Psychiatric Patients in ER

**canoehead, BSN, RN** · Nov 4, 2003

Unfortunately medico-legal ethicists don't agree that a person has the right to kill themselves if they wish.

I would also argue that if they show up at an ER they are asking for help-if they really want to kill themselves they can still do it- afterwards, or by not showing up in the first place. If you think we could treat them AND let them go whenever they wanted to it is physically impossible. They have to be present to get the help.

LisaRN2B · Nov 4, 2003

Please do not feed the trolls!

:stone

Traumsquad · Nov 4, 2003

Physical restraints in our emergency room our rarely used, although I would not hesitate to use them, as a last resort, after every other option has been tried, to keep the patient, staff, other patients or visitors from harm. The use of restraints, any restraints, in our facility require a considerable amount of documentation, including what measures were used before the deciding on restraints, the events leading up to the use of restraints, frequent monitoring of the patient, one - on - one if in 4 points or in seclusion, and frequent documentation while in restraints. We are required to document trial releases and get physicians orders for the continued use of restraints if needed after a certain time period. That being said, i would just like to say again, that restraints are a rarity anymore anyway, and are reserved for the truly violent patient.

As far as letting a patient leave the emergency room after expressing suicidal ideation, especially when that patient has expressed a formal plan, seems to be irresponsible and is not in the best interest of the client. It is true that not everyone who presents with the complaint of suicidal ideation will go out and carry through with the plan, but as a nurse in the emergency room, I have no way of knowing which ones are serious and which ones are not, therefore I feel I must act on the side of caution. There is also the legal aspects of letting a patient leave the ER after expressing suicidal ideation and then, God forbid, they actually go and commit the act or worse, hurt another innocent person. That can open the professional and the institution up for legal action.

MishlB · Nov 4, 2003

Originally posted by Dolphin777
>

Several posters have asked me whether I think it would be all right to let someone expressing suicidal ideation leave the ER, even if they went on to commit suicide. My answer to their questions is YES. You would not detain someone against their will if they announced they were planning to gain 100 pounds and smoke 3 packs a day of cigarettes, would you? Well, if someone states they want to kill themselves, 9 times out of 10 it is a desperate cry for help, a figure of speech, and they need the psych & ER staff to address the REAL, underlying problems instead of using restraints and other degrading measures.

As for the 72 hour hold, those 72 hours only apply to Monday through Friday excluding holidays. If a mental patient arrives the Friday evening before a major holiday weekend, that 72 hours could very easily turn into a one week prison sentence in the psych unit. A whole lot of bad stuff could happen in that one week, or "just" those 72 hours: 1)college student could flunk an exam or get hopelessly behind in their courses and have to drop out of school, 2)working stiff could lose their job, 3)single parent could lose custody of their children, 4)caregiver of a sick spouse or elderly parent could end up with their loved one placed in a nursing home, 5)person could end up homeless as a result of being unable to pay their rent or mortgage.

One of the saddest cases I heard involved a single, childless woman who had three cats. She was locked up in a psych hospital, missed her rent payment, and the landlord went into her apartment, found her cats and took them to the pound where they were euthanized. When this poor woman got home after her psychiatric incarceration, her pets were gone. She soon learned they were dead. Who in their right mind could possibly think this woman was "helped" by the psychiatric staff who imprisoned her, prevented her from paying her rent, and caused her beloved animal companions to be put to death courtesy of the landlord and local pound?????

How can you breathe with your head so far up your ass? You NEVER let someone go who is threatening themselves or others.

Trauma Columnist · Nov 4, 2003

I don't think you're an ER nurse at least. In Illinois (as most states) if you tell me that you are going to kill yourself, you're not leaving. Now...I also don't have time to "talk" with you in great depth, because I have to go do CPR or take care of a trauma patient. However, I will ensure your safety (and feed you too), while I get the psychiatric social worker to come and make an eval. In our ER - the psych social workers are stationed in the ER - so you don't even have a wait. Take care - your posts always seem so dark.

Rena RN 2003, RN · Nov 4, 2003

Several posters have asked me whether I think it would be all right to let someone expressing suicidal ideation leave the ER, even if they went on to commit suicide. My answer to their questions is YES.

this statement alone proves that you do not nor have never worked in the ED and makes me question your validity as a nurse.

You would not detain someone against their will if they announced they were planning to gain 100 pounds and smoke 3 packs a day of cigarettes, would you?

yes, i would detain that person long enough to educate them to the facts of diet, exercise, and encouragement to stop smoking. the same way i provide routes for education to a suicidal patient dealing with mental health issues.

Well, if someone states they want to kill themselves, 9 times out of 10 it is a desperate cry for help, a figure of speech, and they need the psych & ER staff to address the REAL, underlying problems instead of using restraints and other degrading measures.

so tell me exactly how a person is to address the "real" issues of a behavioral patient if that person is acting aggressively towards himself and/or staff? if physical agression is being shown, that person is in no frame of mind to listen to a damn thing or to offer up any clues as to what the real issues are. what are your solutions to your point of view? how exactly do you feel these cases should be handled? should a suicidal patient be allowed to walk outside the ED doors and shoot themselves in the head? should a patient that is abusive to staff be allow to beat us ED nurses about the head without restraint because afterall they have "real" issues and they will eventually get around to telling us what they are if we let them punch us enough? should we allow that person to dig at his flesh until the bone is showing? i mean, if he runs out of arm just maybe he will then tell us the "real" issue? please, please, please, do enlighten me as to how i should really be doing my job as a patient advocate?

