Case of Vague Homicidal Ideation

[AD04]

Hypothetical case:

34 year old black male comes to the ED with complaints of vague homicidal ideation. No specific target. Denied all other psychiatric complaints. Medically cleared by ED physician.

He was last admitted in the unit 2 weeks ago for "schizophrenia". In the previous admission, he claimed to hear voices telling him to kill himself and endorsed suicidal ideation without plan. He is well-known as a frequently flyer, almost always with the same complaints. Every time he is in the ED, he is positive for something in the urine drug screen. He has extensive legal history with the police.

He appears well-kempt, with color-coordinated outfits and neatly trimmed beard. His speech was goal-oriented, not tangential or disorganized. He gets irritated easily when he doesn't get what he wants.

1. Would insurance cover for this admission?

2. Would you admit?

The reason for this case is from the recent news:

A few days ago, Alexander Bonds went to the hospital with homicidal thoughts. He was then discharged from the ED after getting injections. A few days post-discharge, he walked up to a police car and shot the officer point-blank in the head. The officer died. He has an extensive history with the law, which resulted in long-standing grudge against cops.

3. Would the psychiatrist that cleared Alexander be reamed in court (assuming the chief complaint was vague homicidal ideation)? Not only did the patient kill someone, he killed a cop.

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[splik]

Youre bringing up 2 different scenarios. If a patient presents with HI (or even SI) and there is no evidence of mental illness then this doesn't fall under the remit of psychiatry. If you are concerned that there are potentially forseeable victims then depending on your state laws you may have a responsibility to call the police or warn said victims (though the former typically, but not always, discharges a duty to inform the latter), but we don't have a role in treating people who don't have mental illness or suspected mental illness. Patients dont usually get admitted without prior-authorization for the stay and HI usually gets covered. Patients with HI should not usually be admitted voluntarily, and involuntarily hospital admissions usually get covered more easily. If multiple prior hospitalizations have established documentation of no mental illness, that treatment was not indicated, and if you have enough evidence to suggest malingering, dissimulation, or other feigning/exaggeration of symptoms is likely then you would document this as well as the risks and benefits of hospitalizing vs. not. I have kicked my pts out of the ED with HI and SI that were clearly BSing including patients who threatened to kill themselves outside the hospital if discharged. As always, documentation of rationale is key. Clearly you have a negative countertransference towards this patients; do not let that blindside you to the treatment needs of the patient, underestimate the risk of violence, or minimize the presence of mental disorder. At the very least it sounds like he has a substance-use disorder.

In the second scenario someone with a mental disorder reports HI and then kills a cop. Not sure what you mean by "named in court" but the family of the perpetrator could (and almost certainly will) file suit against the hospital/psychiatrist/med student/whomever for negligence. Whether the suit is successful depends on whether they are able to show that this was foreseeable, and that a failure to hospitalize substantially contributed to the incident.

 

[AD04]

After reading more about the patient in the second case, I can see why you see them as two different scenarios. He really does have a mental illness.

But hypothetically --

Let's assume the psychiatrist knew what he was doing and determined that the patient did not meet criteria for admission (i.e. he was malingering) and documented his reasons. Let's say this psychiatrist was right, patient really was malingering.

However, patient's chart reveals history of schizophrenia and antipsychotic use. Patient is a frequent flyer -- usually because he is voluntarily homeless and uses his disability money on drugs -- and by being persistent enough, one of the many psychiatrists he meets will give him a mental disorder diagnosis. He is started on antipsychotics. Now schizophrenia and antipsychotics are part of his history.

After the first admission, other psychiatrists admit him under the same diagnosis (out of convenience) and starts him on antipsychotics. After a while, he's even developed preferences. He's allergic to haldol but seroquel works very well.

The patient was salty about not being admitted. He took it out on a cop. Could your notes really stand in your defense when the mayor / police department / deceased cop's family is out for blood? Could your notes really stand in your defense against the documented history of mental disorder (even though it is a diagnosis of convenience)? Especially when you're judged by civilians rather than by your professional peers?

Or is it better to play it safe and take in anyone with suicidal / homicidal thoughts (no matter how vague)?

 

[splik]

well you illustrate the point of what a massive own goal it is to admit patients who should not be admitted because you redefine the standard of care. By the way it is not "convenience" to label as schizophrenic someone you know not to be so, it is fraud pure and simple. the mayor and police department can't sue you ordinarily. Psychiatrists who do this should be ashamed of themselves.

