Suicidal patients who are discharged from the ER

Katnip, RN · Oct 11, 2007

Any suicidal patient who came to our ER was sent to a psych facility for at least 24-hour observation, even if they said they changed their minds and weren't suicidal anymore. Even when we all knew they just wanted a warm bed.

It would be professional suicide as well if you sent a suicidal patient home without further evaluation.

SnowymtnRN · Oct 11, 2007

All of our patients have to have a psych eval, then the LSW deems whether or not they are a danger to themselves. Many times, people have a feeling of hopelessness or despair and state they want to commit suicide, however when discussing their feelings and given other options they realize it was just a fleeting moment type of feeling. The real issue is if they have a plan or not, etc....

So yes we have discharged many patients from the ER who stated on their arrival they were suicidal.

DoubleblessedRN, ADN, RN, EMT-B, EMT-P · Oct 12, 2007

I was just wondering because many patients who WANT to be hospitalized don't get what they want. I once had a run in which a woman called 911 from a payphone at a streetcorner, stating that she wanted to die. She stated she went to the ER two days prior and the Dr refused to admit her. So she asked the police officer on the scene to commit her and fill out a petition for hospitalization. He did, so when we brought her to ther ER, they had no other choice than to admit her.

Another time, while I was getting ready to transport a psych patient from a crisis center, I overheard a nurse telling another nurse about a pt who wanted to be admitted and wasn't. Security escorted him off hospital property, and he then ran into the middle of the streetin front of a car. Fortunately, the driver swerved and missed him. That was all I heard her say.

I also was called to a fixed income apartment building. The patient was a woman in her mid-20's with cerebral palsy, was wheelchair confined, and had a caretaker. She also wanted inpatient psychiatric hospitalization and didn't get it, although I think she really did need it. She appeared very depressed and probably could have used some intense therapy for a short time. I ended up taking her to another ER two days later.

lupin · Oct 12, 2007

Usually we do the mental and physical workup (labs, ct of head) and call crisis in. Sometimes a pt may feel like dying but may not have active suicidal ideation or a plan. How many of us have felt so bad and hurt that death looked like a release?

But a truly suicidal pt will have an active plan, such as "I will go home and cut my wrists". Crisis usually makes the determination on if they are really suicidal or just wanting hospital admittance. Most of the time, they go to a facility. The only time I remember a pt didn't go to treatment was a runaway who said she would off herself if we sent her back to her parents. She ended up going to juvey instead.

mom2michael, MSN, RN, NP · Oct 14, 2007

I work in 2 states.

State #1 requires you to do a screening by a QMHP for a 96 hour hold for all patients who are a danger to themselves and others. Since we are not a screening facility - these people have to be transfered out. VERY time consuming, very difficult to find beds. Ties up the EMS for HOURS because some beds are 8,9 and 10 hours away. But we don't have a QMHP on site to screen our patients and they CAN NOT be released w/o a screening for a placement. I would guess 99.9% of patients with suicidal ideations get placed for the 96 hours. We have lots of facilities in this state.

State #2 does not have psych facilities. If a patient presents to the ER with suicidial ideations, we call the crisis line...them come....they screen. If they feel they are a threat to themselves and others - we admit - but it has to be 24/7 care for the patient and 1:1, so that means ICU and a sitter and that means waiting on a bed for days sometimes and yes, they wait in the ER. We even have a special room for this particular situation. If the screen determines they are safe to be released home....they go home with a no harm contract and follow up as needed.

cousx2 · Oct 14, 2007

as an undergrad, i volunteered for a suicide hotline and in our training, we were always taught that a person on the verge of suicide would have a plan--a method, a time, a place. i always wondered though, and i am not being facetious, what if this person just isn't that organized? what if they're the impulsive disorganized type (e.g. bipolar mood disorders or borderline personalities) who doesn't plan anything and all they know is they want to die? the particulars will occur to them when they do it--jump out in front of traffic, drive the car of a cliff, grab a knife, take every pill in the house etc. it doesn't take that much planning to kill yourself, you know?

coincidentally, a story about one of the hospitals in my area discharging a suicidal patient who went on to commit suicide by throwing himself from the top story of the hospital parking garage was on the front page of our sunday paper today:

http://www.sptimes.com/2007/10/14/hillsborough/discharged_with_his_d.shtml

sad story. wasted life.

