Psychiatric Advantage Directives in the ER?

[moriahcat]

While I'm partially asking this question for myself, I'm curious how many of you guys have had patients present with a psychiatric advance directive and how it helped/hindered your ER's ability to treat a pt in a psychiatric emergency.

I have Bipolar I and have only had one episode of manic psychosis, but despite me staying compliant with my pmeds and such, it could happen again. Unfortunately during that admission we learned I have an extreme sensitivity to high-potency antipsychotics (ended up with early-stage NMS). Unfortunately Haldol and droperidol are often first-line treatments when a pt presents in any form of psychosis, which is why my pdoc is helping me develop one.

Fortunately he participates in the Medical Exchange in our locality, so he can be reached relatively quickly to give further advice if an admission is necessary, but we know it can take hours before they call a patient or ER back. (Hence "relatively", compared to an ER presentation on a Friday night and not being able to reach the treating physician until Monday.)

He absolutely does not want me to have any first-generation antipsychotic, and we're crafting the directive so that I agree in advance to isolation/physical restraints instead of chemical restraints if restraints are indicated. But how well does that play in an emergency setting, even if the person calling the ambulance/taking the pt to the ER has the paperwork and it gets presented before the MD issues orders?

For example, are there alternatives to first-generation antipsychotics by IM in your ER? I'm pretty benzo-naive so that could be a temporary alternative for sedation until getting sent upstairs, but what about second generation antipsychotics? There's always the chance in any pt in psychosis on admission, even short, slim, weaker patients, that they could become so combative that getting physical restraints in place could be dangerous to the pt and staff.

I'm just curious if such a directive *could* be followed in an ER setting with a pt in psychosis. I'm hopeful it would never be needed, as my pdoc is responsive to calls, even in the middle of the night, and we have a protocol for if I do start heading toward mania to force me to sleep enough that I can avoid the psychosis end. But if it's going to just not work in an ER setting, we may need to craft it differently and be prepared for it to only be followed after an admission in the psychiatric unit itself.

Have any of you run into pts with psychiatric advance directives in the ER? Did they end up being essentially useless because of being unable to, for example, have an isolation area in a smaller ER or being unable to implement physical restraints without chemical sedation first?

Thanks.

[WKShadowNP, DNP, APRN]

I've not heard of this before. The most I've seen are the referral letters from their counselor/psychiatrist/psychologist because they are at risk for threats of violence (To self or others). I suppose a recommendation would help but I can't say that we'd absolutely follow that. We have too few psychiatric facilities here but plenty of psych services as outpatient. When those presenting in psychosis are in danger we do what we can to protect them and ourselves/other patients. That information ahead of time could be beneficial but I don't know that it's a guarantee. It's hard to say as I've not encountered it.