Dealing with malingering

oldiebutgoodie1211

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How do you deal with a patient with chronic suicidality and many similar presentations of coming to the ED and saying they are suicidal add whatever you like meth use, alchohol, HI, agitations/aggressive behavior, telling you he wants housing, etc. Do you discharge a patient even if they are telling you they are going to leave and kill them selves or telling you they are actively suicidal? I know we all have dealt with patients like this before so id like some insight on ways you approach this, articles you’ve read that have influenced your perspectives or your thoughts on the medicolegal liability of discharging suspected malingerers, thx
 

wolfvgang22

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So, I work in the VA. For repeat patients like this, I offer all available services (IOP, substance abuse counseling, groups, ACT/MHICM team support, etc) and frequent follow up. I often have such patients come to clinic just to check in with our triage nurse (daily, or weekly, whatever they will do.) I get social worker involved to help address housing options. I try to get consent for close friends or family to be involved in the patient's care. I make a safety plan with the patient, and a treatment plan. I document patient refusals and document any barriers to care and how we tried to address them. I document everything meticulously. I sometimes get another physician to review the case with me and document our decision making process. Have treatment team meet and document that.
 
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watto

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I reference this article a lot:








Discharging your patients who display contingency-based suicidality: 6 steps
Current Psychiatry. 2014 January;13(1):e1-e3
By Christopher Bundy, MD, MPH Matthew Schreiber, MD, PhD Marcella Pascualy, MD
Discharging patients from a hospital or emergency department despite his (her) ongoing suicidal ideation is a clinical dilemma. Typically, these patients do not respond to hospital care and do not follow up after discharge. They often have a poorly treated illness and many unmet psychosocial and interpersonal needs.1 These patients may communicate their suicidality as conditional, aimed at satisfying unmet needs; secondary gain; dependency needs; or remaining in the sick role. Faced with impending discharge, such a patient might increase the intensity of his suicidal statements or engage in behaviors that subvert discharge. Some go as far as to engage in behaviors with apparent suicidal intent soon after discharge.

Discharging patients from a hospital or emergency department despite his (her) ongoing suicidal ideation is a clinical dilemma. Typically, these patients do not respond to hospital care and do not follow up after discharge. They often have a poorly treated illness and many unmet psychosocial and interpersonal needs.1 These patients may communicate their suicidality as conditional, aimed at satisfying unmet needs; secondary gain; dependency needs; or remaining in the sick role. Faced with impending discharge, such a patient might increase the intensity of his suicidal statements or engage in behaviors that subvert discharge. Some go as far as to engage in behaviors with apparent suicidal intent soon after discharge.
A complicated decision
Such patients often are at a chronically elevated risk for suicide because of mood disorders, personality pathology, substance use disorder, or a history of serious suicide attempt.2 Do not dismiss a patient’s suicidal statements; he is ill and may end his own life.

Managing these situations can put you under a variety of pressures: your own negative emotional and psychological reactions to the patient; pressure from staff to avoid admission or expedite discharge of the patient; and administrative pressure to efficiently manage resources.3You’re faced with a difficult decision: Discharge a patient who might self-harm or commit suicide, or continue care that may be counterproductive.
We propose 6 steps that have helped us promote good clinical care while documenting the necessary information to manage risk in these complex situations.
1. Define and document the clinical situation.Summarize the clinical dilemma.

2. Assess and document current suicide risk.4Conduct a formal suicide risk assessment; if necessary, reassess throughout care. Focus on dynamic risk factors; protective risk factors (static and dynamic); acute stressors (or lack thereof) that would increase their risk of suicide above their chronically elevated baseline; and access to lethal means—firearms, stockpiled medication, etc.
3. Document modified dynamic or protective factors.Review the dynamic risk and protective factors you have identified and how they have been modified by treatment to date. If dynamic factors have not been modified, indicate why and document the recommended plan to address these matters. You might not be able to provide relief, but you should be able to outline a plan for eventual relief.

4. Document the reasons continued care in the acute setting is not indicated. Reasons might include: the patient isn’t participating in recommended care or treatment; the patient isn’t improving, or is becoming worse, in the care environment; continued care is preventing or interfering with access to more effective care options; is counterproductive to the patient’s stated goals; or compromising the safety benefit of the structured care environment because the patient is not collaborating with his care team.


5. Document your discussion of discharge with the patient. Highlight attempts to engage the patient in adaptive problem solving. Work out a crisis or suicide safety plan and give the patient a copy and keep a copy in his (her) chart.

If the patient refuses to engage in safety planning, document it in the chart. Note the absence of any conditions that might impair the patient’s volitional capacity to not end their life—intoxication, delirium, acute psychosis, etc. Explicitly frame the patient’s responsibility for his life. Discuss and document a follow-up plan and make direct contact with providers and social supports, documenting whether contacting these providers was successful.
6. Consult with a colleague. An informal non-visit consultation with a colleague demonstrates your recognition of the complexity of the situation and your due diligence in arriving at a discharge decision. Consultation often will result in useful additional strategies for managing or engaging the patient. A colleague’s agreement helps demonstrate that “average practitioner” and “prudent practitioner” standards of care have been met with respect to clinical decision-making.
 
