Recent patient drunkenly kills motorist

Ruby Vee, BSN · Jul 11, 2017

I am not a Psych nurse, have never been a Psych nurse and wouldn't even play one on TV. But I've been around for a long time, and perhaps you don't need a psych nurse response but a human, common sense response. Please accept this in the spirit of helpfulness in which it was intended.

First, I'm really sorry that you have to deal with this. Having someone you know involved in an accident is a scary, sad thing. Having someone you know show up in the paper as a mug shot is a scary, sad thing. It can only be sadder and scarier if the two things are connected.

You don't have the power to change or to "fix" anyone except yourself. You can do your best to motivate someone to want to change and to help them find the tools with which to do so, but you cannot "make" them change. You cannot fix them. In this respect, psych nursing is a lot like Med/Surg nursing and cardiac nursing and diabetes nursing. You can do your best to motivate your patient to take ownership of her disease, to eat right, exercise, get enough sleep, etc. You can even give them some tools to help them do that, and you can help them find other tools. You can follow up with them and help them to manage specific symptoms. But you can't fix diabetes, and you cannot even make your patient eat sensibly, check their blood sugar or take their meds. In the words of Samuel Shem in "House of God," the patient is the one with the disease. It is up to them to manage their disease -- you cannot manage it for them.

Someone who is under the influence of alcohol makes bad decisions. Mentally healthy or not mentally healthy, alcohol is often associated with bad decision making. The attitude that driving while drunk is OK is an attitude that your patient already had; and you could not have MADE her change that attitude.

How you deal with processing these events? Boundaries. Know what is within your boundaries and what was within your patients' boundaries. (Dr. Henry Cloud wrote a book on Boundaries called, imaginatively entitled "Boundaries: When To Say Yes and How To Say No" that may help you to clarify what you can and should do for someone and what is theirs to manage. The book has a lot of Bible quotes and proselytizing, but if you can get past that it has some good information.) You and your colleagues did your best for your patient; that's what YOU can do. The rest was up to her. That's not on you; that's on her.

I've had plenty of patients in liver failure; patients who were warned that drinking (or drugging) would kill them; that they needed to stop. I've seen them admitted and re-admitted over and over with blood alcohol levels that would stagger a rhinoceros. I had to learn as a very young nurse that I couldn't MAKE them stop drinking, couldn't make them take care of themselves. I could only patch them up and discharge them again. I think that's probably very similar to what you're going through.

I remember one patient years ago, in pretty severe heart failure. We took care of him in the ICU for over a year (before the advent of ventricular assist devices) and finally he was approved for and received a heart transplant. He was eventually discharged in such great shape that he had more energy than he'd had for years. He felt so good that he resumed some of his old, pre-heart failure activities like beating his wife and inviting his friends over so he could watch them rape her. His wife died from the attack. I still feel sick when I think of how that poor woman sat at his bedside all day every day for over a year, comforting him, keeping him entertained, supporting him through his illness only to die at his hands. Perhaps that's more akin to what you're suffering. All I can tell you is that decades later, I still remember that patient with anger and disgust. But it happens less frequently now, and less intensely. Time and understanding have healed that wound somewhat. I hope that it will do the same for you.

Juryizout · Jul 12, 2017

I can't really add much to what the previous poster said because it was so awesome! But I did go through that. Boundaries are what saved me from taking it so personally. As bad as I hated that it happened, I know in my heart we did all we could, and essentially, the rest was up to them. They had to do the work of therapy and be compliant with medication without us.

KatieMI, BSN, MSN, RN · Jul 12, 2017

Ruby Vee, :up:

The thing is, we only have power to change ourselves. Not even our children. Just accept it as a fact of life - YOUR life, not others'. It takes certain level of life's wisdom to come to this level... but so it is. Not your fault. Not something that you could prevent. Not system failure. Just one human's will, maimed by disease.

Meanwhile, I noted one other thing in relation to described situation. I do not know why it is so, but I see numerous cases, both inpatient and outpatient, when people do not say "no", even if this is what they firmly intended to do. A patient might not even consider stopping smoking/drinking/weaning down on Xanax/following up with MH services/doing any other potentially beneficial changes, but the universal responce on education/paln making is "yes". I lost count of cases when we spent a heck of time arranging plans and consults, including MH, just to see patient never following up and, of course, making it back to acute care in worse condition than before.

I do not know why it is so. Maybe because nowadays people perceive any disagreement and saying "no" as being rude by definition, or because they tend to follow "game rules" so that they would feel safer dealing with the same HCP leter on? I wish I know, because it takes time and resources to educate and plan interventions, and when you find out that there were not those ubiquitous "other things that came on my way" and "some wrong decisions I've made" but a solid intention to disregard all good of that while agreeing and telling "yesses" in my face, it doesn't affect my empathy and willigness to help in a positive way.

claddagh · Jul 13, 2017

Milieu, I can relate to your story on multiple levels. I work in an ER with a high volume of mental health and substance abusing patients. As we know, the two often overlap. Many of these patients bounce between our ER, the psych unit, detox, jail and homelessness. It can be very discouraging for both patients and nurses to try to navigate such a broken system. While I often find myself saying, "If only there were better services for these people," I also continually watch my patients burn any bridge that may be built for them. I mostly shrug it off and accept that there are things that are not in my power to fix, but deep down it breaks my heart to know that many of these patients will be trapped in this cycle until they die.

