Placement of medically complicated patients who need need admission

[hebel]

What do you do with CL patients who meet involuntary psych admission criteria, but can't go to inpatient because of subacute medical issues or O2 tubing?

For example, a patient on 24hr O2 s/p suicide attempt (no O2 tubing allowed on our unit). Or a patient with late stage cancer with FTT who needs subacute rehab placement, but is actively suicidal.

Do you d/c to rehab with a 1:1 and make sure they have psych followup there? Do you just keep them on the medical floor in the hospital for CL to just see them daily? There's no geriatric psych units around here as an additional option.

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[Stagg737]

Where I'm at if they'd go to a psych unit, then they stay on the medical floor, with 1:1 if necessary, and are seen regularly by the consult team. We have a rehab unit in our system, so your other situation they can go there, be on 1:1 if needed, and bee seen by psych as often as needed.

Not sure what would happen if they needed to be d/c to a program/facility our hospital doesn't have but still needed psych admission, though I'd imagine they'd stay on the medical floor until psychiatrically cleared.

 

[robellis]

You keep them on the medical unit until they can be safely discharged, you can’t discharge someone somewhere when they are actively suicidal (yes you will get pushback from nurses and medical teams but your job is to the patient not them)

 

[calvnandhobbs68]

Or a patient with late stage cancer with FTT who needs subacute rehab placement, but is actively suicidal.

So I think this is a different situation altogether though. Late stage cancer that's so bad they're getting classified as failure to thrive? Do any of us really think an inpatient psych stay is going to do much for this situation? Some groups and some SSRI and I bet they'll turn right around in 5 days ....I feel like I'd see this person on consults for a while and use that time to help them set up close psychotherapy/outpatient psychiatry but I'd be hard pressed to put someone like this on an inpatient psych unit even if they've been saying they want to kill themselves every day for the past week.

 

[Old&InTheWay]

So I think this is a different situation altogether though. Late stage cancer that's so bad they're getting classified as failure to thrive? Do any of us really think an inpatient psych stay is going to do much for this situation? Some groups and some SSRI and I bet they'll turn right around in 5 days ....I feel like I'd see this person on consults for a while and use that time to help them set up close psychotherapy/outpatient psychiatry but I'd be hard pressed to put someone like this on an inpatient psych unit even if they've been saying they want to kill themselves every day for the past week.

Someone with late stage cancer who wants to die sounds like a pretty reasonable individual and should have that option available to them in one form or another (i.e. comfort care or physician aid in dying if available in your state). What's the plan otherwise, cure them of their depression so they can die in pain happy?

 

[clozareal]

Someone with late stage cancer who wants to die sounds like a pretty reasonable individual and should have that option available to them in one form or another (i.e. comfort care or physician aid in dying if available in your state). What's the plan otherwise, cure them of their depression so they can die in pain happy?

This cognitive distortion of black and white and fatalistic thinking needs to be challenged. Distress is common in cancer patients who are burdened by their multiple physical and psychological problems. However, not all those with cancer who are dying will have a major depressive episode. Clinically significant depression can cause psychological burden, poorer quality of life, more prolonged hospital stays, increased physical distress, poorer treatment compliance, a desire for hastened death, and suicide. If you treat the depression, the outcomes in quality of life, severity of their cancer symptoms, and they have can more functioning in their life up until their eventual demise. You're not forcing someone to be happy so they can die in pain with a smile on their face any more than you are claiming that an SSRI will cure all of their problems and put them in a state of perpetual bliss.

One of my patients with terminal cancer was severely depressed and had such bad anhedonia, he no longer enjoyed even seeing his daughter 1-2 months let alone talk to his wife and family before he passed away. Before, those were some of the things that brought him joy. Outside of his cancer, his depression affected not only his quality of life, but that of his family as well. If he had come to us earlier, he may have had a better shot at being more functional and overall a more meaningful end of life.

 

[Old&InTheWay]

This cognitive distortion of black and white and fatalistic thinking needs to be challenged. Distress is common in cancer patients who are burdened by their multiple physical and psychological problems. However, not all those with cancer who are dying will have a major depressive episode. Clinically significant depression can cause psychological burden, poorer quality of life, more prolonged hospital stays, increased physical distress, poorer treatment compliance, a desire for hastened death, and suicide. If you treat the depression, the outcomes in quality of life, severity of their cancer symptoms, and they have can more functioning in their life up until their eventual demise. You're not forcing someone to be happy so they can die in pain with a smile on their face any more than you are claiming that an SSRI will cure all of their problems and put them in a state of perpetual bliss.

One of my patients with terminal cancer was severely depressed and had such bad anhedonia, he no longer enjoyed even seeing his daughter 1-2 months let alone talk to his wife and family before he passed away. Before, those were some of the things that brought him joy. Outside of his cancer, his depression affected not only his quality of life, but that of his family as well. If he had come to us earlier, he may have had a better shot at being more functional and overall a more meaningful end of life.

I totally agree that people shouldn't suffer needlessly, and we should strive to improve quality of life even when time is limited. I also believe that death may sometimes be a reasonable way for a person's suffering to end.

My response above was directed to one of the examples given by the OP and I stand by my reply. I simply have a hard time imaging how hospitalizing an acutely suicidal person at the natural end of their life does more good than harm.

