Suicide?

[blastoise]

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Hey everyone,

Just a general thought experiment/question here regarding keeping patients against their will in hospital when they voice suicidal ideation. I realize this situation will never happen, I just wanted to see what the opinion would be as i've received heavily variable answers from psychiatrists i've worked with.

In Canada, when a patient is deemed at moderate/high risk of suicide, we typically put them on a "form 1" which gives 72 hours in which the patient is forced to be hospitalized and receive a psychiatric assessment to determine the likely underlying psychiatric condition/stressors that are leading them to voice suicidal ideation.

However, lets say that after 72 hours of assessment. The patient is clean. No medical issues, no psychiatric issues. A general content, happy person who does not meet any criteria for a psychiatric condition. Fully competent mentally. However, lets say they still voice a desire to die. After the 72 hours in which you've held them against their will, they say "thank you for your care, I will be killing myself when i go home today, because I just want to". Are you still able to hold them against their will? Some psychiatrists have told me that they would consider keeping them hospitalized as there 'must' be something wrong with them. But what if there isn't. We allow jehova's witness patients to refuse blood transfusions even in acute need because of their beliefs, this is essentially allowing them to commit suicide. I don't have any particular opinion on the topic, was hoping to learn more.

Just wondering what people think? I recently finished my psychiatry rotation and was thinking about this.

 

[gutonc]

So, after their 72h (or whatever timeframe) hold, they seem totally fine except that the one thing they were held for (SI in your example) is the one thing they still exhibit. And you're asking what to do next? Hold them. They're not "fine". They're still suicidal.

The JW example (as crazy as those folks can be about some things) is a red herring. Also, we're going to leave America's Toupe' out of this conversation as well. If you can find a mainstream-ish religion that has suicide as one of their primary principles, then let me know. Christian Scientists are even more crazy, but we still let them refuse treatment for easily treatable conditions for themselves (but not their children). But we don't allow them to actively harm themselves.

 

[dpmd]

If they are still a danger to themselves the get changed to a 14 day hold where I live and can contest it in court if they want (although going in to court and saying you want to get let out to kill yourself is probably not going to work), then it can be extended to 30 days if the person hasn't figured out how to say the right things to get released. As for your contention that there is no indication of mental illness, I am guessing this is one of those circumstances where the act (of voicing suicidality to psych professionals who then have the ability to keep you hospitalized) speaks for itself.

 

[hamstergang]

I certainly don't believe that all suicides are from mental illness, just the vast majority of them. I just don't see how rational suicidality comes from an otherwise completely well (healthy) person. So in this case, I'd have the patient committed for further evaluation and treatment.

 

[blastoise]

But don't we allow people to deny treatment, which will effectively contribute to their death. A competent patient can refuse surgery even in the acute setting, they can refuse insulin, refuse dialysis etc. All these things are something we allow patients to do, they can refuse therapy which we as a medical community are certain will lead to their death, very soon. In the same situation, a patient who appears completely mentally competent but then voices a desire to commit suicide, how can we force this patient to receive therapy. I agree any rational person would not want to kill themselves, but again I am just wondering if you have done continuous assessment and they are a fully competent/functioning individual who just said they would like to commit suicide. Why do we not honor this request? Why do we force therapy on this patient but not the other situations?

Again, I could be completely off, just looking to see your opinions.

 

[Doctor Bob]

But don't we allow people to deny treatment, which will effectively contribute to their death. A competent patient can refuse surgery even in the acute setting, they can refuse insulin, refuse dialysis etc. All these things are something we allow patients to do, they can refuse therapy which we as a medical community are certain will lead to their death, very soon. In the same situation, a patient who appears completely mentally competent but then voices a desire to commit suicide, how can we force this patient to receive therapy. I agree any rational person would not want to kill themselves, but again I am just wondering if you have done continuous assessment and they are a fully competent/functioning individual who just said they would like to commit suicide. Why do we not honor this request? Why do we force therapy on this patient but not the other situations?

Again, I could be completely off, just looking to see your opinions.

The competent patient who refuses a treatment that without will lead to their death, is opting to not intervene in the natural order of things.

The competent suicidal person is opting to take an active role in the termination of their life. Without their action, the natural order would be continuation of their life.