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wolfvgang22

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I reference this article a lot:








Discharging your patients who display contingency-based suicidality: 6 steps
Current Psychiatry. 2014 January;13(1):e1-e3
By Christopher Bundy, MD, MPH Matthew Schreiber, MD, PhD Marcella Pascualy, MD
Discharging patients from a hospital or emergency department despite his (her) ongoing suicidal ideation is a clinical dilemma. Typically, these patients do not respond to hospital care and do not follow up after discharge. They often have a poorly treated illness and many unmet psychosocial and interpersonal needs.1 These patients may communicate their suicidality as conditional, aimed at satisfying unmet needs; secondary gain; dependency needs; or remaining in the sick role. Faced with impending discharge, such a patient might increase the intensity of his suicidal statements or engage in behaviors that subvert discharge. Some go as far as to engage in behaviors with apparent suicidal intent soon after discharge.

Discharging patients from a hospital or emergency department despite his (her) ongoing suicidal ideation is a clinical dilemma. Typically, these patients do not respond to hospital care and do not follow up after discharge. They often have a poorly treated illness and many unmet psychosocial and interpersonal needs.1 These patients may communicate their suicidality as conditional, aimed at satisfying unmet needs; secondary gain; dependency needs; or remaining in the sick role. Faced with impending discharge, such a patient might increase the intensity of his suicidal statements or engage in behaviors that subvert discharge. Some go as far as to engage in behaviors with apparent suicidal intent soon after discharge.
A complicated decision
Such patients often are at a chronically elevated risk for suicide because of mood disorders, personality pathology, substance use disorder, or a history of serious suicide attempt.2 Do not dismiss a patient’s suicidal statements; he is ill and may end his own life.

Managing these situations can put you under a variety of pressures: your own negative emotional and psychological reactions to the patient; pressure from staff to avoid admission or expedite discharge of the patient; and administrative pressure to efficiently manage resources.3You’re faced with a difficult decision: Discharge a patient who might self-harm or commit suicide, or continue care that may be counterproductive.
We propose 6 steps that have helped us promote good clinical care while documenting the necessary information to manage risk in these complex situations.
1. Define and document the clinical situation.Summarize the clinical dilemma.

2. Assess and document current suicide risk.4Conduct a formal suicide risk assessment; if necessary, reassess throughout care. Focus on dynamic risk factors; protective risk factors (static and dynamic); acute stressors (or lack thereof) that would increase their risk of suicide above their chronically elevated baseline; and access to lethal means—firearms, stockpiled medication, etc.
3. Document modified dynamic or protective factors.Review the dynamic risk and protective factors you have identified and how they have been modified by treatment to date. If dynamic factors have not been modified, indicate why and document the recommended plan to address these matters. You might not be able to provide relief, but you should be able to outline a plan for eventual relief.

4. Document the reasons continued care in the acute setting is not indicated. Reasons might include: the patient isn’t participating in recommended care or treatment; the patient isn’t improving, or is becoming worse, in the care environment; continued care is preventing or interfering with access to more effective care options; is counterproductive to the patient’s stated goals; or compromising the safety benefit of the structured care environment because the patient is not collaborating with his care team.


5. Document your discussion of discharge with the patient. Highlight attempts to engage the patient in adaptive problem solving. Work out a crisis or suicide safety plan and give the patient a copy and keep a copy in his (her) chart.

If the patient refuses to engage in safety planning, document it in the chart. Note the absence of any conditions that might impair the patient’s volitional capacity to not end their life—intoxication, delirium, acute psychosis, etc. Explicitly frame the patient’s responsibility for his life. Discuss and document a follow-up plan and make direct contact with providers and social supports, documenting whether contacting these providers was successful.
6. Consult with a colleague. An informal non-visit consultation with a colleague demonstrates your recognition of the complexity of the situation and your due diligence in arriving at a discharge decision. Consultation often will result in useful additional strategies for managing or engaging the patient. A colleague’s agreement helps demonstrate that “average practitioner” and “prudent practitioner” standards of care have been met with respect to clinical decision-making.
Great article. A colleague of mine, who I usually discuss these situations with, authored one of the references to this article. Small world, lol.
 
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Ideally you aren't evaluating anyone for suicidality who is actively intoxicated. Optimally there is a CPEP or other observation setup for these people. Suboptimally they can be left in the ED until no longer 'drunkicidal.' (Yes the ED hates this because their productivity metrics are often based on time to dispo. Too bad.)

For those who are not intoxicated, it can be helpful to focus on the motivation for the malingering behavior. Someone looking for '3 hots and a cot' has a real need that could be met in more effective ways than psychiatric hospitalization. Someone who chronically expresses suicidality as a way of getting attention, feeling 'seen,' etc. has a different, equally real need that could also be met in more effective ways than psychiatric hospitalization.

Refocusing the conversation on ways to meet the underlying need that triggers the behavior can sometimes be more productive than a probing interview aimed at demonstrating malingering for the purposes of minimizing medicolegal liability.
 
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oldiebutgoodie1211

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Ideally you aren't evaluating anyone for suicidality who is actively intoxicated. Optimally there is a CPEP or other observation setup for these people. Suboptimally they can be left in the ED until no longer 'drunkicidal.' (Yes the ED hates this because their productivity metrics are often based on time to dispo. Too bad.)

