A Cry for Help…What should an MD do when a patient

returns to the ER after 3 suicide attempts?

Kayla Poret, RN, WCC

Here is Max a 55-y.o. brought into the ER after a

3rd suicide attempt using rat poison…..

He is divorced

Alienated from his children

Chronically depressed

Has prescriptions for antidepressants, but has stopped taking them because they caused him to feel sleep

He is incoherent and semiconcious

Psychotherapy and drugs

The last 18 months has been an ongoing battle in and out of the hospital with 2 previous suicide attempts. He has had psych evals, but was not sufficiently impaired to declare him incompetent. So, he was treated with antidepressants, which he chose to stop using, because it caused him to feel sleepy.

WH

AT IS

TH

E D

ILEM

MA

?

Should Max be held for 72 hours , in which two physicians deem him dangerous to himself or others? Should the doctor sign the involuntary commitment and initiate another round of therapy?

DEFINITLEY!!! Max is a danger to

himself He is incoherent and

semiconscious He has rat poison in his

blood He cannot make sound

judgment at this time He has had 3 failed

suicide attempts Point Made…..HE IS

REACHING OUT FOR HELP!

Attempted Suicide “AKA” Parasuicide

parasuicide /para·sui·cide/ (-soo´ĭ-sīd) attempted suicide, emphasizing that in most such attempts death is not the desired outcome. Dorland's Medical Dictionary for Health Consumers

What is it to involuntarily commit someone?

the practice of using legal means or forms as part of a mental health law to commit a person to a psychiatric hospital or ward against their will and/or over their protests.

www.wikipedia.org

Eth

ically

: Wh

at s

hou

ld

the E

R D

octo

r do?

Involu

narily

Com

mit H

im?

Disch

arg

e h

im

Priniple: Beneficence—To do only good for others› Using proportionality: choosing the option

that produces more good than harm ex: determining the best treatment in a given situation

If the doctor involuntarily commits Max, then he will be doing only good for him…

There is a very high risk that Max will try another attempt of suicide. By discharging him, is the doctor not disobeying the ethical principle: Nonmalifience—because he will have unintentionally participated in another suicide attempt by Max should it play out.

“Suicide attempts that do not result in death are much more common than completed suicides. Many of these suicide attempts are carried out in a way that makes rescue possible. These attempts often represent a desperate cry for help.The method of suicide may be somewhat nonviolent, such as poisoning or overdose. Males, especially elderly men, are more likely to choose violent methods, such as shooting themselves. As a result, suicide attempts by males are more likely to be completed.”

http://health.nytimes.com/health/guides/disease/suicide-and-suicidal-behavior/overview.html

Apparently, Max was crying out for help, because he chose poisoning, which is usually “not as lethal”So now, it is the doctors duty to be the rescuer, not the one who slaps him on the wrist, hoping that he has learned his lesson….

Max is a candidate for involuntary commitment and another round of therapy

Increased depression/anxiet

yAnother suicide

attempt

discharge

Another round of therapy

Medication adjustmentPlan of Care EvaluatedSupportPsychoanalytic therapy

Is the threat of a lawsuit really worth someone’s life? There is hope for Max with the proper therapy.

Cognitive Therapy Reduces Repeat Suicide Attempts by 50 PercentRecent suicide attempters treated with cognitive therapy were 50 percent less likely to try to kill themselves again within 18 months than those who did not receive the therapy-The National Institue of Health (NIH)

It is the doctor’s responsibility to commit Max for treatmentHe holds the key to potentially the last chance for intervention

WHAT IS M

AX’S CURRENT

COND

ITION?

Incoherent Semiconcious

He is not in any condition to decide what is good for him at this time…..

So, when he does become competent, prior to 72 hours, shouldn’t he be in a safe place, where he can be protected from himself?HE HAS NO FAMILY SUPPORT..

Prognosis After Suicide Attempt: Standard of Care and the Consequences of Not Meeting ItReid, William H. MD, MPH

A significant number of people who attempt suicide and survive eventually die by their own hands, many within a year of the index attempt. A history of multiple past attempts further increases risk of eventual suicide. That most attempters do not later die by suicide is a statistical fact that should not distract psychiatrists and other mental health professionals from the substantial increase in risk associated with a suicide attempt. Short-term intensive treatment, often with psychiatric hospitalization, reduces immediate risk, but the standard of care often requires more than just a few days of generic inpatient care. Before discharging patients, the psychiatrist should be reasonably certain that the conditions associated with the attempt and initial suicide risk have improved in some significant and lasting way. Although for many patients, severe suicide risk is a relatively transient condition, patients should not be discharged just because they say they feel better or show superficial signs of lessened risk. Before sending the patient into the community, the psychiatrist should have good reason to believe that the dangerous condition(s) that precipitated the attempt and hospital admission have been ameliorated, and that the important improvements in the patient and his or her environment, on which the patient's safety relies, are both real and stable. (Journal of Psychiatric Practice 2009;15:141-144).

Another Ethical principle: Justice The MD can not

justify discharging Max without proper treatment

The MD has all the needed proof to justify his decision to hold Max for the 72 hours that he is allowed with an involuntary commit.

The MD owes it to Max to be his advocate and treat him equally as he would first time suicide attempted patients.

He should not be judged by the staff of MD because of his previous attempts

SO

WH

AT A

BO

UT A

LA

WS

UIT

?

Click icon to add picture

Where do we draw a line between giving the care that is expected of us and what is a wrong move according to lawyers, judges, and the public? Can’t every situation be made in to a legal one if wanted? Should people’s care be less effective because of the HCP fear of a lawsuit?As long as we are working in our scope of practice and being an advocate for the patient, it should not!!!

Max life hangs in the balance, while some contemplate the possibility of a

lawsuit…

Compelling Treatment After SuicideAttemptsIt has been argued that accepting a patient's refusal of treatment for a suicide attempt may be aiding in the suicide, thus leaving a physician criminally liable.The Lanterman-Petris-Short Act directs that any person who "is a danger to others or to himself, or gravely disabled" shall be placed in an approved "facility for 72-hour treatment and evaluation." Under the act,"'Intensive treatment' consists of such hospital and other services as may be indicated."

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1010642/pdf/westjmed00197-0088b.pdf

--THOMAS A. SHRAGG, MD

The MD admits Max for 72 hour observation and treatment…..

This is why he became a doctor and this is what he was trained to do. Any other alternative is just not justifiable according to the HCP Principles of Ethics and will surely be harmful to Max’s overall health. At the end of the day, the doctor will be able to sleep at night and have a feeling of gratification that he attempted to make a difference in his patient’s life. He is attempting to rescue Max from his ongoing cry for help!