Suicidal man at nurses' station

metal_m0nk, BSN, RN · Jul 15, 2011

I agree that the OP may not have phrased this optimally, and maybe should have said that this patient obviously had a significant, active psych issue.

Real, full blown, chemical imbalance or a lifetime of maladaptation type psych issues aren't generally inactive unless it is the period preceding an initial psychotic break. If a person has a significant psych issue, one that is disruptive enough to interfere with functioning, relationships, well being, etc., it will be there no matter. What you may have seen in your experience that you may have termed an individual with an "inactive" psych issue was most likely a well medicated individual. Now, perhaps this facility is like many others in that, perhaps they d/c'd his psych meds upon admission for a medical issue and could have directly contributed to the incident. But that's another convo all together.

The truth is, anyone can be a danger. There is often a very thin line between what is considered sane what isn't. Believe it or not, suicidal ideation is much more common than most would admit and SI in and of itself neither predisposes an individual to chronic psychiatric illness, nor a tendency toward violent or homicidal behavior.

The OP jumped to some conclusions. I think most would agree that the patient should have been dealt with every precaution, but what is most striking about her post was not what should have been done, but the hysteria she exhibits in her reasoning. That's what people who actually have some first-hand, long term experience with the mentally ill are reacting to.

rn/writer, RN · Jul 15, 2011

The OP jumped to some conclusions. I think most would agree that the patient should have been dealt with every precaution, but what is most striking about her post was not what should have been done, but the hysteria she exhibits in her reasoning. That's what people who actually have some first-hand, long term experience with the mentally ill are reacting to.

I have long-term psych experience, and I didn't see any hysteria in the OP's post at all. In fact, I think she was trying to reduce the hysteria that was being created by having this guy across from the nurses' station with a whole bunch of people standing around staring at him.

It would have been prudent for someone to take him to a less crowded area and listen to his concerns. That's what the OP was suggesting.

The only hyper tone in the original message was regarding the administrator who, by this account, didn't have a clue and wasn't taking her suggestions seriously.

The fact that a doc arrived and directed staff to do exactly what the OP said validates her approach, as does the fact that this action (taking the man to a private setting) worked. The entire situation needed to be de-escalated, and that's what getting him away from the crowd of onlookers accomplished.

I DO note an over-reactive tone from some who seem to think that mental illness is a sacred cow and that for staff to act with caution around someone who is actually threatening self-harm is somehow prejudicial and stigmatizing. That bothers me a little.

metal_m0nk, BSN, RN · Jul 18, 2011

I have long-term psych experience, and I didn't see any hysteria in the OP's post at all. In fact, I think she was trying to reduce the hysteria that was being created by having this guy across from the nurses' station with a whole bunch of people standing around staring at him.
It would have been prudent for someone to take him to a less crowded area and listen to his concerns. That's what the OP was suggesting.

The hysteria in the original post is pretty unmistakable. The OP was not suggesting that the patient be taken to a less crowded area so that his concerns could be listened to. The OP was suggesting that the patient was an immediate physical threat to everyone around him and that he should be placed in seclusion:

the asst. admin is talking to the US with his back to the patient. I immediately went to the asst admin and asked him why this man isn't isolated away from us. He gets a "look" and asks me why. I tell him "Are you serious? This guy just walked in and said he's about to kill himself. He could very possibly have a weapon of some sort, he obviously has psych issues and this makes him a potential danger to us, our patients and visitors".

I have worked in psych as well, btw.

Katie82, RN · Jul 18, 2011

I would hope that after this incident, your Management Team developed a protocol for handling such issues in the future, and with the increasing number of emotionallly challenged who enter the system, we all need to become more profient in providing care. There are legal issues in many states with regard to suicide threats. In my state, I am required to call 911 if someone shares with me that they are considering suicide. This is not meant to be puntitive, but will hopefully get someone who is not yet receiving help (as many are not) into the system. Sounds like a job for your Policy Committee, this will prevent people from standing around looking stupid in the event this happens again.

rn/writer, RN · Jul 19, 2011

The hysteria in the original post is pretty unmistakable. The OP was not suggesting that the patient be taken to a less crowded area so that his concerns could be listened to. The OP was suggesting that the patient was an immediate physical threat to everyone around him and that he should be placed in seclusion:
I have worked in psych as well, btw.

Asking why a man who has said he wanted to kill himself (who may or may not have a specific plan or a weapon) hasn't been taken to a less crowded area is not the same as suggesting he be rushed into seclusion. If there was any hysteria, seems like it related more to the insanity of the situation (lots of people possibly in harm's way) than the mental illness of the patient.

When people say they want to harm themselves or others, it's best to take them seriously. Part of that is de-escalating the environment by clearing out unnecessary personnel and bystanders and creating a more peaceful environment. We used to call it removing the audience.

