Suicidal ideation in patient.

[hybr1d]

Hello my follow nurses! I am wondering how you would handle this situation:

Patient in its 20s. Has severe type 1 diabetes with resistance to sc insulin. Taket 250 E doses with not much effect. Has lost 2 pumps due to infection. Is now since 1 month stuck at my ward with continious glucose/insulin drip, can go from 12 to 30 in p-glucose in 2 hours without. Is very private and does not say much.

Has however warmed up to me and we have talked quite much. Has evident suicide ideation, wont verbally say it but nods when asked. Also has suicidal plans. Self-harmed by banging head against bed post. Did not want me to tell anyone due to being afraid of psych, has not had a good experience with them. I told the day nurse about it yesterday. Tonight pt actually called for me when the anxiety got too much which is huge for being this patient, did not self-harm since our last conversation. Patient obviously needs help.

Agreed to me telling day time nurse who in turn could speak to the doctor but did not want to talk to them personally which i said would be difficult cause they need to assess. Patient wished I would work more, feels no contact with the other nurses but yeah I am off now for 10 days. Well I am slightly groggy now but how would you handle a patient who confides in you like this? I am concerned and wish I could do more. I did strongly encourage the pt to be honest if it gets too much and that the only way to avoid psych at this point is to accept treatment.

[jadelpn, LPN, EMT-B]

Back far away from this. You are dangerously close to crossing a professional boundary. When any patient expresses SI complete with a plan, that is something that needs to be dealt with immediately. You should not get yourself into a position where you are the only "confidante" this patient has. That is dangerous. And I am guessing this patient saw you coming from a mile away.

The manipulation aspect of this is glaring. There are significant psych issues that can accompany anyone with a chronic serious illness since childhood. There is a tremendous amount of control issues. 2 pumps, both "infected" due to....? what exactly. Self harm means 1:1 observation and a medical psych facility. (and totally random....why is he in a bed that has a bedpost?) And also remember if his glucose is all over the place, THAT in itself can cause mental status changes.

My guess? Anger due to chronic illness that requires a nasty pump. Of which patient is picking at doing whatever with so it becomes infected (self harm) and has to be removed. Upping the ante and acting out due to this anger/loss of control (and who would not be angry or feel out of control?) Gamey to the point of "I have had bad experiences in psych"

I would feel horrible for this kid too. But as a nurse I would say that you need to step back, not personalize, and get him the treatment that covers all of his particular dynamics. There is skilled care that has a psych component to it. Can you get him home with private duty? Home health? Is his family involved in his care? All things that in light of these current revelations would warrant a care conference.

[Lev, MSN, RN, NP]

When the kid actually self harms and tells everyone that you knew about his SI your job may be down the pipe and your license may be in trouble. When a patient affirms SI, you must contact the provider for a sitter and possibly a psych consult and document what has occurred.

[hybr1d]

I did alert the doctor on call already the first time she told about it plus spoke to my 5 colleagues for advice in the morning. The doctor didnt say much more than "if XX want no contact with psych then XX has to take responsibility and not self-harm". The nurse in charge the first day hadnt even brought it up at rounds which I dont get, was overly clear this needs to be looked at. I told pt that I can not not tell about this due to the severity of it and I think it came across. I like to think I have done my best but I am sure I could have done something different too.

I am a bit naive as a person but yes manipulation aspect of it did cross my mind and I will think of it more. There is no chance of the patient getting home care, its been looked at, neither is treatment at psych, they dont take patient as ill as this. But they can sometimes have staff on our ward watching their patients getting medical care. Re the pumps it became an abscess around it this time so they had to get it. Last time the pump broke and it got infected after they had opened up trying to fix it. They are putting in a new one in a month.

They had a psych consult over some weeks ago and the patient got really upset about it and wouldnt see the doctor. Pt was talking about maybe accepting psych care from the other hospital where she had had a better experience and I told the day time staff too. At the end of our conversation was ok about me telling the day time nurse about everything too.

What did you mean why pt has a bed with a bedpost? My English failing me. We have the same beds across the hospital and same as psych. Maybe i sad it badly, I mean the edge of the bed. I think thats called a bed post? If not please correct me!

[hybr1d]

I did contact the doctor on call at night but yeah didnt get much from it. So I properly informed my colleagues so they could work on it on the day. Not worried about my job, I live in Sweden and I think the laws are very different from other countries, I am very safe in that aspect. But I am of course still much concerned for my patients.

[dishes, BSN, RN]

If the patient is open to accepting psych care where she had a better experience, she should be referred and an appointment made. It is in her best interests to receive psych care with someone she has established rapport. I don't know how it works where you are, but where I am, if the patient wants to see their longstanding psychiatrist while they are an inpatient at another hospital, the inpatient physician sends a referral.

[hybr1d]

Yes it works that way here too. Pt has not been a patient at that clinic but has at some time been a student there and thinks well of the place. I hope the doctors make stuff happen asap. I wish psychiatric issues were taken as seriously as physical ailments, that this patient has held it together this long is a wonder. Its out of my hands and the doctors know about it, but I still wonder how others would handle the confiding.

[dishes, BSN, RN]

I would have advised the doctor and the team just as you did and would have received the same response initially too.

[dishes, BSN, RN]

My attitude about patients who confide to me, is not that they are manipulating me, but they are responding to the communication style I used. When I tell the team what the patient confided, I also tell them what communication style I used, (sat at the bedside, asked open questions, listened and acknowledged concerns) some team members will make a point of using the same communication style with the patient, some will not.

[hybr1d]

Thanks dishes! I'm not suspicious like the first response, wouldn't have crossed my mind to think this patient would be intentionally sabotaging her link to a somewhat normal like (which is obvious in conversations the patient misses very much and wants nothing more than to come home and feel better). I think this patient has had a rough time for a long time and this time was the time that was simply too much. It would be for anyone. I think I do what you do, I described that I sat down beside the patient, asking about how the drawings are going and how's the family and after eyecontact (which takes a long time to get sometimes) start asking questions of how she's feeling. I did ask some leading questions though when the pt said she didn't dare tell me some things because of how we would react. (Like Have you thought and/or planned to hurt yourself?, if yes I ask In what way?) Not very leading but you get what I mean.

I heard back from the daytime nurse when she had some questions and the doctor had refused to deal with the issue because she was only working for the weekend? Eh. Pt had also talked to the daytime nurse and said she knew that I had shared what was going on with her so it's good, it opened up so she could talk to that nurse too about it. :)

[KelRN215, BSN, RN]

Suicidal ideation with a plan means a 1:1 sitter within arms reach at all times where I am. The patient cannot use the bathroom, shower, anything without the sitter present.

Once stabilized medically, the patient will likely require inpatient psych if still expressing suicidal ideation. He's got easy access to a med (insulin) that can kill him very quickly. I remember a patient from when I did my psych clinical was a type 1 diabetic. She was initially allowed to keep her pump on- until she (falsely) told staff that she had bolused/overdosed herself with insulin in an attempt to commit suicide. She promptly got her pump taken away and bought herself 5 shots/day. This patient should not be sent home to manage his own insulin needs until he can contract for safety.

[hybr1d]

Yep! I'm totally on board with that. I get frustrated when I don't get that kind of response from the doctor on call and in the weekend and night it's what I have available to contact. The daytime doctors have to take charge of it but it seems they did not.

This patient has something like 250 E x3 per day but the p-glucose still rockets above the 30s without the drip. Scary with the patient who tried to commit suicide that way!!