You have to have a stake in claim to file a law suit, if you aren't directly affected then you can't sue. There was a famous case of young college student with schizophrenia who sued his psychiatrist successfully after he opened fire on a bunch of people (though the psychiatrist provided excellent care). In order for the police department to sue the psychiatrist, they would have to prove that the psychiatrist had a duty of care to the police department (which we do not). The family of the dead police officer could sue if they could prove that the psychiatrist had a duty to protect the police officer which would be quite a stretch (but possible, see Lipari v. Sears, Roebuck & Co.) The patient's family would most easily be able to file suit since the psychiatrist did have a duty of care to the patient and he was killed. The big thing here will be whether this was foreseeable or not. Psychiatrists cant predict violence, but we can say whether there are enough red flags that we'd be concerned to let someone leave the hospital. This is particularly a challenge with these revolving door patients.

Another point is there is such a thing as partial malingering. Most malingerers are mentally ill - that's how they learned to malinger. They just not been currently symptomatic at the time of presentation. So just because someone has a hx of schizophrenia if they are presenting, clearly feigning symptoms, and do not meet criteria for hospitalization/commitment then as long as you carefully document your reasoning, you should not be concerned about it.Remember this america, people can sue you for whatever they like. As a psychiatrist over a 40yr career you have on average a 100% chance of being sued.

If a patient does not meet criteria for hospitalization or civil commitment (i.e. they do not have a mental disorder that renders them dangerous etc.) then if you discharge them and they go out and kill someone (remember most violent people aren't mentally ill, and most violence is not the product of mental disorder - we have no role in this other than the standard psychotherapist's duty to warn/protect) well it would be a pretty weak case for negligence on the grounds of failure to hospitalize/commit if there weren't grounds to do so. The standard of care is typically the "reasonably prudent practitioner standard" - i.e. you did what any reasonable prudent psychiatrist in similar circumstances would have done. Now you may still consider calling the cops and informing them that this patient has made such statements. You've then discharged your duty (which may not exist if there aren't any reasonably identifiable intended victims anyway).

 

[HarryMTieboutMD]

http://ps.psychiatryonline.org/doi/abs/10.1176/appi.ps.53.1.27

 

[thoffen]

• Firstly, insurance approval is not any standard for admitting someone or not. You need to justify your decision independent of these criteria.
• Secondly, since he was diagnosed with and treated for schizophrenia as recently as 2 weeks before, if your rationale for a decision is based on a separate diagnosis, your burden of documenting why that prior diagnosis is wrong in your opinion is raised
• Third, regardless of actual mental illness and homicidality, there is a lot of evidence here that inpatient hospitalization may not mitigate his risk. In that scenario, I would most likely try to ensure that I did my best to bridge him to what might work
• Since there is no specific target, plan, or intent, there can't be a duty to protect a specific individual. But I'd be careful to document this or if patient remains vague, document diligence to obtain that info and reason not to at least observe longer (likely on a basis of chronic presentation and prior treatment failure)
• Of course, his actions may have nothing to do with mental illness whatsoever. If criminality, particularly violence, is part of his history, documenting why someone's past behavior does not seem connected to mental illness is pretty powerful
• Finally, you don't have to be right. You just can't be negligent. We have poor ability to predict or prevent homicide or suicide. Documenting diligent efforts to evaluate and treat appropriately is all we should ever expect of ourselves. Thinking we can do better is a good way to do worse, IMO.

 

[WingedOx]

Hypothetical case:

34 year old black male comes to the ED with complaints of vague homicidal ideation. No specific target. Denied all other psychiatric complaints. Medically cleared by ED physician.

He was last admitted in the unit 2 weeks ago for "schizophrenia". In the previous admission, he claimed to hear voices telling him to kill himself and endorsed suicidal ideation without plan. He is well-known as a frequently flyer, almost always with the same complaints. Every time he is in the ED, he is positive for something in the urine drug screen. He has extensive legal history with the police.

He appears well-kempt, with color-coordinated outfits and neatly trimmed beard. His speech was goal-oriented, not tangential or disorganized. He gets irritated easily when he doesn't get what he wants.

1. Would insurance cover for this admission?

2. Would you admit?

The reason for this case is from the recent news:

A few days ago, Alexander Bonds went to the hospital with homicidal thoughts. He was then discharged from the ED after getting injections. A few days post-discharge, he walked up to a police car and shot the officer point-blank in the head. The officer died. He has an extensive history with the law, which resulted in long-standing grudge against cops.

3. Would the psychiatrist that cleared Alexander be reamed in court (assuming the chief complaint was vague homicidal ideation)? Not only did the patient kill someone, he killed a cop.

Until you mentioned insurance this case would have described about 30% of the ED consults I saw on call at the VA in residency. In almost all of them the frequent flyer is there because he wants something specific unrelated to the HI.

 

[Madden007]

I guess the take-home point is this: provide and document the best care possible and let the chips fall where they may....