For those who are not intoxicated, it can be helpful to focus on the motivation for the malingering behavior. Someone looking for '3 hots and a cot' has a real need that could be met in more effective ways than psychiatric hospitalization. Someone who chronically expresses suicidality as a way of getting attention, feeling 'seen,' etc. has a different, equally real need that could also be met in more effective ways than psychiatric hospitalization.

Refocusing the conversation on ways to meet the underlying need that triggers the behavior can sometimes be more productive than a probing interview aimed at demonstrating malingering for the purposes of minimizing medicolegal liability.

yes but it’s 10pm at night, the patient is not drunk, he is here because he is homeless, I don’t have a social worker on at this hour to get him a house, he is making it quite clear that if he doesn’t get admitted he will supposedly kill himself, what do you do in this case? I do not have the choice to keep him for observation, it’s either admit or discharge now.
 
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Basis

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As a resident, you usually end up admitting these people unless it's during the day and the attending wants to push back against the ED docs. Pretty much since the 1980s, hospitals have just submitted to these people who make threats to seek the refuge of the hospital. Nobody will push back because the hospital admin is worried about getting sued.

That being said, I think these people should definitely not be admitted to a psychiatric unit. Even as an attending though, good luck doing this in a big hospital system. I wish that units would be a lot more quick to permanently ban these people from the unit. Would you expect a cardiac ICU to keep admitting people without heart problems? Then why do psychiatric units have to keep admitting 'suicidal' people without an actual axis 1 mental illness? It's stupid and has completely destroyed the structure and purpose of these inpatient units. Now 50% of the patient load is just a social safety net situation. And you will have the antisocial patients preying on the anxious ones.

I'm not saying these people seeking refuge in the hospital is a new situation. But, I had an attending who, while practicing in the 60s, would call up patients insurance companies and inform them that the patient was malingering to stay in the hospital (if that was the case). Often the insurance companies would tell the patient they weren't going to cover their stay anymore. It was amazing how fast they wanted to leave and weren't suicidal all of a sudden. Often the unit would then ban the patient from coming back.

Here are two excellent articles talking about just this issue:

"Seven-Year Outcomes of Patients Evaluated for Suicidality"

'Characteristics and six-month outcome of patients who use suicide threats to seek hospital admission'

Hopefully the links work to view the full PDFs.

My favorite line is probably "No suicides were identified in the contingently suicidal group".

I also think of contingent suicidality as a protective factor. Obviously they are invested enough to try to get the reward they want, that's not the action of an apathetic and anergic person.
 
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clausewitz2

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As a resident, you usually end up admitting these people unless it's during the day and the attending wants to push back against the ED docs. Pretty much since the 1980s, hospitals have just submitted to these people who make threats to seek the refuge of the hospital. Nobody will push back because the hospital admin is worried about getting sued.

That being said, I think these people should definitely not be admitted to a psychiatric unit. Even as an attending though, good luck doing this in a big hospital system. I wish that units would be a lot more quick to permanently ban these people from the unit. Would you expect a cardiac ICU to keep admitting people without heart problems? Then why do psychiatric units have to keep admitting 'suicidal' people without an actual axis 1 mental illness? It's stupid and has completely destroyed the structure and purpose of these inpatient units. Now 50% of the patient load is just a social safety net situation. And you will have the antisocial patients preying on the anxious ones.

I'm not saying these people seeking refuge in the hospital is a new situation. But, I had an attending who, while practicing in the 60s, would call up patients insurance companies and inform them that the patient was malingering to stay in the hospital (if that was the case). Often the insurance companies would tell the patient they weren't going to cover their stay anymore. It was amazing how fast they wanted to leave and weren't suicidal all of a sudden. Often the unit would then ban the patient from coming back.

Here are two excellent articles talking about just this issue:

"Seven-Year Outcomes of Patients Evaluated for Suicidality"

'Characteristics and six-month outcome of patients who use suicide threats to seek hospital admission'

Hopefully the links work to view the full PDFs.

My favorite line is probably "No suicides were identified in the contingently suicidal group".

I also think of contingent suicidality as a protective factor. Obviously they are invested enough to try to get the reward they want, that's not the action of an apathetic and anergic person.

Huge advantage for places that have a dedicated psych ED is that you generally don't admit these people. I feel like I spent the first three months of residency mostly not admitting these people and documenting it. I am sure in some stated/institutions "I will kill myself" is a trump card but I have personally, solo and with little to no attending input, discharged more than one person who told me that because I did not admit them they were going to kill themselves and it would be my fault. I would tell them that ultimately their safety was their responsibility and that I hoped they would not.

Sometimes they would leave and come back a few hours later. Then I would see them again and document "willingness to seek care" as a protective factor. The psych ED record for most returns was 5 times in a single shift. One of our emergency psychiatrists once told me "y'know, we could just discharge everybody who comes in here and it probably wouldn't show up as a statistically significant increase in completed suicides."

Later on the DBT/TFP approach to chronically suicidal people came fairly easily. Though quite honestly about half the time validation of distress and just making it clear that you think their situation is bad enough that you don't want to make it worse by admitting them did the trick and they would no longer want to be admitted.

That said we also had some chair space where some people were allowed to fall asleep while "awaiting evaluation" and were let sleep until day shift, as long as it didn't become a habit. I am sure that helped.
 