As for the 72 hour hold, those 72 hours only apply to Monday through Friday excluding holidays. If a mental patient arrives the Friday evening before a major holiday weekend, that 72 hours could very easily turn into a one week prison sentence in the psych unit.

don't know which happyflowerkiddieland you live in but in my ED, healthcare is given 24/7/365. doctors and nurses work holidays and even weekends.

A whole lot of bad stuff could happen in that one week, or "just" those 72 hours: 1)college student could flunk an exam or get hopelessly behind in their courses and have to drop out of school, 2)working stiff could lose their job, 3)single parent could lose custody of their children, 4)caregiver of a sick spouse or elderly parent could end up with their loved one placed in a nursing home, 5)person could end up homeless as a result of being unable to pay their rent or mortgage.

1. won't matter if he is dead because he told someone he was going to kill himself.

2. - 5. see also #1.

One of the saddest cases I heard involved a single, childless woman who had three cats. She was locked up in a psych hospital, missed her rent payment, and the landlord went into her apartment, found her cats and took them to the pound where they were euthanized. When this poor woman got home after her psychiatric incarceration, her pets were gone. She soon learned they were dead. Who in their right mind could possibly think this woman was "helped" by the psychiatric staff who imprisoned her, prevented her from paying her rent, and caused her beloved animal companions to be put to death courtesy of the landlord and local pound?????

were you involved in this case? no? then how could you possibly know all the intricate details of that case? is this person you?

Milehighnurse · Nov 4, 2003

Originally posted by Dolphin777
>

Several posters have asked me whether I think it would be all right to let someone expressing suicidal ideation leave the ER, even if they went on to commit suicide. My answer to their questions is YES. You would not detain someone against their will if they announced they were planning to gain 100 pounds and smoke 3 packs a day of cigarettes, would you? Well, if someone states they want to kill themselves, 9 times out of 10 it is a desperate cry for help, a figure of speech, and they need the psych & ER staff to address the REAL, underlying problems instead of using restraints and other degrading measures.

As for the 72 hour hold, those 72 hours only apply to Monday through Friday excluding holidays. If a mental patient arrives the Friday evening before a major holiday weekend, that 72 hours could very easily turn into a one week prison sentence in the psych unit. A whole lot of bad stuff could happen in that one week, or "just" those 72 hours: 1)college student could flunk an exam or get hopelessly behind in their courses and have to drop out of school, 2)working stiff could lose their job, 3)single parent could lose custody of their children, 4)caregiver of a sick spouse or elderly parent could end up with their loved one placed in a nursing home, 5)person could end up homeless as a result of being unable to pay their rent or mortgage.

Wow Dolphin, you sound as though you have had personal experience with a 72 hour hold, hope they were able to help you.

I work on a in-pt psych unit and we get 72 hour hold pt's all the time from the ER and I have yet to have one pt state that they really wanted to die. Yes they felt suicidal at the time they presented to the ER d/t alot of stressors; psychotic break because they went off their meds; spent all their money for bills on gambling and felt that suicide was their only option; went on a bender to try and make their problems easier to deal with or go away; experienced a loss of a close relationship and felt that their world had just caved in on them, the list is endless. These people are experiencing profound depression and do not know that they can work through their problems. We get them, get them into therapy and they find out that 1) they're not alone in their sentiments, many people feel suicidal at one time or another for various reasons, 2) they don't have to go through their hell alone and have many options open to them, 3) can get help with their lives through external resources, even while hospitalized.

These people are husbands and wives with families, sons and daughters with life still ahead of them, children who are acting out to express their frustrations the only way they know how. Imagine how many families would be torn apart over the loss of a loved one because we didn't get them the help they needed.

ER's are the first line of help for all kinds of trauma and their job is to stabilize, then refer them to further treatment, if needed, be it in-patient hospitalization or out-patient treatment. ER's are not the place for extended treatment or therapy, they need to move these pt's out asap for the patients sake and for the sake of the next incoming trauma. In the case of psych pt's, ER's do not need their beds tied up for hours over non-pyhsical trauma when other resources are available. They needs those beds, and staff, available for the child that just got squashed by a drunk driver or has a temp that is sky high and is seizing, a father that is experiencing an MI, a mom that is getting ready to deliver and doesn't have an OB in the area, a son or a daughter that is having an asthma attack and can't breathe.

I am so sorry to see that you are in so much pain yourself, maybe you could consider getting some help for yourself and allow these folks to do the same.

sanakruz, ADN · Nov 4, 2003

Dont feed the trolls.

Sharon · Nov 4, 2003

Dolphin777

I don't think you realize that many states have laws against releasing patients from the emergency department after they have made a threat to themselves or others. In most states minimally the adult protect laws come into effect. If a nurse or doctor releases the patient before the evaluation it is considered a felony in many localities. And if injury occurs to anyone after a threat and an evaluation was not done as prescribed by law then the nurse and or doctor can be charged with many different criminal charges up to and including murder.

Tink RN · Nov 4, 2003

Originally posted by Dolphin777
I am interested in studying post traumatic stress disorder in psychiatric patients resulting from being placed in seclusion and/or restraints in the emergency room or psychiatric unit. Many patients arrive who are not criminals or violent, just suffering from strong emotions or intense mental anguish, and their misery is made much, much worse as a result of being subjected to restraints and seclusion. To the nurses who work in these places, have you observed patients suffering worsened emotional problems after being treated with involuntary measures in the ER or psych unit?

Thanks.

Well Dolphin, you seem to be the expert ... perhaps you could tell us?

sanakruz, ADN · Nov 4, 2003

I'm surprised that this thread is still here. Maybe we should talk about the weather now?

athomas91 · Nov 4, 2003

ok , i fought this hard...

can anyone say BORDERLINE?!?

sorry, had to feed the trolls one last time...