ED Ethics In Self Harm

5th amendment rights

If the person refuses to answer and the person is not displaying any signs or symptoms of going cray cray, not much you can do.

Does this type of behavior merit further attention without the pt's consent?

I'm not really sure what you mean by this. Do you mean should Psych be consulted?

When I'm asked this question, I simply lie and say no. I don't believe my history from 11+ years ago is relevant today in that regard.

I would just document her response and report it to the next caregiver and keep watching her. You have to realize that not every person is immediately comfortable with all the personal questions we throw at them . I often find that once a rapport has begun to be established it is easier for patients to share the details of their life,especially if they see you as willing to help with any physical or psychosocial problems !

I agree that the question of "have you ever" is kinda silly for an assessment. If the question was "do you feel..." and it was relevant to the present situation, and the patient refused to answer...

I would dig more deeply. The refusal in the current sense could be a signal that she needs more questioning on the topic. It also means she should be watched closely. It also needs to be reported to the doctor on-duty, and documented in detail. Don't do things behind the patient's back. Tell her you're going tell the doctor. Patient confidentiality doesn't apply if she is suicidal.

Our triage asks both "have you ever" and "do you currently want to harm yourself or others".

Yeah, why on earth would the ED screening question be have you ever had thoughts of harming yourself or others? Kazillions of people have had SI, HI, or even suicide attempts in the past that have no bearing whatsoever on their current situation.

And this may be why the patient was hesitant to answer. Maybe she didn't want to be labeled as a psych patient. Maybe she had issues as a teenager that are long over and she doesn't care to rehash.

Whether or not we're willing to admit it, patients are judged based on psych history. This happened many years ago when I was a staff nurse and I will never, ever forget it. I came in for a night shift, one of my patients was a teenager s/p spinal surgery. We did written report. This patient happened to have a history of self injury. Under the psychosocial section of our written report, the nurse handing this patient off to me had written "hx of cutting but so nice you would never know!" I was appalled then and remain appalled now at this statement. What on God's green earth does "being nice" have to do with cutting?

And I am unclear on why suicide is such a dirty word.

Wouldn't it make sense if we just came out and asked "Are you thinking about committing suicide?" It can not be any more shocking and/or irrelevant than any other screening question asked in triage--"Do you have unprotected sex" or "Do you feel safe at home" or "do you drink alcohol or use illegal drugs"

Sometimes the "harm yourself or others" is taken in a non-literal sense. ie: "Last week I could have killed my man for___________" or "I could shoot myself over the bad luck I have been having lately".

We live in a world where even the most "off the cuff" comments are taken to the nth degree. Not that we shouldn't listen and ask further questions if warranted, but I can see how someone is hesitant to say anything that could be construed as ideations.

Yeah, why on earth would the ED screening question be have you ever had thoughts of harming yourself or others? Kazillions of people have had SI, HI, or even suicide attempts in the past that have no bearing whatsoever on their current situation.

Good question, but this is the standard in many ERs. The idea is that you can't help someone if you don't know what they need. In practice, it doesn't work in my opinion. I have asked hundreds of patients (if not thousands) if they are safe at home, for example, and I've never had one say they weren't (this is for patients who present for other problems. Obviously if their complaint is an injury from DV the answer is self evident).

I can share my perspective, Ive never worked in ER, but I work in Public Health, so I visit patients in their home and can have long conversations with them. I see a lot of mental health cases. There are so many "it depends" situations. You may want to think of "pressing the issue" rather as "further assessing the patients psycho-emotional health". and remember the next step, if they have "thoughts" is to assess for a plan and commitment to harm themselves. even though it is standard to ask about SI, it should be asked very sensitively, and i agree the question should be have you had thoughts of hurting yourself RECENTLY, in a setting such as an ER unless you TRULY need to know their psych history, rather than their current situation.

obviously you observed it being a touchy subject so if you were really concerned, i would try get more information. This is what I have said in similar situations, I put my pen down and look them in eyes with concern and gently say "I noticed this is a sensitive subject for you, would you like to share whats been on your mind or whats going on in your life that is causing you to feel this way?" Avoid using any words that are associated with stigma.

Your situations has happened to me a few times, one woman looked me in the eyes and said "im not going to answer that question". so i said "okay thats fine. so hypothetically, without telling if you have had those thoughts or not, if you were to possibly hurt yourself, have you thought about a plan and how you would do it?" and i knew her pretty well, and with her body language, the way she shrugged and shook her head no, i knew she wasnt seriously considering it or making a plan. another factor i considered was that she was grieving the death of her baby, and when she complained about her s/sx of grief and insomnia to her OB, she was prescribed antidepressants. and she didnt take them everyday, only to "help her sleep". i advised my patient SSRIs are know to increase suicide thoughts in younger patients and advised her to discuss the medication with the doctor and maybe ask for a sleeping pill instead, reminded her grief is a normal human process, referred to grief counseling resources and how to use her insurance for further counseling. also assessed for family and social support, which she had, so i knew she was safe living with her family.

hope that helps gives you insight into what is within your scope of practice. lastly, you can always request a social work consult or a psych consult without the patients consent - a consult is not an intervention, its an assessment. hope that helps!