 

[CopaceticOne]

In the same situation, a patient who appears completely mentally competent but then voices a desire to commit suicide, how can we force this patient to receive therapy

This depends on the laws in the various states. For example, in Wisconsin you need a separate and specific court order for forced psychiatric treatment (medication etc). This is in addition to the normal order of a pt not being competent for medical decisions (i.e. pt can not refuse their BP meds) and/or court order for hold due to being a danger to themselves / others.

 

[IMPD]

Hey everyone,

Just a general thought experiment/question here regarding keeping patients against their will in hospital when they voice suicidal ideation. I realize this situation will never happen, I just wanted to see what the opinion would be as i've received heavily variable answers from psychiatrists i've worked with.

In Canada, when a patient is deemed at moderate/high risk of suicide, we typically put them on a "form 1" which gives 72 hours in which the patient is forced to be hospitalized and receive a psychiatric assessment to determine the likely underlying psychiatric condition/stressors that are leading them to voice suicidal ideation.

However, lets say that after 72 hours of assessment. The patient is clean. No medical issues, no psychiatric issues. A general content, happy person who does not meet any criteria for a psychiatric condition. Fully competent mentally. However, lets say they still voice a desire to die. After the 72 hours in which you've held them against their will, they say "thank you for your care, I will be killing myself when i go home today, because I just want to". Are you still able to hold them against their will? Some psychiatrists have told me that they would consider keeping them hospitalized as there 'must' be something wrong with them. But what if there isn't. We allow jehova's witness patients to refuse blood transfusions even in acute need because of their beliefs, this is essentially allowing them to commit suicide. I don't have any particular opinion on the topic, was hoping to learn more.

Just wondering what people think? I recently finished my psychiatry rotation and was thinking about this.

It's not uncommon (esp amongst adolescents and those with adolescent-level maturity) to use "thoughts" of suicidality as a drama-generating device. Chronically suicidal patients are sent home from Psych emergency rooms every day. It takes reasonably good and experienced clinical judgement to do this. All patients with persistent suicidality are not the same.

 

[dpmd]

But don't we allow people to deny treatment, which will effectively contribute to their death. A competent patient can refuse surgery even in the acute setting, they can refuse insulin, refuse dialysis etc. All these things are something we allow patients to do, they can refuse therapy which we as a medical community are certain will lead to their death, very soon. In the same situation, a patient who appears completely mentally competent but then voices a desire to commit suicide, how can we force this patient to receive therapy. I agree any rational person would not want to kill themselves, but again I am just wondering if you have done continuous assessment and they are a fully competent/functioning individual who just said they would like to commit suicide. Why do we not honor this request? Why do we force therapy on this patient but not the other situations?

Again, I could be completely off, just looking to see your opinions.

We allow them to refuse treatment only if they can make an informed decision to do so. But a completely healthy person saying they are going to kill themselves would need to prove they are mentally capable of making that decision. The fact that continuing to voice those thoughts results in them staying hospitalized shows they are not thinking rationally (the rational person would lie and say they no longer want to do it so they can get out of there) and therefore we should protect them from themselves. No actual therapy is forced in that case though (psych meds would take a court order to force on them and no one can force them to talk), they are just denied the ability to leave and harm themselves. On the other hand if someone has a well thought out and consistent reason for why they don't want to be kept alive I have no problem getting them into hospice and allowing nature to take its course (assuming they have a natural reason that they will succumb to), and if they happen to help things out a bit with some extra meds I am not going to stop them. But without a reason they would be expected to die (of natural causes) within a year, it is going to be difficult to convince me that the reason is well thought out and consistent.

 

[californiaappli1]

I am sure someone has said it more eloquently above but :

Withholding treatment is not morally equivalent to killing yourself.

Some try to make an argument that it is, but it is not the most popular of positions.

 

[psych md jd]

IMO, the person who says "I will be killing x" earns a golden ticket admitting him/her to the psych unit. I can't do a proper evaluation in the limited time available in the PER. The person will stay on a hold as long as his/her risk of harm is unacceptable. Some of my current patients have been on involuntary commitment since the 80's.

The right to die, right to live, right to be born, and the right to refuse treatment certainly have some doctrinal overlap with involuntary detention, all ultimately resting upon Constitutional underpinnings. Involuntary detention has traditionally been implemented to further an important state interest: to protect the health, welfare, and safety of its citizens, by allowing [a temporary] suspension of an individual's rights. By invoking these powers as justification, the state usually trumps all other interests. Most statutes also include some mechanism to comport with due process.

