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A defensible chart for the possibly suicidal patient

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migm

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What needs documenting on a patient being evaluated for potential suicide? How do you handle a suicidal patient who declines to 'allow' you to contact family member for collateral? Is documenting "pt states they are not suicidal" sufficient?

My vignette: I had a patient come in to the ED for longstanding but undiagnosed AH. He had a complicating history of IVDU. He was in the ED for a while as it took time to get to him, eventually got belligerent and demanded discharge. He reported no suicidal thoughts. Somewhat surprisingly he ended up attempting suicide the following day. Is my chart stating "several month history of AH, but no SI" defensible if the patient had completed his suicide attempt?
 

Venko

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I'm sorry you went through this. Before EM, I did one year of psych residency and I can tell you it was mentally more taxing and at times more scary than my EM cases.

I am not a lawyer and have no legal background other than what I have been told so my comment is only that good...

It seems to me you are asking what are the key elements of a safety evaluation for someone for whom suicidality is a consideration or is being raised.

When suicidality is a realistic consideration, it is important to evaluate the patient for
1. organic causes (brain tumor, seizures, intoxication, dementia, etc)
2. Serious self injury (overdose, strangulation, major cuts)
3. Medication side effects as psychotropic medications have many side effects that may warrant medical admission first.
4. Incidental emergent medical issues (broken ankle from running from cops, DKA because they stopped taking their meds from negative symptoms of schizophrenia)

Once these have been cleared then you're really at the point of assessing ability to go home versus requiring psychiatric admission.

To do this, I always remember my teachers stressing that unlike other encounters in medicine, the suicidal patient does not share the same goal as us. In fact we as their doc and they as the patient are at complete odds with each other and we must carry a healthy sense of skepticism about what they tell us.

To that end, we always need collateral information to corroborate and or time for observation. I have gone to family members before and said, I am not permitted to give any information about anyone but I am permitted to receive any information that you want to provide me. I have told people that in the absence of collateral information I would not be able to let them leave and would put them on a hold for safety concerns.

There were times when the person truly had no one in their social structure and not only is this more risky for suicidal behaviors but very difficult to feel comfortable discharging. I sometimes watched these people for a day or two before discharge to make be able to add some more clues to whether they are safe or not safe.

I don't know if that helps, and either way I'm sorry for the situation. I know that you did your best and regardless of where the truth may lie, you feel partly responsible for letting his go and him dying. I've been there. It's a terrible feeling.

The next time you see a psychiatrist...give them a hug...in my opinion the job sucks.


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gman33

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I'd argue that a drug abuser hallucinating has no capacity to make decisions.

If there was a bad outcome, that would be a tough case to defend.
 

migm

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Gman: agree that's a concern, but he has no psychosis on exam, no thought bloxking, he is calm and linear but complaining of months of symptoms . Do you then commit him when he wants to leave? And yes AH was shorthand for auditory hallucinations, sorry it was murky
 

Daiphon

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Gman: agree that's a concern, but he has no psychosis on exam, no thought bloxking, he is calm and linear but complaining of months of symptoms . Do you then commit him when he wants to leave? And yes AH was shorthand for auditory hallucinations, sorry it was murky
I'm not sure you can:

Involuntary admission = threat to self, others, or unable to comprehend disease process leading to likely harm to self or others.

AH alone, and your exam well documented in the capacity realm, IMHO is insufficient. One could argue that if AH were command-type and pt refuses to provide collaterals, then 1) may not understand ramifications of disease and 2) may have inadequate safety plan... so maybe holdable for a psych eval.

This is a sticky wicket. Not illegal to be crazy, just illegal to be dangerously crazy...

Semper Brunneis Pallium
 
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Promethean

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Auditory hallucinations are neither as rare nor as pathological as they are made out to be in popular media. Simply experiencing auditory hallucinations is not sufficient to legally deprive a person of their liberty and legal rights. Not even if they also use drugs, assuming that they are not presently dangerously impaired. I've have experienced auditory hallucinations myself, when I've been very tired or stressed. I've discussed the matter with friends who have had similar experiences and who are very hesitant to tell anyone, especially a doctor, about it, lest they be branded as dangerously crazy.

OP, If you didn't feel that the person was an immanent danger to themselves or others, then you would have had no legal right to intervene more aggressively.

You can't involuntarily commit everyone who presents with psychiatric anomalies. There'd be no one left to staff the psych ward, for one thing. The best you can do is what you did... assess the patient, determine to the best of your ability whether they are likely to harm themselves, whether they have a plan/intent. No matter how thorough your exam and your charting, some people will still put themselves in mortal danger after your encounter with them, and there is no way to absolutely avoid that.
 