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oldiebutgoodie1211

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Huge advantage for places that have a dedicated psych ED is that you generally don't admit these people. I feel like I spent the first three months of residency mostly not admitting these people and documenting it. I am sure in some stated/institutions "I will kill myself" is a trump card but I have personally, solo and with little to no attending input, discharged more than one person who told me that because I did not admit them they were going to kill themselves and it would be my fault. I would tell them that ultimately their safety was their responsibility and that I hoped they would not.

Sometimes they would leave and come back a few hours later. Then I would see them again and document "willingness to seek care" as a protective factor. The psych ED record for most returns was 5 times in a single shift. One of our emergency psychiatrists once told me "y'know, we could just discharge everybody who comes in here and it probably wouldn't show up as a statistically significant increase in completed suicides."

Later on the DBT/TFP approach to chronically suicidal people came fairly easily. Though quite honestly about half the time validation of distress and just making it clear that you think their situation is bad enough that you don't want to make it worse by admitting them did the trick and they would no longer want to be admitted.

That said we also had some chair space where some people were allowed to fall asleep while "awaiting evaluation" and were let sleep until day shift, as long as it didn't become a habit. I am sure that helped.

so you’ve had people tell you and the staff that “if i leave I’m going to kill myself” you then documented that in the note and discharged him?
 

clausewitz2

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so you’ve had people tell you and the staff that “if i leave I’m going to kill myself” you then documented that in the note and discharged him?

Yes. The assessment was, of course, very thorough and well documented and their record of having had identical presentations in our system many times in the past was reviewed and referenced, but absolutely yes.

TFP tells you that if the client says they are going to kill themselves, you say something like "I would like to keep working with you and I hope you don't kill yourself but if you do complete suicide, my life will go on."


Documentation explicitly lays out my assessment that these are instrumental threats in the absence of identifiable psychiatric pathology beyond the "suicidal/homicidal" statement. Also risk factors are chronic and/or not modifiable during inpatient psychiatric hospitalization, pattern of continuing escalation directly triggered by any suggestion that admission will not be forthcoming, and not infrequently the warrants out for them that they did not feel the need to disclose.

And in one memorable case, the fact that patient had been discharged from inpatient unit twenty minutes earlier, walked out the exit, and right around the corner into the psych ED entrance saying he needed to be admitted.
 
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oldiebutgoodie1211

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Yes. The assessment was, of course, very thorough and well documented and their record of having had identical presentations in our system many times in the past was reviewed and referenced, but absolutely yes.

TFP tells you that if the client says they are going to kill themselves, you say something like "I would like to keep working with you and I hope you don't kill yourself but if you do complete suicide, my life will go on."


Documentation explicitly lays out my assessment that these are instrumental threats in the absence of identifiable psychiatric pathology beyond the "suicidal/homicidal" statement. Also risk factors are chronic and/or not modifiable during inpatient psychiatric hospitalization, pattern of continuing escalation directly triggered by any suggestion that admission will not be forthcoming, and not infrequently the warrants out for them that they did not feel the need to disclose.

Yeah I mean you’re absolutely right. The first issue though is that documentation takes up a lot of time a busy ED psychiatrist might not have, the second thing is it still looks pretty bad when you write in your note he stated he would kill himself upon leaving then he does kill himself, I mean how is a jury going to not side against you there? I think it’s possible to do it if your note is good enough but I think an easier way would be to not include that he stated those words...I Have ethical qualms about this but have seen some people do this. Another thing is, its not feasible to write no psychiatric pathology because you will not find a malingerer that has not been diagnosed with some thing in the past whether that’s psychosis or MDD in their long history
 

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Yeah I mean you’re absolutely right. The first issue though is that documentation takes up a lot of time a busy ED psychiatrist might not have, the second thing is it still looks pretty bad when you write in your note he stated he would kill himself upon leaving then he does kill himself, I mean how is a jury going to not side against you there? I think it’s possible to do it if your note is good enough but I think an easier way would be to not include that he stated those words...I have seen some people do this

Negligence is not being wrong. It is not delivering standard of care in a way that demonstrably hurts the person in question in the context of a doctor-patient relationship. You make it crystal clear how you arrived at that conclusion and that you put serious, considerate thought into it. Make it clear that the motivation for suicide appears to be things that will be just as true about the patient's life when they are discharged and they do not appear to be having acute psychiatric or medical symptoms.


The first few times you document this it takes a bit but i got really good at typing up a note explicating this sort of situation quickly.
 
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Negligence is not being wrong. It is not delivering standard of care in a way that demonstrably hurts the person in question in the context of a doctor-patient relationship. You make it crystal clear how you arrived at that conclusion and that you put serious, considerate thought into it. Make it clear that the motivation for suicide appears to be things that will be just as true about the patient's life when they are discharged and they do not appear to be having acute psychiatric or medical symptoms.


The first few times you document this it takes a bit but i got really good at typing up a note explicating this sort of situation quickly.

Yep.

Its been very well established by case law that you are not generally held responsible for errors in judgment as long as you document a reasonable explanation for what you did. It’s well established that we cannot predict short term suicidality with any degree of confidence. Forensic psychiatrists will say the same thing.

