potential murder/suicide?

Consider placing him on suicide precautions.

If your facility provides inpatient counseling for patients, get him hooked up and processing while he is still inpatient...he needs support now.

Have social work involved if they do case management and get him connected to outside services (ie counseling, housing, home health nurse), especially if they make home visits, for post discharge follow up.

I agree with thunderwolf, he needs to be placed on suicide precautions and have a sitter. What did psych said? Did they place him on a hold due to potetially causing danger fo himself? If not this should be done asap...Is he medically clear, if so he should get sent to the psych floor for further eval. You are doing a good job for picking up the signs that this pt is showing. I would get the social worker involved too so they can find any family...if possible...good luck!

I would contact the hospital legal team and risk management.

What legal obligation is there to warn the girlfriend and former best friend of the threats he has made against their well-being?

Thanks for your suggestions and help. An update. Now he's suddenly "chipper" and feeling all better. Everyone else is like "oh, he's gotten his head around it" and all I can think of is, no, he's figured out how he's going to do it and he's telling us what we need to hear so he can get out of here (not that he's going anywhere with his foot like it is...).

I called psych again, and they're trying to get him to a larger facility that can handle a psych with this guy's medical issues (our psych unit only takes pts who are self care and meds only medical, and this guy's FSBS goes from the 60's to the 300's in the space of 90 minutes, a wound vac and he's got a BKA in his future). I'm checking on him regularly, but because he's got no insurance, no job, no money, there's not going to be a sitter. What ticks me off to no end is this guy's treatment would be radically different if he had blue cross/blue shield and a good job.

I also sent it up the food chain to find out if we have an obligation (or a right) to contact the police to let them know about his homicidal ideations, but no instructions yet. Right now he can't leave, not with that wound vac, anyway, but once he's mobile, I'm worried.

This is a good article that covers the legal obligation to warn vs the person's rights. We were talking about this in class the other day. It is aimed at those in the psych field but I am pretty sure it extends to all licensed personnel.

Warning a Potential Victim of a Person's Dangerousness: Clinician's Duty or Victim's Right?

Alan R. Felthous, MD

I agree that he's got a plan now, and is more dangerous. I hope he's on suicide precautions. Keep the lines of communication open with him- his situation is so bad it can't get much worse- perhaps that's the only bright side. I would be trying very hard to get him to laugh about how horrible it all is. I know that sounds unfeeling, but it's the most effective coping mechanism I've found for total tragedy. Reflecting feelings of sadness and desperation can only get you so far, at some point the patient has to climb out of the pit. Ask him if he's ever considered taking up writing music for Nashville, he's a shoo-in. (lost my girl, lost my job, lost my toe, doo-dee-doo...)

I agree with canoe, I've always heard and believe that when you have a severely depressed person who all of a sudden acting chipper and extremely up beat that you better watch them. They've either got a plan or they're going to be emotionally fragile to the point that the slightest thing is going to cause them to nose dive into an even deeper depression. I wish you luck in getting this pt help, I hope they're able to place him in a psych facility.

Thanks for your suggestions and help. An update. Now he's suddenly "chipper" and feeling all better. Everyone else is like "oh, he's gotten his head around it" and all I can think of is, no, he's figured out how he's going to do it and he's telling us what we need to hear so he can get out of here (not that he's going anywhere with his foot like it is...).

I called psych again, and they're trying to get him to a larger facility that can handle a psych with this guy's medical issues (our psych unit only takes pts who are self care and meds only medical, and this guy's FSBS goes from the 60's to the 300's in the space of 90 minutes, a wound vac and he's got a BKA in his future). I'm checking on him regularly, but because he's got no insurance, no job, no money, there's not going to be a sitter. What ticks me off to no end is this guy's treatment would be radically different if he had blue cross/blue shield and a good job.

I also sent it up the food chain to find out if we have an obligation (or a right) to contact the police to let them know about his homicidal ideations, but no instructions yet. Right now he can't leave, not with that wound vac, anyway, but once he's mobile, I'm worried.

I would be willing to bet that you are closer to right with his attitude change recently. It's not like the med has had time to kick in, IMO, and from my past experience with some pts in similar situations, probably the only thing he has gotten his head around is how he thinks he can pull it off, and try to pull an attitude change to maybe decrease nursing observation to give him some time to pull off whatever he's got in his head.

Anne, RNC