 

[michaelrack]

But a completely healthy person saying they are going to kill themselves would need to prove they are mentally capable of making that decision. .

competency to make a decision has little to nothing to do with psych holds/commitments in many states.

 

[Doctor4Life1769]

competency to make a decision has little to nothing to do with psych holds/commitments in many states.

Isn't competency more of a legal definition?
We determine capacity, but not competency.

 

[J ROD]

Isn't competency more of a legal definition?
We determine capacity, but not competency.

exactly. or at least that's what I have done on my C/L rotations and was taught by my Forensics Psych PD

 

[Mad Jack]

We allow them to refuse treatment only if they can make an informed decision to do so. But a completely healthy person saying they are going to kill themselves would need to prove they are mentally capable of making that decision. The fact that continuing to voice those thoughts results in them staying hospitalized shows they are not thinking rationally (the rational person would lie and say they no longer want to do it so they can get out of there) and therefore we should protect them from themselves. No actual therapy is forced in that case though (psych meds would take a court order to force on them and no one can force them to talk), they are just denied the ability to leave and harm themselves. On the other hand if someone has a well thought out and consistent reason for why they don't want to be kept alive I have no problem getting them into hospice and allowing nature to take its course (assuming they have a natural reason that they will succumb to), and if they happen to help things out a bit with some extra meds I am not going to stop them. But without a reason they would be expected to die (of natural causes) within a year, it is going to be difficult to convince me that the reason is well thought out and consistent.

See, where it gets weird is if you get someone that is, say, a nihilist.

Like, what if someone has logically concluded that the suffering of life is not worth continuing to exist for and they aren't depressed or anything but they just think existence is a bum deal? You don't need to be crazy to feel that way. I mean, in a lot of ways, I totally understand that train of thought, but I'm just very "whatever" about it because generally the plusses of life seem to outweigh the minuses. But if they didn't, why keep going, you know?

 

[dpmd]

See, where it gets weird is if you get someone that is, say, a nihilist.

Like, what if someone has logically concluded that the suffering of life is not worth continuing to exist for and they aren't depressed or anything but they just think existence is a bum deal? You don't need to be crazy to feel that way. I mean, in a lot of ways, I totally understand that train of thought, but I'm just very "whatever" about it because generally the plusses of life seem to outweigh the minuses. But if they didn't, why keep going, you know?

It would take some demonstrated actual suffering before I would buy that logic as sound (and probably being willing to try an antidepressant because nihilism sounds like it has a lot of overlap with dsm criteria for mood disorder but I am not a psych).

 

[Crayola227]

the rational person set on suicide fakes being OK, jumps through the hoops, and goes home and gets it done

the person who likely is impulsive or having mood issues are more likely to reveal than the clever person above
so telling you is either a sign of not very clever thinking perhaps proof positive of psych issues, which deserves some investigating with a hold, or is a cry for help, in which case you should hold

it's not rocket science that way

and comparing wanting to kill yourself to refusal of treatment leading a poor health outcome or death, really apples and oranges

also keep in mind that there are different element in competency as determined legally
someone may not be considered competent in handling finances and have a conservator, but does have enough mental function to demonstrate decision making capacity in a health context

someone may also have capacity for some health decisions and not others
example: someone is able after you educate the, to summarize back the proposed treaments, benefits, and potential harms, and articulate a choice, for say something simple to understand like a blood tranfusion. This same person may not be able to demonstrate that same capacity in deciding whether or not to have a complex surgery, stoma, and chemo

some may be able to articulate code or no code, help set goals of care (for example pain mangagement) but beyond that perhaps not

it's important to be clear on this stuff so that we don't take away more autonomy than we are justified in taking

 

[michaelrack]

Isn't competency more of a legal definition?
We determine capacity, but not competency.

whatever u call it- competency or capacity, it has nothing to do with a psychiatric hold/commitment for suicidality in most states. The standard is dangerousness to self/others, not capacity/competency

 

[psych md jd]

Basically, with regard to competency, the question is competency to do what?

Competency to do x is likely different from competency to do y.

Refusal of meds, procedures, surgery etc. is a capacity question. All physicians can/should be able to assess capacity. Don't call for a psych consult.

 

[rokshana]

Basically, with regard to competency, the question is competency to do what?

Competency to do x is likely different from competency to do y.

Refusal of meds, procedures, surgery etc. is a capacity question. All physicians can/should be able to assess capacity. Don't call for a psych consult.

yeaah...dont hold your breath...