You are held liable for errors of fact though (ex. Did not ask if patient had a gun at home and then he goes and shoots himself with said gun two days later). However, it is perfectly reasonable to document that he does have a gun but you believe he does not warrant inpatient hospitalization for blah blah blah reasons (especially when we’re talking about involuntary hospitalization) and then for the guy to go shoot himself the next day. You collected all the facts, documented your decision and reasoning behind it. There was an exact case where this occurred and the psychiatrist was found not liable. It bears repeating that you are not held responsible for predicting suicide if you have reasonably gathered all the facts, documented a reasonable assessment and carried out a reasonable plan. Even if the court can find some other psychiatrist to say the would have hospitalized this person, the plaintiff will be hard pressed to prove that hospitalization would have prevented the suicide (since there’s literally no evidence proving that inpatient hospitalizations decrease suicide risk). The way they go for you is arguing that you actually did NOT do a good history and assessment which is easy when your documentation is a 2 line A+P.

Any one person committing suicide within a short timeframe (generally defined as <6 months if you look at most papers, shortest timeframe I’ve ever seen in a paper is 1 month) is a statistically fleetingly rare event for all the commotion made about suicide rates going up. Most experienced attendings will also tell you that it’s never the people who show up to the ED saying they’ll kill themselves if they don’t get admitted...it’s usually the ones you don’t expect (thus our terrible short term prediction ability).
 
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Same as clausewitz2 here. As a resident you don't have a lot of control over this: ultimately it's the attending's license on the line so if they want to admit, you go ahead and admit.

As an attending I documented extensively and discharged as clausewitz2 discussed. (Good documentation is not only CYA for the current presentation but also an accumulation of evidence for repeat offenders, as the multiple prior similar presentations will weigh in favor of discharge being a safe and appropriate option.)

But I always discharged with some assistance in the direction of the actual need. We were lucky to have social workers in our ED, and using an MI approach to lay out the advantages of a sandwich and a shelter bed over a psych admission often went a long way towards a cooperative discharge.

If you don't have SW on site I would ask your residency program or ED staff to compile a resource booklet to help with this type of dispo.

If forced to admit, renal diet, q4h vitals, suicide precautions (no forks etc), max limitation on outdoor privileges, and whatever else you can do to make the stay as unpleasant as possible may reduce the chances of the same individual repeating the strategy in the future.
 
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"Continued hospitalization is likely to reinforce a pattern of maladaptive behavior whereby the patient continues to seek housing resources via the mental health system as opposed to more appropriate and sustainable means, such as area homeless shelters and by accruing net 'homeless days' (which inpatient stays do not count toward) which will allow them to qualify for section 8 housing."

Is a thing I put in a lot of these notes when the patient has a known pattern of doing this sort of thing.
 
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oldiebutgoodie1211

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I just want to say I’m very impressed with the responses here, I thought this was a difficult topic for attendings too but it seems you guys have a good understanding and comfort with dealing with these patients so that gives me hope moving forward..I appreciate all the insights greatly
 
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If forced to admit, renal diet, q4h vitals, suicide precautions (no forks etc), max limitation on outdoor privileges, and whatever else you can do to make the stay as unpleasant as possible may reduce the chances of the same individual repeating the strategy in the future.

I love the combination of diet orders based on BMI + labs in AM. I also provide motivation by telling them they have no chance of leaving until they demonstrate self-sufficiency and progress: attending mandatory twice daily group therapy, meeting daily with the nagging social worker, getting housing, setting up appointments with a therapist, psychiatrist, PCP and/or (pain) specialist, etc. All these things are beneficial to them anyway, regardless of malingering, as well as good arguments in the DC summary to why their risk has been lowered (in addition to documenting possible malingering, decreased likelihood of improvement and worsening with a longer stay).

Regarding admissions, the only dog I have in the fight is to not get blamed for neg outcomes as a resident. But it is a societal debate as to whether malingerers are taking others' resources. Arguably, a short stint in the psych ward is the psychiatric equivalent of chest pain patients who get an EKG, trops, and maybe observation or holter. It also depends on the capacity in which I am functioning: ED psych, ED consult, floor consult, or random doc with the admissions pager? I am more comfortable declining admission if I see them in person. But if there are detailed red flags brought up by 3rd parties (police, family, therapist, ED Dr/RN/SW), then I'd probably err on the side of caution.
 

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This is one of those things not handled in conventional academia. Oh yes there's stuff on mechanisms of SSRIs, etc but there's not much on dealing with very difficult patients who come in time and time again.

Aside from the above which is very good advice there needs to be a good team effort. E.g. notes on such chronic frequent flyers need be written in a manner that informs treatment providers that this guy's pattern is chronic.

While I was a resident many residents and even attendings wrote their notes in a format that didn't lend to it supporting future providers. E.g. guy came in, malingering, it's even quite well established he's malingering (e.g. he admits he's malingering, he's showing no signs of mental illness) and then the attending tells the resident to write down Bipolar Disorder as the diagnosis cause he wants to make sure the hospital can bill the system and then prescribe a med that even this guy doesn't think is even needed.

Such a note now puts onus on a future provider to disprove the guy has Bipolar Disorder and makes it that much harder to get rid of the guy if he shows up again..

