HH patient with homicidal ideation...

[rprn2009]

So today I saw a patient, late 60s, history of IV drug use when younger, depressive symptoms, crying spells, Hep C positive, has had some issues with dementia lately (dx as Alzheimer's per PCP) and is on aricept and namenda. Has had HH for about 4 weeks for debility and fall hx. Patient recently has had some decline with memory and functionality. UA performed and was negative.

The patient's spouse that lives with him and is primary caregiver calls me last night stating, "He's been hiding knives under his pillow and scissors in places." I go there to see the patient today and ask him, "Do you have any thoughts of hurting yourself or others?" He tells me that he wants to stab someone in the neck at his church he attends every Sunday with a little pocket knife - next time he sees that man because he is flirting with his wife. He gives me a name, the spouse states "but that's the Deacon and he and I have to talk to one another because we work close together." I check the patient's orientation. He is able to tell me who he is, where he is (city and home), who the president is, what day of the week it is, but can't tell me what year it is. Speaking in clear sentences. Flat affect. I see this as mild to moderate dementia (disoriented to time). So what do I do? The man has a plan to hurt someone else, I have to report this. Long story short, the patient is willing to go to the hospital. I tell the wife to take him to a local ED with a psych unit to be worked up for a psych evaluation.

Earlier tonight I get a call from an ED doc stating, "The patient you sent here has Alzheimer's, sometimes they say things they don't mean. That patient is not appropriate for inpatient psychiatric care. I wanted to call you to educate you about the Alzheimer's disease process." I tell the doc that I'm very well aware of what Alzheimer's disease is and the patient has a history that involves potential for mental health issues. I tell the doc I don't need him to educate me, but thanks anyway. He hangs up on me. Am I supposed to ignore the patient's threats and assume "the patient doesn't mean them" just because he has dementia? What kind of logic is that? I have my patient and family to protect AND license to protect, thank you.

What are your thoughts on this situation? Any similar experiences?

[Isabelle49]

Document everything. Let your managers know about this in writing. Send a fax to the patient's primary doctor (you can call the primary about these issues, but follow up with a fax). If your agency has psych nurses, this patient needs to be seen by them, for an evaluation for sure.

[IVRUS, BSN, RN]

Wow,

I wonder if anyone was as conscientous as you are when they dealt with the Navy Yard killer, or Fort Hood massacre. I'd say no, they just let it drop. I applaud you for attempting to find him help. I too would not ignore it.

[kparry]

Long story short, the patient is willing to go to the hospital. I tell the wife to take him to a local ED with a psych unit to be worked up for a psych evaluation.

Sounds like you got exactly what you requested.

I get a call from an ED doc stating, "The patient you sent here has Alzheimer's, sometimes they say things they don't mean. That patient is not appropriate for inpatient psychiatric care. I wanted to call you to educate you about the Alzheimer's disease process."

[MauraRN]

HIPPA is a problem, but if you document as discussed above, in writing with PCP, try convincing wife to discuss with her deacon. He may be able to have patient hospitalized because of homicidal threats. Don't put that conversation in writing.