 

[calvnandhobbs68]

This cognitive distortion of black and white and fatalistic thinking needs to be challenged. Distress is common in cancer patients who are burdened by their multiple physical and psychological problems. However, not all those with cancer who are dying will have a major depressive episode. Clinically significant depression can cause psychological burden, poorer quality of life, more prolonged hospital stays, increased physical distress, poorer treatment compliance, a desire for hastened death, and suicide. If you treat the depression, the outcomes in quality of life, severity of their cancer symptoms, and they have can more functioning in their life up until their eventual demise. You're not forcing someone to be happy so they can die in pain with a smile on their face any more than you are claiming that an SSRI will cure all of their problems and put them in a state of perpetual bliss.

One of my patients with terminal cancer was severely depressed and had such bad anhedonia, he no longer enjoyed even seeing his daughter 1-2 months let alone talk to his wife and family before he passed away. Before, those were some of the things that brought him joy. Outside of his cancer, his depression affected not only his quality of life, but that of his family as well. If he had come to us earlier, he may have had a better shot at being more functional and overall a more meaningful end of life.

I mean I would expect "fatalistic thinking" in someone with terminal cancer. Again though all those things you're talking about are best addressed in an outpatient setting with someone who is developing or has developed a relationship with the patient, not an acute inpatient stay which is, let's be honest, mainly geared towards safety, slight med changes and quick/dirty CBT for the patients who are there with SI. I think regular psychotherapy with honest reflections on a person's life/regrets (which the vast majority of the time drives the "depression" in these cases), discussion about a person's philosophy and fears around death and making meaningful change to make whatever time they have left as meaningful and enjoyable as possible is absolutely warranted.

So I agree with @Old&InTheWay I have a hard time figuring out how an acute inpatient psychiatric hospitalization is going solve much for someone with an obviously progressing terminal illness. Maybe if they wanted to voluntarily do it...

 

[clozareal]

I wasn't talking about acute inpatient stays for those with cancer with poor prognoses. I was referring more so to treat those who have end-stage cancer and associated depression with medications and/or psychotherapy (e.g., meaning-centered psychotherapy).

 

[hebel]

Where I'm at if they'd go to a psych unit, then they stay on the medical floor, with 1:1 if necessary, and are seen regularly by the consult team. We have a rehab unit in our system, so your other situation they can go there, be on 1:1 if needed, and bee seen by psych as often as needed.

Not sure what would happen if they needed to be d/c to a program/facility our hospital doesn't have but still needed psych admission, though I'd imagine they'd stay on the medical floor until psychiatrically cleared.

That's what I figured, good to hear that's generally standard most places.

 

[hebel]

So I think this is a different situation altogether though. Late stage cancer that's so bad they're getting classified as failure to thrive? Do any of us really think an inpatient psych stay is going to do much for this situation? Some groups and some SSRI and I bet they'll turn right around in 5 days ....I feel like I'd see this person on consults for a while and use that time to help them set up close psychotherapy/outpatient psychiatry but I'd be hard pressed to put someone like this on an inpatient psych unit even if they've been saying they want to kill themselves every day for the past week.

Yeah, these situations are always tough and I think they could be better served by a hospital psychology service.

 

[hallowmann]

They'd go to the Med-psych unit here. If for whatever reason they can't, then they stay on the floor with a 1:1 with the CL service seeing them until they are medically cleared to be admitted to inpatient psych or discharge whenever appropriate. Someone who can technically medically discharge to acute rehab, but that needed psych admission would go to psych before the SNF but have PT services see them on the unit.

I agree that in the case described it's not clear that I would recommend psychiatric hospitalization assuming there is limited access/ability to self-harm at the facility.

 

[Stagg737]

I mean I would expect "fatalistic thinking" in someone with terminal cancer. Again though all those things you're talking about are best addressed in an outpatient setting with someone who is developing or has developed a relationship with the patient, not an acute inpatient stay which is, let's be honest, mainly geared towards safety, slight med changes and quick/dirty CBT for the patients who are there with SI. I think regular psychotherapy with honest reflections on a person's life/regrets (which the vast majority of the time drives the "depression" in these cases), discussion about a person's philosophy and fears around death and making meaningful change to make whatever time they have left as meaningful and enjoyable as possible is absolutely warranted.

So I agree with @Old&InTheWay I have a hard time figuring out how an acute inpatient psychiatric hospitalization is going solve much for someone with an obviously progressing terminal illness. Maybe if they wanted to voluntarily do it...

Generally I agree, but I do think this is situational and there may be times when inpatient can be beneficial. Say you've got a cancer patient with prognosis of 3-4 months who has been relatively positive about end of life and coping well who suddenly becomes suicidal for 4-5 straight days and is considering acting on it. I'd argue a brief admission may be beneficial if family/primary teams notes that this is very out of the norm for the patient and feels they would still want to enjoy a few more months of life. To the bolded, I'm assuming they're willing to be admitted in this situation, if we're talking about involuntary admission that creates a difficult situation and I'd likely be placing an ethics consult regardless of my decision.

As a note, I'm saying this as someone who agrees that patient with a terminal illness should have control over their end of life. But imo acute changes in attitude/decision-making after medical work-up is negative warrant consideration for admission.