Instead what SHOULD'VE BEEN DONE IS, 1-diagnosis of Adjustment Disorder. It fits and it's not a lie. The guy was stressed and wanted something so he acted quite inappropriately and had symptoms such as desperation/anxiety. That still fits the criteria of diagnosis without having to lie on a chart which by the way is illegal. 2-Write down what was going on. Write the guy even admitted he was exaggerating his problem. Don't say that's your judgment, quote him instead. Then do as Flowrate suggests. Write the note showing his chronic pattern and that behaviorally you're trying to prevent it from happening again.

E.g. "Patient was discharged with a referral to whatever mental health services because he had symptoms of mental health disorder. At this time due to his disorder not showing any physiological etiology, but being more behavioral/personality/situational in nature I also had the social worker provide him with referrals for housing and other social services."

Now the problem I had as a resident were several attendings just wrote down a diagnosis they didn't even think was going on and just wanted to get the guy out the door without considering they've just shot everyone else in the hospital for when the guy comes back. It was a department problem. Yes there were attendings who didn't like it but they didn't outnumber the BS attendings. In that department the problem continued and it wasn't going to change unless some of those attendings left.

One of those things I didn't fully understand until my later years in residency.

I later became a professor at UC and at their PES they handled it right from the start. Attendings, residents, nurses all knew how to document this thing correctly and deal with chronically difficult patients. The place you do residency matters.
 
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While I was a resident many residents and even attendings wrote their notes in a format that didn't lend to it supporting future providers. E.g. guy came in, malingering, it's even quite well established he's malingering (e.g. he admits he's malingering, he's showing no signs of mental illness) and then the attending tells the resident to write down Bipolar Disorder as the diagnosis cause he wants to make sure the hospital can bill the system and then prescribe a med that even this guy doesn't think is even needed.

Such a note now puts onus on a future provider to disprove the guy has Bipolar Disorder and makes it that much harder to get rid of the guy if he shows up again..

Instead what SHOULD'VE BEEN DONE IS, 1-diagnosis of Adjustment Disorder.

Z76.5
Malingerer [conscious simulation]
Z76. 5 is a billable/specific ICD-10-CM code that can be used to indicate a diagnosis for reimbursement purposes. The 2020 edition of ICD-10-CM Z76. 5 became effective on October 1, 2019.
 

whopper

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Z76.5
Malingerer [conscious simulation]
Z76. 5 is a billable/specific ICD-10-CM code that can be used to indicate a diagnosis for reimbursement purposes. The 2020 edition of ICD-10-CM Z76. 5 became effective on October 1, 2019.

And the problem there is (not that you are wrong) is that if you put in the word malingering into a chart you are opening yourself up for a serious lawsuit where there's a precedent of such wording being used against you. Also while I was a resident, many of the attendings above me had an erroneous notion that you could only bill for serious mental illness disorders such as MDD or Bipolar Disorder.

What's happened in such cases (and I disagreed with this) is the argument was put forth that the physician treating the patient us supposed to defend and help the patient not judge them and use of that term of highly judgmental. Well here's where I disagree. Malingering is literally the term for someone exaggerating/fabricating/misleading/lying about a medical problem for some type of gain that has market value. There is no other term for it. So if they want to get mad at us for using such a mean term then give us some PC term to use instead but there is none.

Kind of like calling a patient morbidly obese in a chart when they meet all of the definitions of it, getting sued for it, then losing.

Now here's what I do agree about "malingering." Phil Resnick brought up at AAPL lectures avoid it like I wrote above, but if you do put it in make sure you got solid data backing you up such as psychological testing that strongly shows it, plus everything else strongly backs it up.

In clinical charts, with malingering, I usually avoid the term but only because I'm covering my butt, but I wrote down basically the person is malingering without using the term. E.g. " The patient's signs do not match his symptoms, I do not see strong reason to believe he is suffering from an Axis I disorder other than Adjustment Disorder as the cause of his visit to the ER, and for this reason he is not appropriate for an admission into the inpatient unit."

"Due to his desire for inpatient hospitalization despite that this is not warranted, I have reason to believe he needs to work on improving his coping mechanisms, and this is in part at least based on a cluster B personality trait where he expects hospitalization for things it is not meant to treat such as homelessness. For this reason he was referred to outpatient therapy and a social worker will give him referrals for housing options."

The only times I wrote malingering in the chart, and again I don't recommend you do so lightly or at all given that you can say it without using the term, is when patients literally admitted they were malingering and it was witnessed by others or the data is just so strong and damning.

Another reason why I disagree with courts ruling against physicians for the term malingering is it's been used in medical texts as the word to describe the phenomenon, and the diagnosis itself shouldn't be the crux. What was done to treat the person should be. In my example able, I didn't slap the guy, call him an a-hole, kick him out of the ER in a disrespectful manner or anything of the sort. I was polite, told him that yes I agree he needs help but that such help was outside the hospital and wished him well. So what he didn't like it, or didn't get what he wanted?

And getting back to what I wrote above, it's a damned shame that several attendings teach residents to get rid of these patients without writing accurately in the chart. A diagnosis to bill such as Bipolar Disorder is illegal, unethical, it makes it that much harder for the future providers, and I've seen it happen time and time again. I had a patient who was rehospitalized over 12 times and while on my forensic unit I stopped all of his meds and he showed no signs of any mental health disorder ever. I went through all of his prior charts and not 1 sign of mental illness was reported. Oh yeah it was filled with stuff like he beat up another patient for their desert but nothing that was mental illness. I even called up over 6 of the doctors whose names were in the older charts who continued his diagnosis of Schizoaffective, Schizophrenia, and Bipolar Disorder and all of them stated they never once saw him psychotic and were just continued the diagnosis in the chart from his prior admission. One of them was like "he has to have schizophrenia! What kind of person would beat up someone for a piece of cake? Only a schizophrenic!"