 

[psych md jd]

Once when I was called for a capacity consult I directly quoted the patient:

Mr. X states he would take his medication if he was told why his dose was being increased.

True story.

 

[clausewitz2]

As far as I can tell the only reason non-psychiatrists can't do capacity evaluations is if they really can't bring themselves to speak to the patient in question. Which, y'know, sometimes understandable, but not a problem that is going to be solved by a psych consult.

Edit: there is of course also the genre of "patient is refusing treatment I want them to have, consult psych to make patient agree to treatment."

 

[dpmd]

As far as I can tell the only reason non-psychiatrists can't do capacity evaluations is if they really can't bring themselves to speak to the patient in question. Which, y'know, sometimes understandable, but not a problem that is going to be solved by a psych consult.

Edit: there is of course also the genre of "patient is refusing treatment I want them to have, consult psych to make patient agree to treatment."

Sometimes it is just that the consequences are so immediately severe that if you just go along with it you are going to get hassled by so many people (nursing and then administrators as they kick it up the chain) that you just want to both cover your butt and be able to shut all those folks down. For example my 40 y/o vent dependent but able to breathe some quad who decided to come off vent but then needed comfort care dosing of meds to deal with the air hunger but the nurses felt those doses were killing him quicker (they were but at that point you shouldn't care) and didn't want to give them so instead we had the patient suffering while i went through hoops to get it figured out. His age and robust appearing (though newly immobile) body made his decision difficult for some to understand. So as a resident with psych readily available it was just easier to get them involved than to try to make a stand that i evaluated him and found he had decision making capacity.

 

[Crayola227]

yep, sorry psych, sometimes there's no getting around the CYA consult

sucks

 

[Promethean]

I have a dear friend who occasionally wants to discuss his (ambivalent) wish to not exist. He isn't especially mentally ill, other that that he has this persistent feeling that living is a lot more trouble than it is worth, and that the good that he can do with his life, however great it may be, does not quite balance out the costs of the resources that he consumes along the way. We have philosophical debates about it. Again, I say, he isn't exactly depressed. He is just a very thoughtful soul, one of those people who are entirely too brilliant for their own good. His reasons for wanting not to exist derive from carefully constructed logical arguments.

I don't try to commit him because he doesn't voice an immanent plan to do himself harm, and he assures me that he will not commit suicide because of how that would impact the many people who love him. Just, if he had the option to have not existed, he would prefer that. He does see a therapist who specializes in very smart people who talk themselves into bizarre existential boxes.

So, he is very much the patient you are discussing hypothetically. Here is the thing... if he were held for psychiatric eval, he would lie. Or at least stop repeating his desire to die. Someone who knows that they will be detained further for continuing to voice a desire to die, who continues to make those statements, is in some sense accepting that detention. If they genuinely, certainly, and completely wished to die, the simplest expedient would be to tell you that it was only an figure of speech, that they had no intent to harm themselves, and then to nip off and do it the moment you let them stroll out the door. The hypothetical patient is ambivalent, evidenced by voicing their desire to those who have the power to prevent them from achieving it. That is a patient who is asking for help, on some level.

I do think that at some point, there is a strong likelihood that my friend will kill himself. When that time comes, I don't expect that he will give anyone advanced notice. There is nothing to be done to prevent this. That is, although I believe that my friendship and support is helpful in giving him one more reason to stick around... he cannot be forced to live. It isn't practical or morally defensible to institutionalize someone indefinitely against the risk that they may someday decide to commit suicide, when they aren't presently a danger to themselves. That would be more likely to hasten their demise, if anything. The very clever, physically healthy person who is determined to accomplish such a goal will find a way to do so, even under the most careful supervision.

 

[Crayola227]

you say there is nothing that can be done to prevent this
I don't know in your friends case

It's funny they are always selling this slogan about suicide being preventable
I don't know what I think about this
eh, it's a human life. probably worth trying anyway

 

[evilbooyaa]

I have a dear friend who occasionally wants to discuss his (ambivalent) wish to not exist. He isn't especially mentally ill, other that that he has this persistent feeling that living is a lot more trouble than it is worth, and that the good that he can do with his life, however great it may be, does not quite balance out the costs of the resources that he consumes along the way. We have philosophical debates about it. Again, I say, he isn't exactly depressed. He is just a very thoughtful soul, one of those people who are entirely too brilliant for their own good. His reasons for wanting not to exist derive from carefully constructed logical arguments.