Had I been the OP, I. too, might have been upset that these obvious measures hadn't been taken. And that the administrator was also clueless. The doc who arrived shortly after the OP made the same suggestions because that is typically what is needed when you have a potentially volatile situation.

What I don't see recognized is that this man was potentially volatile, not simply because he had a mental illness, but because he said he wanted to kill himself. How could that not have been taken at face value and followed by de-escalation efforts?

Esme12, ASN, BSN, RN · Jul 20, 2011

The hysteria in the original post is pretty unmistakable. The OP was not suggesting that the patient be taken to a less crowded area so that his concerns could be listened to. The OP was suggesting that the patient was an immediate physical threat to everyone around him and that he should be placed in seclusion:
I have worked in psych as well, btw.

Which gives you a more unique ability to have insight to this situation that a nurse who has no experience in psyche issues. A medsurg nurse in a LTC setting with a disorganized, discheveled, appearance (in a patient gown, naked with a leaking colosotmy) and thought process admitting to SI needs to be secluded to ensure the saftey of all....including the patient. It is a form of restraint but the patinet has admitted to SI and clearly has porr impulse judgement (he ran out of a hospital in patient gown with a leaking colostomy and into a nursing home)) Until the situation can be better accessed and evaluated without endangering the general patient population was a reasonable expectation for ths nurse and in an emergency room setting, as you wil learn, our main goal is to protect everyopne involved and will isolate as necessary until any volitile situation is thouroughly evaluated and deemed safe and in control......:twocents:

metal_m0nk, BSN, RN · Jul 21, 2011

I am not and did never argue that some form of action was inappropriate to the situation mentioned. If you continue to believe that, it is of your own volition with no assistance from me.

What is being discussed here (and it is a valid point) is the stigma of mental illness and the fact that it is alive and well, even within the medical community for those who have no direct experience with it.

Again, the hysteria in the original post, insofar as it is obvious that the OP made the assumption that since the patient is believed to be suicidal, that patient is an immediate threat of physical harm to those around him, is very apparent. It's the reasons, not the actions that some might take offense to.

During a clinical rotation, I had the opportunity to care for a 45 year old man with multiple comorbidities and failing systems. During a psycho-social assessment he mentioned that sometimes he wished the docs would just let him be and let him die so that he wouldn't have to spend another agonizing day lying in a hospital bed. I would have been horrified if someone had taken that admission and decided to place him in seclusion under the assumption that he was an immediate physical threat to any and all around him.

And while it is unrealistic to hope that I never have to work with someone who holds the same assumptions as the OP, I do hope I am able to hold my tongue when the thought crosses my mind to restrain and seclude them instead.

rn/writer, RN · Jul 22, 2011

There's a big difference between someone saying they want to be left alone to die and a disheveled and disorganized person who has left the hospital where he was admitted saying he wants to kill himself. The second example is by far the more immediate and urgent.

And there's a difference between wanting to get the person away from prying eyes and "putting them in seclusion."

it is obvious that the OP made the assumption that since the patient is believed to be suicidal, that patient is an immediate threat of physical harm to those around him, is very apparent.

I would entertain that possibility myself (with years of psych nursing experience) as you just don't know to what lengths such a patient will go if he's feeling desperate enough. Besides, he's also a threat to himself. Separating him from the crowd doesn't have to be punitive. It's not the same as putting someone in seclusion. It's just plain common sense. If it was easier to clear out all of the other people, that could have been done, too. But because this all took place at the nurses' station, I'm assuming it would have been somewhat difficult to keep things quiet there.

I get that too many people feel like mental patients are the bogeyman that'll get 'em if they don't watch out. I also get that some folks are so worried that patients might feel bad that they tip-toe around reality.

When I had someone who was threatening suicide, I would ask if they had a plan and/or a timetable. We'd talk about what had them so upset and what methods they were considering. If a crowd gathered I sent them away or got other staff members to run interference. Many times, patients said it felt good to just be able to put it all out there on the table and talk about what was on their minds.

I never had anyone attempt to harm themselves on my watch.

Again, this guy was a threat, not because he had a mental illness, but because he said he was, even if that threat was to no one but himself.

metal_m0nk, BSN, RN · Jul 22, 2011

I get that too many people feel like mental patients are the bogeyman that'll get 'em if they don't watch out. I also get that some folks are so worried that patients might feel bad that they tip-toe around reality.
When I had someone who was threatening suicide, I would ask if they had a plan and/or a timetable. We'd talk about what had them so upset and what methods they were considering. If a crowd gathered I sent them away or got other staff members to run interference. Many times, patients said it felt good to just be able to put it all out there on the table and talk about what was on their minds.
I never had anyone attempt to harm themselves on my watch.
Again, this guy was a threat, not because he had a mental illness, but because he said he was, even if that threat was to no one but himself.