In court I just did what I was supposed to do. I told the judge that I had no faith in the prior physicians' diagnosis, my partner psychologist backed me up, and the judge and I worked together on several dozen prior cases and knew what I was talking about because he's seen the same thing too from other psychiatrists.
 
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And the problem there is (not that you are wrong) is that if you put in the word malingering into a chart you are opening yourself up for a serious lawsuit where there's a precedent of such wording being used against you. Also while I was a resident, many of the attendings above me had an erroneous notion that you could only bill for serious mental illness disorders such as MDD or Bipolar Disorder.

You can bill for whatever you want. In the past, many insurance companies would only *pay* for 'parity diagnoses,' i.e. specific psychiatric diagnoses that in their estimation deserved 'parity' with other medical diagnoses.

This was outlawed by the Mental Health Parity Act in 2008.


In court I just did what I was supposed to do. I told the judge that I had no faith in the prior physicians' diagnosis, my partner psychologist backed me up, and the judge and I worked together on several dozen prior cases and knew what I was talking about because he's seen the same thing too from other psychiatrists.

So somebody actually sued you for diagnosing malingering? Can you say more about this?
 
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calvnandhobbs68

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You can bill for whatever you want. In the past, many insurance companies would only *pay* for 'parity diagnoses,' i.e. specific psychiatric diagnoses that in their estimation deserved 'parity' with other medical diagnoses.

This was outlawed by the Mental Health Parity Act in 2008.

Interesting did not know this. I feel like a lot of people are still under the impression they have to bill for certain diagnoses.
 

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Interesting did not know this. I feel like a lot of people are still under the impression they have to bill for certain diagnoses.
This is not true. There are "parity diagnoses" and non-parity diagnoses may well not be covered depending on the insurance plans. This differs based on state laws and is not explicitly addressed by federal legislation. Also bear in mind there is a difference between what the law says and what actually happens. There are whole law firms set up to fight parity claims and many psych hospitals have a lawyers on retainer to fight denials of payment. Insurance companies also do not have to cover psychiatric care at all, but if they do there has to be parity with physical care. Finally, Medicare and Medicaid are exempt from MHPAE and ACA laws governing parity. Often complaints to the state department of managed care, insurance commissioner, lawsuits, or repeated appeals of denials are required for enforcement.

In terms of malingering, I agree with whopper, which is that it is best to avoid putting malingering if possible. Better to describe as he says the issues (e.g. inconsistencies, changing reports, observations vs subjective, contradictions from collateral, atypicality of presentation, poor effort, lack of benefit from treatment, any psychological testing). It is often better to use "feigning" rather than malingering as well, since the latter has perjorative connotations and the patient's motivations are not always clear-cut (and often overdetermined). While rare, it is possible to be sued for labeling a patient as a malingering, and if filed as a defamation/libel suit, your malpractice may not cover you. If you just put "malingering" alone you should expect to get the service denied as "not medically necessary." Also most insurances will not accept a z code as the primary diagnosis, you need to have an F code as the primary diagnosis.
 
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PsyDr

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@whopper

1) Can you point to any lawsuits where the attending diagnosed malingering and was sued for defamation? I know Resnick stated that could be an outcome, just unaware of it happening.

2) IMO, many of the concerns about malingering revolve around the idea that treatment professionals are unable to determine the truth. This is a legal distraction and they know it. It is easy to counter this line of inquiry. "Counselor, if you are suggesting that I am incapable of determining if someone is telling the truth, I would like to refer my patient who insists he is Tupac, to you.".
 
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whopper

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So somebody actually sued you for diagnosing malingering? Can you say more about this?

I have not been sued for the above but Resnick mentioned it has happened, specifically in his malingering lecture. Also while in St. Louis a Washington U physician was successfully sued. I knew about because some colleagues mentioned it to me (who did not know each other but they are all mental health professionals) and the results were also that he lost because he was "placing a negative character judgment" upon his patient. I don't know the name of the actual case.
 
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I document malingering when I have evidence from neuropsychological testing and / or evidence from a report of investigation. The latter includes some incredible surveillance footage I have seen over the years. "A" for effort to the guy with a phobia of driving who drove to a block away from the doctor's office, then had his wife drive into the parking lot.
 

whopper

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2) IMO, many of the concerns about malingering revolve around the idea that treatment professionals are unable to determine the truth. This is a legal distraction and they know it. It is easy to counter this line of inquiry. "Counselor, if you are suggesting that I am incapable of determining if someone is telling the truth, I would like to refer my patient who insists he is Tupac, to you.".

I guess it's like non-epileptic seizures. They aren't seizures, they're not non-epileptic (the medical data shows that the overwhelming majority of people with pseudoseizures already have epilepsy) but for whatever reason someone felt "pseudoseizure" was pejorative despite that most people including those who have it don't even know what it is.