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GeneralVeers

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I document no SI, HI, hallucinations. I document "answers all questions appropriately" and "no signs of acute intoxication".

If I took away decision making capacity from every patient on drugs in my inner-city Vegas ED, I would be able to discharge maybe 10% of patients on a shift.
 
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Venko

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Gman: agree that's a concern, but he has no psychosis on exam, no thought bloxking, he is calm and linear but complaining of months of symptoms . Do you then commit him when he wants to leave? And yes AH was shorthand for auditory hallucinations, sorry it was murky

Auditory hallucinations IS psychosis.

Doesn't mean holdable, or lacks capacity though.


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Promethean

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Auditory hallucinations IS psychosis.

Doesn't mean holdable, or lacks capacity though.
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Psychosis necessarily includes failure of reality testing. (While sober) I've had both auditory and visual hallucinations, but I was not psychotic because I retained the real-time ability to discern that I was having a sensory experience that was not congruent with consensus reality.

Psychosis may present with hallucinations. But all hallucinations are not manifestations of psychosis. You've almost certainly experienced hallucinations. Tinnitus. Seeing things "in the corner of your eye" that weren't there. I've chosen approachable examples, but I think that the experience of "hearing voices" that aren't there, at least on occasion, is not much less prevalent than these.
 

gman33

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Gman: agree that's a concern, but he has no psychosis on exam, no thought bloxking, he is calm and linear but complaining of months of symptoms . Do you then commit him when he wants to leave? And yes AH was shorthand for auditory hallucinations, sorry it was murky

With that additional clarification you can make a better case for capacity.

I agree that mental illness and/or drugs doesn't remove capacity, but you need to be careful about what you (and the nurses) document.

There are cases when I have a pretty clean chart, but someone else writes some other garbage that makes it all look bad.

A case like this there may be a nursing note about what a raging, intoxicated a-hole this guy was.

My only point was that the potentially intoxicated psych patient is tough to convincingly document that capacity is present.
 
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Venko

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Psychosis necessarily includes failure of reality testing. (While sober) I've had both auditory and visual hallucinations, but I was not psychotic because I retained the real-time ability to discern that I was having a sensory experience that was not congruent with consensus reality.

Psychosis may present with hallucinations. But all hallucinations are not manifestations of psychosis. You've almost certainly experienced hallucinations. Tinnitus. Seeing things "in the corner of your eye" that weren't there. I've chosen approachable examples, but I think that the experience of "hearing voices" that aren't there, at least on occasion, is not much less prevalent than these.

Sorry buddy, I went to a different type of medical school. We did not consider tinnitus an auditory hallucination.

But if you would like to include it...well then since it is a misperception of reality then it would be a psychosis.

Maybe I'm unique...it won't be the first time.
 
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BAM!

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What needs documenting on a patient being evaluated for potential suicide? How do you handle a suicidal patient who declines to 'allow' you to contact family member for collateral? Is documenting "pt states they are not suicidal" sufficient?

My vignette: I had a patient come in to the ED for longstanding but undiagnosed AH. He had a complicating history of IVDU. He was in the ED for a while as it took time to get to him, eventually got belligerent and demanded discharge. He reported no suicidal thoughts. Somewhat surprisingly he ended up attempting suicide the following day. Is my chart stating "several month history of AH, but no SI" defensible if the patient had completed his suicide attempt?

Make sure you write "NO SI/HI."
Obviously make sure you don't write "He eventually became belligerent, and I discharged him."
It's not surprising to me that he attempted suicide the following day given the way you phrased your message.

Sometimes it's helpful to say the case out loud to yourself when deciding if safe to discharge. Here goes:
26 year old M with auditory hallucinations. No prior psychiatric history or outpatient psychiatrist. Pt is belligerent and uncooperative.

This seems easy to defend placing a temporary hold to let him chill out and for a psych eval. Remember, he won't be the one suing you when he kills himself. it'll be his family.

What was the CC? Why was he there in the first place? Would he contract for safety?


