I saw a very touchy situation the other day of a hypertensive female, early 20s (c/o headache, fatigue) who absolutely *refused* to answer in triage when asked if she "has ever had thoughts of harming herself or others." Only one question, not making a huge deal of it or anything, just screening. First time she pretended she didn't hear but wouldn't make eye contact, the second time she mumbled something about 'none of your business' to the nurse doing the triage. Clearly it was a very sensitive topic for her and she was not going to commit to an answer.
Question: because mental health is not chief presenting complaint, would you press the issue? Does this type of behavior merit further attention without the pt's consent?
I'm on my way to nursing school and I cannot wait to work in the ER so all perspectives are very much welcome!
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!
Sure, you can order whatever you like, but the individual has the right to refuse/decline to talk to psych or social work, same as people have the right to refuse any other offered treatment.
Not sure how it works in other places, but in one of the facilities I work in, any mention towards a suicidal ideation starts the 72 hour hold, court hearing, etc process. I think it is way over used, and probably trains people to never mention it again. I hope this is not the norm, but I fear in many places it is. Heck, we'd get people sent from the counselor's office, who went to seek help and discuss their issues, who then get locked in a tiny ****** little room for three days to who knows how long, all because they took the step to seek professional help. What did we teach them? To keep their mouth shut and don't seek help. Pretty broken system. I still ask the question, but I'm pretty careful about what I chart/pass on. Yes that does put my neck on the line a bit, but if I feel that mentioning it is going to put the patient needlessly into that system, when they are there for an unrelated complaint, I tend to do what I think is best for the patient.
I ask "are you having any thoughts of hurting yourself or anyone else?" Present tense. My patients are often soldiers, and that "ever" is a can of worms. If they are not presenting for behavioral health issues, I don't press the matter.
Most of these "screening" question are not used in any meaningful way.
Take, for example, the question as to whether one feels safe at home. I would guess that it is the exception that a triage nurse requests that the room be clear of others before asking this question.
Unless you isolate each and every patient for a private triage, this is a ridiculous question. As are questions about alcohol, drugs, etc.
Most of these "screening" question are not used in any meaningful way.
Take, for example, the question as to whether one feels safe at home. I would guess that it is the exception that a triage nurse requests that the room be clear of others before asking this question.
Unless you isolate each and every patient for a private triage, this is a ridiculous question. As are questions about alcohol, drugs, etc.
Ditto the uselessness of individual questions. Maybe one of the reasons this girl got to me a little is that I lie all the time about my issues as a teenager because it's not relevant now and the system mentioned by wyosamRN above always worries me.
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.
I used to work on a suicide hotline. We didn't use the term "committing suicide" because it came from back in the day when suicide was illegal, and sounded kind of punitive/accusatory. If I'm wondering if someone is feeling suicidal, I usually ask "are you thinking of doing something to try and kill yourself?" If they answer yes, I go a bit deeper by asking "have you thought about how you might do that?" I like the question "are you thinking of hurting yourself or somebody else?" because it also covers non-suicidal self-injury, which is exceptionally prevalent and something worth assessing, in my opinion. If they answer yes to that question, I'll often then say "tell me more about that".
Suicide risk assessment (as I'm sure any of our psych nurses here can tell us) is important and complex. Unfortunately the ER setting really isn't the best place to get into it, for either nurses or the patient. It's a bummer and something we (as a system) could be working to improve.
Specializes in Psychiatry, Community, Nurse Manager, hospice.
Please don't immediately jump to the idea of doing something without the patients consent as though there was something emergent about a patient not wanting to answer this deeply personal, highly invasive, totally irrelevant question.
If I went to the ER for a broken arm or some other thing, and the nurse asked me if I had ever had thoughts of harming myself I would definitely be tempted to tell her to go **** herself. I probably wouldn't do that, because my impulse control is good, but if my pain level was high enough, or I had a dose of a painkiller, or any of the many other stressful things associated with being in the emergency room was happening, I hope I would say that's none of your business instead of go **** yourself.
I want you to think hard about what the point of asking a patient about self harm thoughts is in the emergency room. There is a point but it is not what you are thinking.
The point is not to go on a hunt for any self harm thoughts past or present and treat them as emergencies. They are not all emergencies and they are extremely common. If you have never thought of harming yourself, know that you probably will one day, when something bad happens. There is nothing unusual about it.
The point is to give the patient an opportunity to get help for something if help is needed. When your patient responds with "none of your business" that means no help is needed. Move on quickly.
Specializes in Psychiatry, Community, Nurse Manager, hospice.
Not sure how it works in other places, but in one of the facilities I work in, any mention towards a suicidal ideation starts the 72 hour hold, court hearing, etc process. I think it is way over used, and probably trains people to never mention it again. I hope this is not the norm, but I fear in many places it is. Heck, we'd get people sent from the counselor's office, who went to seek help and discuss their issues, who then get locked in a tiny ****** little room for three days to who knows how long, all because they took the step to seek professional help. What did we teach them? To keep their mouth shut and don't seek help. Pretty broken system. I still ask the question, but I'm pretty careful about what I chart/pass on. Yes that does put my neck on the line a bit, but if I feel that mentioning it is going to put the patient needlessly into that system, when they are there for an unrelated complaint, I tend to do what I think is best for the patient.
This facility needs to get sued for false imprisonment if the NPs and Pdocs don't have the courage to prevent this abuse.
The problem is the stigma of behavioral health issues. They may feel that they don't want to be labeled. I've worked in the past with behavioral health patients and there were many times when they were out in the community that they did not want to talk with people about there diagnosis or past histories for fear of being labeled "crazy". I do believe that just being straight forward and asking the patient point blank can be an appropriate measure. We don't have psych in the hospital where I work so we have no way of getting a consult. I find talking to people frankly, but with empathy, tends to be the best course.
I understand and sympathize with the patient in the original example. Who among us has not at some point in time, even momentarily, thought about harming ourselves or someone else? And as we have read in previous posts and know from our own experiences, individuals are sometimes miscast by over-zealous, well-meaning or just plain incompetent practitioners.
My daughter is a college junior majoring in something as far removed from healthcare as possible :). Prior to Christmas vacation, she experienced a couple of episodes that sounded to me like panic attacks. At the time, she was planning an elective surgery and shortly thereafter, scheduled to start an intensive practicum for her major. She is not one to share her thoughts, feelings or moods freely, and it doesn't surprise me to know that she experienced the symptoms she described. She made an appointment with our family doctor, had an exam & labs to rule out a physical cause and decided to consult with a therapist.
She called me last week following the appointment. She knows this woman from campus and would have preferred an appointment with someone else, but didn't want to wait too long for an initial consult. She described the stressors of the last few months, as well as the episodes that involved waking during the night feeling short of breath, among other things. After a few brief questions, the therapist told my daughter that she needs a psychiatric referral due to self harm. My daughter questioned whether the therapist had listened and heard her correctly. She emphatically stated that she was not, and had no intention to, harm herself, and didn't understand how the therapist construed awakening with distressing symptoms an indication of self harm.
Dear Daughter left the office and called a psychologist friend of hers (a former professor) who kindly gave her a phone consult offering some reading material, along with the professional opinion the therapist is a wack-a-doodle, and she should hold out for an appointment with the person she wanted to see in the first place.
These experiences, unfortunately, leave lasting impressions.
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?
Yeah for real! I have hx and I can still lie about it just fine!
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elkpark
14,633 Posts
Sure, you can order whatever you like, but the individual has the right to refuse/decline to talk to psych or social work, same as people have the right to refuse any other offered treatment.