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Ethical Question: End of life, and suicide mentioned

Discussion in 'Psychiatry' started by whopper, Apr 10, 2007.

  1. whopper

    whopper Former jolly good fellow Physician Faculty 10+ Year Member

    Feb 8, 2004
    Had a case like this my first year.

    A caucasian female, in her 60s has both HIV and Cancer. She's been diagnosed as terminal and the oncologist reccomended palliative care. She's been told she only has about 3-5 months to live.

    Yeah well guess what. To the pt's detriment she mentioned the suicide word. She said she wasn't going to do it but thought suicide would just be easier.

    So the oncologist refers her to the crisis psychiatry unit.

    The psyche attending decides to commit the poor lady, while she sat in the "behavioral room" for about 8 hrs.

    So then she's transferred to the inpt psyche unit as a committed pt.

    The inpt attending (and I was working with the inpt attending at the time) now reads the chart and is ticked. I'm talking ticked. This poor lady has only a few months to live and now she's been committed so now she's going to have to waste of few of her last remaining days on the unit. She came in on a Friday afternoon. He told me first thing Monday he was going to discharge her unless anything serious happened.

    OK---dilemna here.

    Pt has significant medical stressor, said the S word, has several sx of depression--so its enough for a valid legal commitment.

    Inpt attending (and I agree with him) says that we're doing an unethical thing because in his opinion she's really not going to commit suicide and we're robbing her of her final days. Further he claimed he felt the crisis psyche doc was just committing the pt to cover her ass and play defensive medicine, and not doing what was in the pt's best interest.

    Well I agreed with the inpt attending (and I know them both, the inpt doc is a better doctor)...

    But the question here is--what would you have done? Would you let a pt who fits enough of the criteria for depression and has a severe risk factor for suicide (terminal illness) go, especially if you had a hunch (though not provable) that she wasn't going to commit suicide?
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  3. Adam_K

    Adam_K Indentured 5+ Year Member

    Nov 28, 2004
    Off to the plantation
    Had a very similar case (hospitalized for atypical TB, had chronic pain, few months to live, stated SI), on the psych C/L service, except the patient was much younger.

    My attending took the position that he wasn't going to transfer the patient to the inpatient psych unit unless he absolutely had to. He said that he would rather put the patient on constant observation on medicine. Fortunately, it did not come to that as the patient's family was extremely supportive (one of them was with the patient throughout), the medicine attending was not stingy with pain meds and the nursing staff stayed on top of the situation.
  4. Doc Samson

    Doc Samson gamma irradiated Physician 10+ Year Member

    Dec 2, 2005
    Not Boston anymore
    No, I wouldn't. Your opinion is ultimately the only thing that counts here. The history is important, but only so far as it informs your opinion.
  5. Encephalopathy

    Encephalopathy 5+ Year Member

    Apr 11, 2007
    I'm not sure that having a terminal diagnosis, with ensuing depressive symptoms that would be natural and expected, and saying the word "suicide" qualify someone for valid legal commitment. This may vary by state, I don't know.

    I think the context of the usage is what matters. There was no ideation and no plan and a qualifier that she had no intention of actually committing suicide. The patient basically just made a comment on the utility of euthanasia.

    There is no mental illness here. I would document that clearly and then have no problem discharging her. Of course, it's easy to say that randomly on the internet.
  6. toby jones

    toby jones 2+ Year Member

    Jan 7, 2007
    she is going to die anyway
    i think she should be allowed to handle that as she sees fit

    it isn't like she is going to regret it anyway or her family is going to sue - is it?
  7. whopper

    whopper Former jolly good fellow Physician Faculty 10+ Year Member

    Feb 8, 2004
    That's the rub.

    The oncologist-I understand why he "turfed" it to psychiatry. Suicide is not his field. Its our field.

    The crisis psychiatrist IMHO was playing defensive medicine at the cost of good medicine. However in her defense you often don't know what's going on with the family in that situation.

    Its really only by the time they reach inpatient where you got a social worker calling the family to get a real understanding and you get to see the patient for a few days just to make sure.

    Also add to the situation that sometimes even when the family is contacted and a bad outcome happens, unknowns come out of the woodwork claiming to be family (whether they are or not and whether or not they actually gave a damn about the pt) so they could sue & make a buck.

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