Here's a case from MMI which may be helpful:
Would you discharge a patient who refuses to sign a “No Harm Contract”?
Patient hangs self in jail following ED evaluation
HAWKINS v. County of Lincoln, Nebraska
Facts: An adult male slashes his wrist when arrested following a police chase and is taken to the ED for a mental health evaluation prior to booking. His risk factors include depression, bipolar disorder, legal problems, impulsivity, prior suicide attempt, recently failed relationship, unemployment and PTSD. His wounds are superficial and require no sutures. He is evaluated by a social worker. A psychiatrist is consulted by phone and believes him to be safe to go to jail. When presented with his Discharge Instructions and a No Harm Contract, he refuses to sign the latter, yet is discharged - only 25 minutes after arrival. There is no documentation of any discussion with the patient or amongst the staff about his refusal to sign. Two days later he hangs himself in his cell.
Plaintiff: My brother’s life was in danger. He was telling you he would kill himself. You knew that or you wouldn’t have asked him to sign the No Harm Contract. He told you that he would only sign if he were released from custody, and that was not an option. You should have admitted him. All you did was call the jail and tell the jailer to put him “naked in a bare cell.” A jail is for incarceration, not suicide prevention.
Defense: He was safe to go to jail. We evaluated your brother properly. In fact we did a triage evaluation, vital signs, registration, financial agreement, nursing assessment, an 11-item "ED Mental Health Evaluation,” a complete history (including HPI, PFSH, and review of 8 systems), exam of 10 systems including neuro and psych, dressing of wounds, telephone conversations with a psychiatrist and Lincoln County jailer, complete medical decision making and treatment plan, DC instructions, a "No Harm Contract" and dictated a report prior to transfer - all in 25 minutes.
Result: Settlement for undisclosed amount.
Takeaway: When evaluating suicidal patients, take and document a complete history, then pay attention to what you’ve found. Most such patients in the typical ED can be safely discharged. Some with a host of risk factors deserve more than a 25 minute evaluation - especially when they then refuse to sign a “No Harm Contract.” Even if they do sign, the form is not what protects you but the process, discussion and documentation that accompanies it. Reference ->
 

Birdstrike

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What needs documenting on a patient being evaluated for potential suicide? How do you handle a suicidal patient who declines to 'allow' you to contact family member for collateral? Is documenting "pt states they are not suicidal" sufficient?

My vignette: I had a patient come in to the ED for longstanding but undiagnosed AH. He had a complicating history of IVDU. He was in the ED for a while as it took time to get to him, eventually got belligerent and demanded discharge. He reported no suicidal thoughts. Somewhat surprisingly he ended up attempting suicide the following day. Is my chart stating "several month history of AH, but no SI" defensible if the patient had completed his suicide attempt?

Just document, 1- no suicidal or homicidal ideations, 2- that there's a follow up plan in place (along with what it is) and 3- patient told to call 911 immediately if such thoughts develop. That's all you can do. You can't commit every non-suicidal non-homicidal drug user and schizophrenic. You're going to see these patients constantly.

That being said, if you have reason to believe some will kill their self or another, then document why and commit them without hesitation. If not, document the three things above and move on.


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migm

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Make sure you write "NO SI/HI."
Obviously make sure you don't write "He eventually became belligerent, and I discharged him."
It's not surprising to me that he attempted suicide the following day given the way you phrased your message.

Sometimes it's helpful to say the case out loud to yourself when deciding if safe to discharge. Here goes:
26 year old M with auditory hallucinations. No prior psychiatric history or outpatient psychiatrist. Pt is belligerent and uncooperative.

This seems easy to defend placing a temporary hold to let him chill out and for a psych eval. Remember, he won't be the one suing you when he kills himself. it'll be his family.

What was the CC? Why was he there in the first place? Would he contract for safety?

I did write exactly that. The patient came in asking for evaluation for several months of auditory hallucinations. He denied any suicidal thoughts in the presence of his partner. While obtaining a medical workup for his hallucinations, he decided he wanted to leave. When it took a few minutes to contact me, he became angry and I was called that the patient was being belligerent about wanting to go. Having no reason to hold him involuntarily, he was discharged. I don't see why documenting this has any effect on my medicolegal risk? My assessment was this patient was not committable, that he was requesting assistance, and I was in process of doing so when he changes his mind. If he had been in the non-locked part of the ED ( he was only placed in same because of a psych complaint) he could have gotten up and walked out on his own. The only physical thing stopping him was where the triage nurse placed him and the door (well, and a lot of police officers too). With regards to contracting for safety, I don't think that does anything to reduce my risk additionally in this case. The patient denied suicidal ideation. His family member was in agreement and without concerns.
 

BAM!

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I did write exactly that. The patient came in asking for evaluation for several months of auditory hallucinations. He denied any suicidal thoughts in the presence of his partner. While obtaining a medical workup for his hallucinations, he decided he wanted to leave. When it took a few minutes to contact me, he became angry and I was called that the patient was being belligerent about wanting to go. Having no reason to hold him involuntarily, he was discharged. I don't see why documenting this has any effect on my medicolegal risk? My assessment was this patient was not committable, that he was requesting assistance, and I was in process of doing so when he changes his mind. If he had been in the non-locked part of the ED ( he was only placed in same because of a psych complaint) he could have gotten up and walked out on his own. The only physical thing stopping him was where the triage nurse placed him and the door (well, and a lot of police officers too). With regards to contracting for safety, I don't think that does anything to reduce my risk additionally in this case. The patient denied suicidal ideation. His family member was in agreement and without concerns.