I'll say it again. I am not and did never argue that some form of action was inappropriate to the situation mentioned. If you continue to believe that, it is of your own volition with no assistance from me. The point you are trying to drive home is irrelevant. Something must indeed be done. However, if it is done with the assumption that the individual involved is an immediate threat of danger to everyone around him, it WILL be perceived as punitive. It's not about tip-toeing around reality. It's about safety, of course, but it is also about dignity and human rights. It is sometimes a difficult balance to strike, but it is an imperative one.

Esme12, ASN, BSN, RN · Jul 22, 2011

I'll say it again. I am not and did never argue that some form of action was inappropriate to the situation mentioned. If you continue to believe that, it is of your own volition with no assistance from me. The point you are trying to drive home is irrelevant. Something must indeed be done. However, if it is done with the assumption that the individual involved is an immediate threat of danger to everyone around him, it WILL be perceived as punitive. It's not about tip-toeing around reality. It's about safety, of course, but it is also about dignity and human rights. It is sometimes a difficult balance to strike, but it is an imperative one.

I hear what you are saying.......and I agree on most levels. My concern, in this senario, for this patient, was the impaired judgement and impulsive nature of his bolting from the hospital across the street, in a patient gown, probably nothing under the hospital gown, with a leaking colostomy who duckes in the first door he saw and was found cowering on the floor saying he was going to kill himself. I am going to presume that the patient is of fragile metal state and therefore a threat to himself (which the patient admitted by declaring SI) and a potential threat to those around him........the patient is at present unstable.

I will respond to a patient being mentally unstable threating suicide, as quickly as I respond to a patient with a patient physically unstable with a sucking chest wound and cyanosis. In this instance with body fluid exposure risk, not knowing the patient, not knowing any history, seeing a distraught, unpredictable human being in OBVIOUS distress declaring they want to kill themself......I would move him out of the hallway (isolate)and off the floor for his own privacy, dignity and safety; as well as others safety, until I could get a better handle on the situation.

Your experience with psych will be of enormous value in your nursing but you need to remember that your are outside of the "psych" world and in the general population, so to speak, and things are handled a little different in the med-surg population world...........I worked at a hospital that had a psych (closed) within the hospital. It housed many psych patients with medical co-morbidities that were cared for there so their medical needs were attended to as well. The psych nurses required the help of the med-surg nurses and the med-surg nurses required the help of the psych nurses. I found as supervisor that they both evaluated a situation from very different prespective......but BOTH from a place of caring, knowledge, and reverence for the patient. Both VERY DIFFERENT. Everybody here was very used to needing each others speciality that they recognized, respected, and appreciated each other greatly.....and both benefitted from the relationship.

You are interested in ED and flight and I will tell you that's a whole different species all together and a whole different learning curve from psych and med-surg. Things happen quickly and unpredictably....and from my experience.......safety is key and negotiation not always initally possible to contain a situation and violence is your new nemisis/freind. I have learned it's not the message but the delivery of the information that influences a patients perception of a situation even when they may be having trouble with perception......just my :twocents: peace

rn/writer, RN · Jul 22, 2011

However, if it is done with the assumption that the individual involved is an immediate threat of danger to everyone around him, it WILL be perceived as punitive.

My concern, in this senario, for this patient, was the impaired judgement and impulsive nature of his bolting from the hospital across the street, in a patient gown, probably nothing under the hospital gown, with a leaking colostomy who duckes in the first door he saw and was found cowering on the floor saying he was going to kill himself. I am going to presume that the patient is of fragile metal state and therefore a threat to himself (which the patient admitted by declaring SI) and a potential threat to those around him........the patient is at present unstable.

The bolded part is what I have been saying. This patient is unstable. Taking him to an empty patient room doesn't have to have any punitive overtones at all. It's simply a prudent move when you have someone who is acting in an impulsive manner and threatening self-harm. His fragile mental state and lack of connection to the staff in this facility (i.e., they don't know anything about his history--his diagnosis, how serious he is about his threats, what upset him in the first place, etc.) means they have to act as if he is a danger because his words and actions indicate instability and a measure of desperation.

This has far less to do with the stigmatization of mental illness than the specific words and actions of this particular patient.

One more thought. The difference between taking this man to an empty patient room or some other quiet place and "putting him in seclusion" is that someone would be going with him and hopefully helping him to calm down and communicate. They wouldn't be isolating him but rather protecting him from those who see him as a spectacle. If that's not concern for dignity and human rights, I don't know what is.

talaxandra · Jul 22, 2011

Also, 'seclusion' is very much a psych concept - seclusions rooms don't exist on the med/surg wards at my hopsital, and the only place I've heard the term is during my psych education and rotation. The likelihood of non-psych nurses thinking that is remote.