Every week I see the mugshots of multiple former patients of mine. I also see them when the local jail sends them to us as patients. Most of them are convicted of petty crimes. Most come low socioeconomic backgrounds. Most will never have the resources or the opportunities that allow people to achieve recovery from addiction and mental illness. Every week, often several times a week, the ER staff, EMS and the police will spot a mugshot of one of our "frequent fliers" and we'll have a chuckle about their latest antics and joke that it is the jail's "turn" to put up with them. It's easier than crying about the very broken system we work in, a system where our clientele bounce between psychiatric and police custody as matter of routine. Only one mugshot of a former patient has shocked me. Only one mugshot of a patient has ever made my stomach churn. It was the mugshot of a man named "Andrew" who I treated over the winter.

Andrew presented to the ER with the complaint of a panic attack. After Andrew had calmed down we began to chat about life after college and its challenges. I could tell Andrew and I were from similar backgrounds. We both came from supportive middle class families where our parents made sure we had great educational opportunities and expected us to go on to successful careers. We were close in age and had several acquaintances in common. After what I thought would just be a few minutes of pleasant and therapeutic small talk, I began to get an uncomfortable feeling in my stomach. I no longer desired to speak to Andrew or even be in the same room as him. He never said anything inappropriate or rude. He was not the slightest bit threatening, but there was just something about the way Andrew presented himself that was strange. Something in my gut told me that this guy was, for lack of a better term, not right in the head. Andrew was discharged shortly afterward. He pleasantly thanked me for my help and went on his way.

Several months later I saw his picture on the news. He had stabbed a stranger to death after a brief verbal altercation at a traffic light. My gut feeling was right and it turned out he was more than just a bit "off." I felt a little disgusted and a little angry, but I mostly didn't know what to feel. I wished that odd feeling I'd had during our brief encounter would somehow have turned into an action that would have prevented that horrible crime from happening. Objectively, I know that's impossible. Andrew gave no indication that he had any tendency towards violence. He made a horrible choice because he could not control his anger. He went from just another kid with an anxiety disorder to a murderer. There was absolutely nothing I could have done.

I still don't really know how to feel about the whole ordeal. I attribute it to just another thing I'll never understand about life. But it does make wonder. I don't have any helpful advice for dealing with what you're feeling, but I hope you can feel a little better just knowing you're not alone. Nursing is raw and complicated. Sometimes the only comfort I can find when dealing with its many harsh realities is knowing that I've got my team behind me and knowing that even in the darkest and most challenging moments of my job, I'm there to help and I'm a positive force. I feel fortunate to work with people on the fringes of society because it reminds me how blessed and fortunate I am. I try to make a difference in what little way I can. I know haven't stopped a whole lot of bad things from happening, but I have done my best to replace some of the bad with good.

MilieuRN · Jul 13, 2017

Wonderful replies, thank you all so much for weighing in on this topic and my personal situation. I returned to work, and sharing the former patient's actions, we are all shocked by her choices. I really appreciate you all taking the time to share your insight and own experiences. It really does help knowing I'm not alone. The experience with this former patient is one I'm sure I'll never forget.

allnurses Guide · Jul 14, 2017

Good morning, nurses. I started my career as a nurse in an up and coming psychiatric hospital. During nursing school, I developed a passion for mental health and for advocating for patient rights while fighting the stigma that surrounds the mentally ill. I had these great aspirations to help make a difference and to provide excellent and safe care. I still do, but I am having somewhat of a problem with personal/occupational morale today. One particular patient I had worked with seemed to have a solid plan regarding how to stay well, and I felt good about her discharge. Yesterday, however, I see that she has been involved in a traffic accident in which she was drunk, with her child in the car. One dead, one in critical condition. When I saw her mugshot attached to the article, it was like a swift kick to the gut. Now, I know I don't have the power to "fix" anyone. I know people get locked into destructive patterns that are difficult to break out of. I feel though, that the system somehow failed her (please note this is attached to emotion, I'm not entirely sure how we could have better assisted her). Normally, I would question the mental health of someone driving drunk with their child, and say "Well, if only we had better mental health care..." etc.. Has anyone been in a similar situation? And how do you deal with processing these events? I have an odd mix of emotions that I rarely experience while I'm assigned to patients in the facility. I am able to intellectualize, compartmentalize, etc., patient stories, behavior and attitude, however this situation is one I haven't encountered before. Thanks in advance for your insight!

Mental health systems fail patients everyday - the chronic nature of mental illness especially when combined with a dual diagnosis of chemical dependency means that we will see many patients again and again. In some cases the mental health issues depression, anxiety etc... are the easy part to treat but take an alcoholic with an axis 2 diagnosis and there's only so much you can do. I discharged a patient today who I thought in my mind was either going straight to an AA/NA meeting or her dealer. I may see her again I may not. I may see her on the news. Still she did not meet legal criteria to keep in the hospital against her will.

I have learned not to beat myself up about the treatment failures - It was not poor care in most cases but a system that pushes patients out the door before they are ready.

Rest assured that you most likely gave excellent care to your patient but even God can't fix and alcoholic/addict if they don't want to change.

Hppy

Orca, ADN, ASN, RN · Jul 18, 2017

I'm not sure what makes a psychiatric hospital "up and coming", but I digress. Some people are going to continue down a self destructive path regardless of what kind of mental health treatment they have gotten. An adverse event doesn't mean that the system has failed.

I deal with these situations by maintaining the same professional distance that I did when the person was a patient. I did the best that I could for them while they were hospitalized, and that is where it ends. Neither I nor my colleagues are responsible for anything that a patient does after they leave the unit. Sometimes you are dealing with behaviors that are so deeply ingrained that you aren't going to reverse them in a few days on a mental health unit.

I once had a patient who was implicated (and eventually convicted) in connection with racially-motivated church burnings. It was a sad outcome, but one that we couldn't have prevented. This patient had a limited mental capacity, and it was clear to any of us who worked with him that he could not have possibly planned the things that went on. He was used by others to carry out their plans.