Question for PMHNPs about clinical scenario

[FullGlass, BSN, MSN, NP]

Hello. Need some guidance from PMHNPs or NPs experienced in psych:

Middle-aged adult patient comes in for treatment. Pt lives independently and is not under guardianship. Pt is accompanied by mother. Pt is assessed as NOT at acute risk to harm self or others. Appointment proceeds, then ends. Pt's mother then asks to speak to me privately and wants me to "5150" the patient. I explain that pt is not assessed as suicidal, but mother is insistent. With patient's permission, I then assess the patient again, with mother present, and reach same conclusion. I also speak to consulting psychiatrist, who agrees with me. Mother is upset with me and files complaint against me.

Pt saw LCSW shortly before seeing me, who assessed patient the same as I did.

Pt returns to clinic 3 weeks later to see another provider, then asks front desk to speak to me, which I do. Pt is alive and well and making plans to improve self-care and living situation and asks me for help, which I provide.

My reasoning:

1. Mother has no legal standing

2. If I called 911, first responders would have performed same assessment and received same responses to patient, so would have come to same conclusion. Even if they took pt to ER, it is unlikely ER would have 5150'ed patient.

3. My assessment was proved correct.

How would you all have handled this?

[verene, MSN]

If there is no imminent harm you do not have the ability to hold the patient - I may have spoken further with the mother 1:1 to find out why she believes the patient needs involuntary hospitalization when multiple clinicians are not reaching the same conclusion. However - you handled this well, you assessed patient, reached out to your specialty resource for additional assessment/confirmation, and did not violate patient rights in the face of parental pressure. It also seems that you established rapport with the patient if they are seeking you out for additional care following that initial visit.

[FullGlass, BSN, MSN, NP]

1 hour ago, verene said:

If there is no imminent harm you do not have the ability to hold the patient - I may have spoken further with the mother 1:1 to find out why she believes the patient needs involuntary hospitalization when multiple clinicians are not reaching the same conclusion. However - you handled this well, you assessed patient, reached out to your specialty resource for additional assessment/confirmation, and did not violate patient rights in the face of parental pressure. It also seems that you established rapport with the patient if they are seeking you out for additional care following that initial visit.

Thank you. The patient is homeless; lives in tent city, has friends there, and there are support services there. Pt has troubled relationship with parents, there seems to be a lot of yelling and arguing. Pt had made comments to parents about taking all their meds at once to commit suicide. On the other hand, this could have been said just in anger of the moment. Pt was clean and quite well groomed and dressed, did not appear or act depressed, was making future plans and asking for help in improving living situation, and stated repeatedly no suicide attempts anymore due to becoming religious and attending church. My intuition also said not suicidal. In addition, I didn't want to violate patient trust on first visit to me as patient might not ever have returned.

[verene, MSN]

22 hours ago, FullGlass said:

Thank you. The patient is homeless; lives in tent city, has friends there, and there are support services there. Pt has troubled relationship with parents, there seems to be a lot of yelling and arguing. Pt had made comments to parents about taking all their meds at once to commit suicide. On the other hand, this could have been said just in anger of the moment. Pt was clean and quite well groomed and dressed, did not appear or act depressed, was making future plans and asking for help in improving living situation, and stated repeatedly no suicide attempts anymore due to becoming religious and attending church. My intuition also said not suicidal. In addition, I didn't want to violate patient trust on first visit to me as patient might not ever have returned.

Again - good judgement - the patient has risk factors but also has some solid protective factors -- they are a patient I'd want to keep an eye on and reassess periodically but doesn't seem imminent risk. Not violating trust and having the patient continue to engage in services is huge!

How do you assess for suicide risk in your setting? Is it solely clinician judgement or do you use a validated screening tool?

[FullGlass, BSN, MSN, NP]

2 hours ago, verene said:

How do you assess for suicide risk in your setting? Is it solely clinician judgement or do you use a validated screening tool?

Thank you. I needed the validation. ? No, they didn't give us a standard tool to use as the management is arguing about how to screen for this. Place is a mess.

[verene, MSN]

14 minutes ago, FullGlass said:

Thank you. I needed the validation. ? No, they didn't give us a standard tool to use as the management is arguing about how to screen for this. Place is a mess.

I high recommend the Columbia Suicide Severity Risk Scale - it's evidence-based, easy-to-use, has a triage-aspect built in, is available in EHR and paper formats, and best of all is FREE! http://cssrs.columbia.edu/

You might recommend it to management where you work. ?

[FullGlass, BSN, MSN, NP]

3 hours ago, verene said:

I high recommend the Columbia Suicide Severity Risk Scale - it's evidence-based, easy-to-use, has a triage-aspect built in, is available in EHR and paper formats, and best of all is FREE! http://cssrs.columbia.edu/

You might recommend it to management where you work. ?

Thank you very much for this - I'll be using it and recommend it, too.!

[djmatte, ADN, MSN, RN, NP]

5 hours ago, verene said:

I high recommend the Columbia Suicide Severity Risk Scale - it's evidence-based, easy-to-use, has a triage-aspect built in, is available in EHR and paper formats, and best of all is FREE! http://cssrs.columbia.edu/

You might recommend it to management where you work. ?

That was added into our ehr recently and I’m a fan.