All good thoughts and I completely understand.

However here are some alternate viewpoints:
- The nursing staff thought he was unsafe to leave and thus placed him into the psych lockdown unit of your ED.
- Apparently a bunch of police officers agreed to place him into the psych ED.
- He was actively hallucinating and acting belligerent after only waiting a few minutes. Could this be interpreted as not having normal mental capacity? Could this be interpreted as him being irrational and perhaps gravely disabled?
- The fact is, regardless of standards of practice, you were wrong in discharging him; he tried to commit suicide the next day.
- His partner is not going to sue you. His mother, sister, or children will.
- Is it safe to release a belligerent person onto the streets? What if he injures someone else?

You don't want to document things that make you look bad. You look bad when you document that he was belligerent and hallucinating and you let him go home. You look bad when he then attempts suicide the next day. You look bad if he doesn't agree to come back if feeling like hurting himself, and then he hurts himself. Remember, standard of care is not decided by academic physicians and textbooks. It is decided by a panel of layperson jurors. Make yourself look good for them.

What I like to do in this situation is remember that time is your friend. Reason with him, have him chill out for an hour or two. Work with him such that he can PROVE to you that he is a capable, cooperative, non-belligerent person. This will make your chart much cleaner, and maybe give you more time to work up his medical auditory hallucinations. Give him some food. OR snow the belligerent patient. When he wakes up, he'll likely be more calm.
 

migm

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All good thoughts and I completely understand.

However here are some alternate viewpoints:
- The nursing staff thought he was unsafe to leave and thus placed him into the psych lockdown unit of your ED.
- Apparently a bunch of police officers agreed to place him into the psych ED.
- He was actively hallucinating and acting belligerent after only waiting a few minutes. Could this be interpreted as not having normal mental capacity? Could this be interpreted as him being irrational and perhaps gravely disabled?
- The fact is, regardless of standards of practice, you were wrong in discharging him; he tried to commit suicide the next day.
- His partner is not going to sue you. His mother, sister, or children will.
- Is it safe to release a belligerent person onto the streets? What if he injures someone else?

You don't want to document things that make you look bad. You look bad when you document that he was belligerent and hallucinating and you let him go home. You look bad when he then attempts suicide the next day. You look bad if he doesn't agree to come back if feeling like hurting himself, and then he hurts himself. Remember, standard of care is not decided by academic physicians and textbooks. It is decided by a panel of layperson jurors. Make yourself look good for them.

What I like to do in this situation is remember that time is your friend. Reason with him, have him chill out for an hour or two. Work with him such that he can PROVE to you that he is a capable, cooperative, non-belligerent person. This will make your chart much cleaner, and maybe give you more time to work up his medical auditory hallucinations. Give him some food. OR snow the belligerent patient. When he wakes up, he'll likely be more calm.

All psych complaints that are felt by the nurses to not require to go to the main side are placed in the psych unit - complete with locked doors and guards. It is a fishbowl of the very crazy and the safely dischargeable. Police are always present for this reason. My comment that there were police there is nothing more than this - they are there for safety, they have no part in assessing or figuring out who goes in there, who can leave or who can stay. You assume he was actively hallucinating - and that he was only waiting for a few minutes. In fact, by the time I saw the patient he had been in the ed for 2.5 hours waiting to be seen by a provider. He agreed calmly with my plan of care and wanted help. I interpreted his wanting to leave as impatience with the system, probably wanting to get high, and potentially withdrawal although again he was not clinically responding to hallucinations, intoxicated, had no thought blocking, nor had disorganized or irrational thoughts or actions when I saw him. Wanting to get high is not committable, nor is having hallucinations. The counterargument - is it safe to hold a person against their will when they agree that all they want is to leave and don't have thoughts of hurting anyone else? They've changed their minds - the question is do they meet the definition of something more than just a voluntary evaluation. Does demanding to leave + report of auditory hallucinations automatically mean hold the person against their will? What if theyre just belligerent but not actively hallucinating? I don't know.

That he attempted suicide the next day is the only reason why I'm interested in this. I am sure that the last thing in the chart is Dr. Migm said the belligerent patient could go and the next thing being suicide or an attempt is not great. Some people are going to slip through the cracks. I am questioning the defensibility of same. I appreciate your points you are making but want to clarify what may be unclear.
 
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