I don't try to commit him because he doesn't voice an immanent plan to do himself harm, and he assures me that he will not commit suicide because of how that would impact the many people who love him. [Just, if he had the option to have not existed, he would prefer that. He does see a therapist who specializes in very smart people who talk themselves into bizarre existential boxes.

The bolded are the two main reasons that people with passive suicidal ideation are considered safe to be managed as an outpatient.
However, if he is willing to speak to somebody who is a professional regarding this (even as an attempt to see if he would be interested in discussing it) then I would 100% refer him to somebody.

 

[Bartelby]

The situation as presented is odd, and releasing such a patient without some clarification would be a poor choice. The patient exhibits no signs of mental illness whatsoever, appears genuinely happy, and then explains to you that he is going to kill himself. Why? If he said "no reason, just going to kill myself because I want to" then without a doubt further evaluation should happen. Maybe:

-the patient is good at masking his symptoms and does in fact have a reason to want to die?
-the patient is personality disordered and provocative, and rallying some kind of support would be important to avoid a suicidal gesture?
-the patient is not telling you about some major stressor (terminal illness, something shaming, who knows?) and a frank conversation about the issue might decrease suicidality?
-the patient wants to obtain housing, food, miss a court date, etc and they are being dishonest about their suicidal intent in order to obtain the secondary gains of the hospitalization that these statements could bring?

As described in your hypothetical it seems those three days were spent peering at the guy through a glass pane while he watched T.V. in the day room. Why not explore this decision with him? Why not contact family members to see if they have insight into his strange conduct? Why not send for collateral from his other treaters? In the end with the discharge you will have to write a risk assessment, and "he didn't look depressed so I sent him out even though he assured me he would kill himself for some unknown reason" seems insufficient.

 

[Mass Effect]

After the 72-hour hold, the attending/resident can go to court to argue for commitment on the basis of the patient being a harm to himself/herself. We only allow people to make decisions about refusing treatment when they have capacity. The argument regarding suicide in a patient is who is depressed is that severe depression, the kind that leads to suicide, results in cognitive changes that affect capacity. Ever seen a truly severely depressed person? Some of them are close to catatonia before someone commits them for treatment. But even when they're not at that point, a truly depressed person considering suicide has impaired judgment, likely secondary to the depression and such patients are commitable.

 

[hamstergang]

We only allow people to make decisions about refusing treatment when they have capacity. The argument regarding suicide in a patient is who is depressed is that severe depression, the kind that leads to suicide, results in cognitive changes that affect capacity.

This is not true, in that the laws for committing psychiatric patients are not based on capacity.

 

[Doctor4Life1769]

After the 72-hour hold, the attending/resident can go to court to argue for commitment on the basis of the patient being a harm to himself/herself. We only allow people to make decisions about refusing treatment when they have capacity. The argument regarding suicide in a patient is who is depressed is that severe depression, the kind that leads to suicide, results in cognitive changes that affect capacity. Ever seen a truly severely depressed person? Some of them are close to catatonia before someone commits them for treatment. But even when they're not at that point, a truly depressed person considering suicide has impaired judgment, likely secondary to the depression and such patients are commitable.

Yeah, the resident is going nowhere. The attending doesn't want to get involved either.
This is why psych is often consulted. Medico-legal CYA so that someone else can do the dirty work.

 

[Mass Effect]

This is not true, in that the laws for committing psychiatric patients are not based on capacity.

I was responding to the notion that we allow people to refuse treatment on the medical floors when I mentioned that they can refuse only if they have capacity. I was making a comparison between that and why we keep psych patients. We don't call it capacity on the psych floors because it doesn't fit into the traditional definition/assessment of capacity, but imo, it's equivalent. We're saying that this person demonstrates impaired judgment due to a mental illness, such as depression. Just as someone with physical ailments may not have capacity due to delirium, a psych patient can be just as vulnerable to bad decisions, such as leaving "AMA" due to depression.

Yeah, the resident is going nowhere. The attending doesn't want to get involved either. This is why psych is often consulted. Medico-legal CYA so that someone else can do the dirty work.

I was talking about psych. I should have made that clear. I'm a psych resident and I was answering the question as a psych resident. This is the protocol on the psych floor. Medicine attendings wouldn't be involved in commitment because they don't work on the psych inpatient unit (or they don't have admitting privileges there), so it would be silly for them to commit someone.