A patient tells me, “I’m going home tomorrow. One step closer to my shotgun, or my .44.” Oh, shit. This night is going to suck. By policy, we’re supposed to have someone sit in the room 24/7 if a patient is a suicide risk. This guy said if we did that, he’d walk out the door. Then we’d have to place him on a mental health hold. Has to be seen by a Designated Examiner (the evaluators of the mental health system) within 3 days, but in the meantime he isn’t allowed to go anywhere. If they decide he is legitimately suicidal, he will be transferred to an inpatient psych facility, until a Designated Examiner says he’s no longer a risk to himself.
This is one issue that is a continual personal conflict for me. Our mental health system is structured with a total disregard of liberty and freedom. However, so much of the time these patients are legitimately not in their right mind. In cases of true mental health issues, they are not capable of making reasoned decisions or acting in a rational manner. In many cases, they are appreciative after the fact for their treatment and apologetic for any screaming, swearing, hitting, or kicking that may have happened.
I believe our treatment of patients in these cases needs to revolve around three principles. The first is, what would the patient want if they were in their normal state of mind? If the patient would consent to treatment in their normal mental state, we may need to provide treatment despite their resistance in their current state. On the flip side, there are patients who, even in a balanced mental state would refuse treatment. We need to respect those wishes. The question is, how do we know? I believe we need to develop a system of a “mental health living will.” Once a patient’s mental state is stable, they should complete a written document stating their wishes for future treatment when mentally altered.
The second principle: If the patient is mentally altered, with each decision we need to evaluate if the patient is mentally able to make THIS decision. Even if a patient thinks they are an alien form of clock, they may be able to meaningfully state they don’t want to have a CT of their head done due to the risks of excess radiation. Or if they don’t want someone sitting and staring at them all night – that seems like a rational decision, regardless of the patient’s mental state otherwise.
Third: In cases where we do need to override a patient’s current desires, we should do so with the least aggressive measures possible. Even if a patient says no to a medically necessary procedure, we should use persuasion and time before thinking about restraints and force. Mental illness fluctuates drastically – a no now may be a yes in 30 minutes. Unless you need the test immediately (and in the patient’s interests, not because you want to clear the bed fast), there’s no reason to use force.
I could keep writing on this topic for hours, but I’ll leave it there. My suicidal guy ended up contracting with me for safety, and agreed to leave his door open and having frequent checks by staff. No sitter, no storming out, no mandatory mental health eval. Now we’ll see what my boss has to say about my decision not to force the issue.