loss of a sense that might trigger a reactive depression in a potentially vulnerable person, and because I happen to suffer from a progressive hearing loss condition (otosclerosis), which I'm already partially deaf from, I kind of just went with something like that, because for me (especially as someone who loves music, and sounds of nature, and rhythms and dance) the idea that one day I won't be able to hear, or I'll only be able to hear through artificial aids is something I do find, I wouldn't say 'devastating', but something I don't like to really think about too much lets put it that way.

There is one thing in the report that I neglected to mention when I updated the outcome of the case (I had an inkling people would probably assume completed suicide with it being a matter of public record) and that is some of the criticism (although to me it didn't really read as 'criticism' more like an expert simply stating a disagreement with certain findings) that was leveled at the attending physician was tempered with the expert witness saying that he did feel the attending physicians assessment of the case was coloured by the environment he worked in. The Crisis Intervention Unit (that's not the actual title by the way, again I'm trying to protect identities by making some minor adjustments here and there) generally treats the sickest of the sick, those who really are in imminent danger of harming themselves or others. So when you have a patient being assessed by case workers who are writing notes like (paraphrased) 'Hard to determine exact level of risk; however patient reports they are happy to wait for another appointment, no risk at present', and the rest of the notes you're presented with paint a picture of a young person with chronic suicidality and no immediate plan in place, or a plan in place that has been stated numerous times to be something that would take place in the future, and in the meantime you've got a severely psychotic bipolar patient climbing the walls in one room, and you're arranging an immediate involuntary transfer to hospital for a floridly psychotic patient who's threatening serious harm on people in the other, and you can kind of see how that sort of environment would lead you to review this patient's notes and think 'Oh, okay, well clearly she needs help, but we've got time to work with her'.

The attending physician in this case at some point did start to take on cases that were outside the scope of the crisis intervention centre, but which would have otherwise seen patients who were still very much in need of treatment slip through the cracks simply because they hadn't quite crossed that line between 'unwell' and 'get thee to a psych ward stat'. I was one of those patients that was taken on by him after initially being rejected from the crisis intervention centre's services because I was 'sick but not sick enough'. He ended up gathering a bit of a collection of us over the years so I believe, the ladies at the front desk reception used to affectionately refer to us as 'J's specials'. I have always wondered if him taking on more long term care type patients (complex cases especially), against clinic policy, was a result of the outcome of this particular case. Like I said previously though I've never spoken to him about the case, but I do know he demands a high level of excellence from himself in terms of the care he gives to patients so it wouldn't surprise me if a case like this did make him think 'something is lacking in this system, I need to do more'.

 

[michaelrack]

I also agree that it would not make sense to detain someone based on notes as my patient/doctor relationship is not established until I have actually met the patient. I don't know if the law would even allow for it to happen and I could be found guilty of unlawful detention or something to that effect. .

A patient/doctor relationship can be established before meeting the pt in many circumstances. Sometimes it is necessary to detain someone before seeing them (example: inpt psychiatrist accepts a patient with a recent Sucide attempt from an outlying ER . Pt arrives by ambulance at 11 pm at night and immediately asks to leave. That psychiatrist would be perfectly justified in using a 72 hr hold in my state).

 

[Ceke2002]

A patient/doctor relationship can be established before meeting the pt in many circumstances. Sometimes it is necessary to detain someone before seeing them (example: inpt psychiatrist accepts a patient with a recent Sucide attempt from an outlying ER . Pt arrives by ambulance at 11 pm at night and immediately asks to leave. That psychiatrist would be perfectly justified in using a 72 hr hold in my state).

If you scroll up I copy/pasted the relevant laws in South Australia as they pertain to level 1 Involuntary Inpatient Treatment Orders, which is what the patient in this case would have been placed on initially had she been detained. You will see the law under the mental health act states that the patient must be examined by a Doctor, and then examined again within 24 hours by a separate Doctor who can then confirm or revoke the order. Any Doctor can make a detention order, it doesn't have to be a Psychiatrist who does it initially it just has to be a Psychiatrist who confirms or revokes the initial order. When my Mother was placed on a Level 1 ITO for delirium the initial order to detain was given by a Orthopaedic registrar, who then had the order confirmed by one of the hospital Psychiatrists.

 

[Ceke2002]

So in terms of predicting suicide what can we learn from this particular case? Apart from you can't always predict when someone is going to suicide.

 

[smalltownpsych]

A patient/doctor relationship can be established before meeting the pt in many circumstances. Sometimes it is necessary to detain someone before seeing them (example: inpt psychiatrist accepts a patient with a recent Sucide attempt from an outlying ER . Pt arrives by ambulance at 11 pm at night and immediately asks to leave. That psychiatrist would be perfectly justified in using a 72 hr hold in my state).

Good point and I have told the EM docs to hold a patient who is intoxicated and I will check on them in the am. In our state, any physician can detain for up to 24 hours in a crisis so the one initiating the detention who has examined the patient would be the EM doc and they are consulting me until I see the patient. This case was a bit different as they are in the community. As I think about it more, they become our patient once they come to our facility whether I am there or not. That can be a bit sticky at times as I found out yesterday in court. Court seemed willing to accept that I don't run the other departments of the hospital but there is a presumed relationship just because I work at the same corporate entity.

 

[splik]

So in terms of predicting suicide what can we learn from this particular case? Apart from you can't always predict when someone is going to suicide.

You can never ever ever predict when someone is going to commit suicide.

 

[Ceke2002]

You can never ever ever predict when someone is going to commit suicide.

Good point, and true, of course very true. I suppose I was thinking more from the point of view of having risk management and assessment type stuff in place would at least reduce risk factors to a degree, or why bother having them in place at all. Although I guess then you're still just identifying who's a suicide risk, which does equate to a completed act of suicide. I suppose this is a side of Psychiatry that a lot of people don't really think about, the fact that sometimes patient do die, and despite you're (all encompassing 'you're) best efforts there are going to be times when there's not a darn thing you can do about it. I mean people think of that sort of stuff with Doctors working in the ED, or General Practice, or IM, but I think to a lot of people they don't really stop and think 'well you know Psychiatrists have to face dealing with patient deaths as well'. And of course on the other side of that coin it's easy enough for someone to see an ED Doctor shock someone's heart back to rhythm and think they're a hero for saving someone's life, but a Psychiatrist uses well chosen words and empathy to convince a suicidal person to live another day and the reaction seems to be more like 'meh'.