So they change a name where I've seen no one claim it was pejorative to something that's blatantly false. Calling it a seizure when it's not a seizure and calling it non-epileptic when in fact there is an association with epilepsy on some level. I'm not even arguing to keep the term pseudoseizure. I'm arguing if you want to change the term then change it to something accurate.

It's BS but if you call it such you're digging your own grave if you try to win the argument against the people who think it's pejorative when there's no other term to call it by.

Its like if I were on the witness stand about a prostitute.
Lawyer: What is Ms X's profession?
Me: Ms. X's profession is prostitution.
Lawyer: I want to strike that off the record. Prostitute is a pejorative term.
Me: Is there a term the court would rather hear to denote someone who sells herself for for sexual servives?
Lawyer: A non-sexual abstainer.
Me: But there's sex involved and the person is not abstaining.
Lawyer: The term the committee came up with was non-sexual abstainer! You sir are a speaker of pejorative terms and in violation of your fiduciary responsibility to your own patient!
 
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wolfvgang22

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See the patient together with another MD/NP/SW and all chart together! This is all so much easier with a team based approach as opposed to just you and the person presenting.
I like this idea, but often it's just me at 3am in the E.R. The E.R. doc is off somewhere.
 
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PsyDr

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I guess it's like non-epileptic seizures. They aren't seizures, they're not non-epileptic (the medical data shows that the overwhelming majority of people with pseudoseizures already have epilepsy) but for whatever reason someone felt "pseudoseizure" was pejorative despite that most people including those who have it don't even know what it is.

So they change a name where I've seen no one claim it was pejorative to something that's blatantly false. Calling it a seizure when it's not a seizure and calling it non-epileptic when in fact there is an association with epilepsy on some level. I'm not even arguing to keep the term pseudoseizure. I'm arguing if you want to change the term then change it to something accurate.

It's BS but if you call it such you're digging your own grave if you try to win the argument against the people who think it's pejorative when there's no other term to call it by.

Its like if I were on the witness stand about a prostitute.
Lawyer: What is Ms X's profession?
Me: Ms. X's profession is prostitution.
Lawyer: I want to strike that off the record. Prostitute is a pejorative term.
Me: Is there a term the court would rather hear to denote someone who sells herself for for sexual servives?
Lawyer: A non-sexual abstainer.
Me: But there's sex involved and the person is not abstaining.
Lawyer: The term the committee came up with was non-sexual abstainer! You sir are a speaker of pejorative terms and in violation of your fiduciary responsibility to your own patient!

Eh. Those are just word games.

"Counselor, i can think of two ways about this. One, if you can cite a definitive resource that describes which words in common and technical parlance are pejorative I would be happy to comply. Alternatively, I believe that the manner in which you address me is pejorative in violation of the civility rules.”
 
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psyguru

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A better term to use in the documentation would be "Biased Symptom Response". This term covers malingering, factitiousness, and other non-malingered presentations (i.e. someone who is depressed and pessimistically overreports symptoms or if there is some sort of "cry for help").
 

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I guess it's like non-epileptic seizures. They aren't seizures, they're not non-epileptic (the medical data shows that the overwhelming majority of people with pseudoseizures already have epilepsy) but for whatever reason someone felt "pseudoseizure" was pejorative despite that most people including those who have it don't even know what it is.

Not related to the thread itself, but my time on a VEEG unit was counter to this notion. Something like 9-20% of people with PNES also had verifiable epileptiform activity. (Locke et al., 2006; Binder & Salinsky 2007; Reuber & Elger, 2008). I have a couple pdf'd ref books if you're interested.
 
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whopper

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Yes I would be interested. I have seen studies (years ago so I don't remember them which one) showing that the percent of people with PNES with real seizures/epilepsy was well over 50%. So this brings up several arguments. 1-that perhaps having epilepsy imparts some type of extra stress on the person increasing their risk of PNES assuming it's a form of conversion disorder. 2-perhaps the epileptic patient was afforded several unintended benefits (e.g. day off from school, work) due to their health problem and the person learned to exploit it. 3-there might be some type of neurological issue going on in PNES that is somehow linked to real epilepsy that medical science cannot yet grasp among others.

Such a link can be very important. It begs the question that for people with PNES what if any is the psychosocial root of this problem. Shouldn't clinicians try to examine the root cause of the person's diagnosis and wouldn't that help in the effort to treat it?

IT's a reason why when they called it "non-epileptic seizures" I was like WTF!??!! There is a link with it to epilepsy, a link we don't yet understand, and there's plenty of non-epileptic seizures (e.g. from alcohol withdrawal) that are called such in the hospital that aren't pseudoseizures/PNES adding to the confusion and increasing the risk of miscommunication.

If someone wants to argue pseudoseizure is a pejorative term, aside that I never once heard anyone claim it as such, in lectures they brought up the pejorative implications and why the name was being changed, yet no one could cite any data showing it was pejorative. E.g. no patient or clinician interviewed cited they felt they were uncomfortable with the term. Okay, fine, change the term out of abundance of caution for those who could be offended despite that no one I know ever saw one case of anyone being offended, I'm not trying to be insensitive, but they didn't have to change it to something that caused the problems I mentioned above. Calling it something it clearly wasn't and citing it's non-epileptic when it does have some connection we don't yet understand to real seizure disorders.
 
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