discharged with his demons

the son needed more help. now the father needs more answers.

by justin george, times staff writer

published october 14, 2007

james allen left tampa general hospital's psychiatric unit on july 31 with a bus pass and a pledge to check out a list of homeless shelters a nurse gave him. but four hours later he was back, saying he was so depressed he thought about jumping in front of a car. it wasn't an idle threat. a month before, another hospital had discharged him, and allen, 43, walked in front of a bus - something tampa general had record of. but doctors evaluated him again and released allen at 12:30 p.m. with instructions to go to a mental health care center the next morning. turned away, he climbed to the fifth floor of the hospital's parking garage that evening and walked to the edge. the revolving door had stopped. allen, who had asked for help so many times, wouldn't ask again.

how could a man with a clear history of mental illness, who had tried suicide at least once, return to a hospital for help and not be saved, his father wonders.

"i probably will never get all the answers," john allen said, "but i'd like more."

james allen became homeless after he left his father's forgiving safety net for one last shot at rehabilitation in the tampa bay area. at home in new mexico, his dad always caught him when he relapsed into alcohol or drugs. but alone in florida, no one did.

tampa general declined to talk about allen's case, citing confidentiality laws.

"there has never been a tool published, a set of questions to ask, a blood test to run; there has never been an instrument or a tool to predict who will kill themselves and who wouldn't," said dr. brian keefe, tampa general's director of psychiatric services.

the length of allen's stay at tampa general - a total of six days - indicated serious mental problems, said martha lenderman, who ran the state program that oversaw involuntary psychiatric examinations, as well as pinellas and pasco county mental health offices for the department of children and families. drug tests show he had come in clean.

lenderman said he would have qualified to be screened for institutional placement. the legal burden of proof is tough, however, since judges don't want to deprive patients of civil rights and lock them up when voluntary - typically outpatient - treatment is available. but options are slim in florida, which ranks 48th in how much it spends per psychiatric patient.

keefe described resources in hillsborough county for mental health treatment as "abysmal." he said his hospital routinely keeps patients longer than required because treatment centers are overbooked or there's no medically supervised "step down" shelter to help the homeless back into the community.

sandra tabor, spokeswoman for mental health care inc., the county's largest aid provider, said that keefe hadn't expressed his complaints to mental health care providers and that most people's needs are met quickly.

all john allen knows is that his son needed help and seemed to go to the right place to get it.

"you tend to like to trust the medical profession, because they tend to try and do a good job," allen said, "but sometimes they fail."

* * *

john allen, 76, a retired nuclear laboratory field engineer, says he succeeded at nearly everything in life but fatherhood. he guesses he has spent about $100,000 trying to rehabilitate james and an older son, who was also hooked on drugs.

he kept the parable of the prodigal son in mind, hoping for one last homecoming. only his older son returned to albuquerque, n.m. he still lives at home at age 53, hooked to oxygen after emphysema ruined his lungs.

as for his youngest, john allen still searches for clues.

there was no apparent childhood trauma. dad worked, mom took care of the two boys. the couple rarely drank. a bottle of wine spenta year in the refrigerator.

james backpacked in colorado, camped in national parks, raced sailboats. a bit of a loner, he played guitar. he built an early motorola computer from a kit and rebuilt car engines as a teen.

but he also discovered marijuana.james barely graduated from high school. he dropped out of college and technical school, stole money from his parents for cocaine and spent months in treatment.

in his 30s, he was drinking a fifth of liquor a day. his dad gave him $3,000 and kicked him out. three weeks later, he asked for more.

he laid in the street so he could be taken to a mental hospital, where he could get vouchers for methadone, a drug he abused.

clean. relapse. clean. his life was like the tide.

when brother richard received a $1,500 car accident settlement, the pair went on a cocaine binge, and james hit one of his counselors, earning a night in jail.

john allen once asked his son how things had gone so wrong.

james couldn't explain, except to say he felt hooked to marijuana the first time he tried it. james' grandfather was an alcoholic. addiction might be in the genes, john allen surmises.

his son slept in shelters, abandoned cars and under a sheet of plastic in a field near the airport.

two years ago, james called home for help. he was bloody and bruised, mugged for $3. john allen picked him up and told his tearful son about the spencer recovery center in st. pete beach, a place a colleague had recommended.

two days later john allen put his son on a plane and paid about $25,000 for three months of treatment.

he gave james a new wallet before he left.

* * *

james allen spent five months at spencer in 2005. he was taking prozac, his brother recalled.

"he seemed to be doing well," john allen said.

james allen moved to the mustard seed inn in st. petersburg, a drug and alcohol recovery center. he went to alcoholics anonymous meetings and washed dishes at a nearby cafe. then he went to the sophie sampson center of hope, where they gave him his own room. james went to bible study. his father sent him a laptop to do freelance computer work.

but in april, james relapsed. he was evicted for drinking or abusing prescription drugs, john allen said. the father called st. petersburg police in may and reported his son missing. they told him james was admitted to a mental hospital. john allen called everywhere, but privacy laws stonewalled him.

he felt like he was following a ghost.

"any time i got close to finding him," allen said, "they would tell me he wasn't there or had been discharged." he wonders how hospitals cared for his son or other homeless people. no one can check because of privacy laws, he says.

"sometimes you wonder if it's being used as an excuse," said rosanna esposito, senior legislative and policy counsel for the treatment and advocacy center, a national nonprofit.

john allen didn't know his son had gone to the st. pete beach police department on may 10 and talked about walking into traffic. an officer drove james to treatment under protective custody, a police report states.

in late june, john allen hired tampa bay investigators to find his son. the next day, unknown to him, a bus driver swerved to avoid a man who "didn't look right" on fifth avenue n in st. petersburg.

james allen told police he tried to kill himself because his life was a mess. paramedics drove him to st. anthony's hospital, where he was again held under the baker act, the state law allowing for involuntary psychiatric examinations. he had just been released from there after a week of treatment for suicidal thoughts, police records show. his father's private investigator found james allen there and left him a prepaid calling card.

james never called home.

"the father really cared about his son and went out of his way to try and find him," said carol sciannameo, who owned the investigation firm."it's a really sad story."

* * *

on july 31, two nurses on the fourth floor of the parking garage saw a body fall past them. they raced to the bottom and found james allen face down on the sidewalk. for two hours, doctors tried to save him; his ribs were fractured, aorta shredded, lungs and liver lacerated. he died at 9:35 p.m.

* * *

his ashes remain in an urn to be buried in the family's arkansas hometown. john allen won't bury him yet. he wants explanations from tampa general and st. anthony's hospitals. it's not even clear how james allen got to tampa general.

"they kept releasing him with all those suicidal tendencies," he said. "that's the part that's disturbing." like tampa general, st. anthony's says it can't comment.

to qualify for involuntary placement in a mental health facility, the state requires a person to be mentally ill. he would have to refuse treatment - it's unknown if allen did at any point - or be unable to understand treatment was needed. he also would have to be either incapable of surviving alone and be in danger of neglect or seem likely to hurt himself or others.

james allen's history of walking into traffic may not have been enough for a judge to commit him. "you're going to have to have clear and convincing evidence," lenderman said.

to john allen, nothing could be more clear than his son's track record of attempting suicide after being discharged, something tampa general had record of, according to the hillsborough medical examiner's investigation.

james allen left no note. his only belongings, a wallet and eyeglasses, were returned to his father recently.

in the wallet, john allen found the phone card the private investigator had slipped to james.

john allen now has proof that james knew his father reached out to him one last time. he wonders why he never called home.

justin george can be reached at [email protected] or 813 226-3368.

fast facts:

after the hospital

although hospitals do sometimes keep psychiatric patients when long-term treatment centers are full, most are released after initial treatment at hospitals or mental health centers.

mark engelhardt, a faculty member at the florida mental health institute at the university of south florida, said that makes discharge planning crucial.

the state requires hospitals to keep written discharge policies. tampa general's, updated in 2001, assigns responsibilities from doctors and nurses to social workers and dietitians.

the goal, engelhardt said, is to meet as many of a psychiatric patient's needs as possible; from treatment and transportation to medication and monitoring. giving patients a sheet of outpatient recommendations should be the least hospitals do, engelhardt said.

they should coordinate with mental health or substance abuse treatment providers in the community and inform them a patient is on the way, he said.

tampa general won't comment on its discharge plans for james allen.

24-hour suicide prevention help

in hillsborough county: 211

in pinellas county: suicide hotline, 727-791-3131; mental health assistance, 727-541-4628

elsewhere: 1-800-784-2433