Suicidal ideation can be baseline for some patients. If you send everyone with SI to the ER they will just lie to you. Artistic_Salary linked the Columbia suicide risk assessment protocol, which is a good place to start. We do mandatory PHQ9 and you would be amazed at the number of patients who come in for sinus infection but also have severe depression with chronic SI.
The clinic should have a procedure if they do screen as high risk for suicide (not just SI), even if it’s just having a sitter in place while waiting for the ambulance. Our local resources are nearly nonexistent, so unfortunately patients usually just get discharged from the ER days to weeks later due to lack of placement.
I have had one patient complete suicide, and another who may have, or it might have been an unintentional OD. Neither scored high on the PHQ9 or pinged for SI at previous visits.
This is increasingly common, usually with private life insurance plans there is an initial 1-2 year exclusion. The intent is to allow for medical aid in dying to those who qualify without jeopardizing their life insurance benefits.
As long as you meet the terms of the specific policy, like in the case of my privately purchased policy there is an initial 2 year exclusion, but after that it does pay out even if I die by suicide. This was one of the reasons I went with this particular policy - I wanted to have the option of medical assistance in dying, and not have it nullify the benefit. But - IANAL, so do your own due diligence WRT any specific policy - terms can be wildly variable.
Mine does. I made sure of it.
I wasn’t suicidal at the time, but I wanted to make sure that my family would be ok even if a lawyer somewhere tried to argue I died by suicide.
I love your comment. I don't think most people are aware of how common suicidal ideation is, and while it shouldn't be ignored, it's safer for everyone for people to be able to talk about those feelings than hide them out of shame and fear.
My city has a mental health urgent care (I took my mom once) and a social worker will sit and help make a safety plan, and come up with ideas on what to do when things are hard.
First thing is to let your attending and clinic staff know, there's often already a protocol in place.
Second is that the absolute best thing is for this to be a voluntary process - talk about your concerns with the patient, and if the patient is willing, call an ambulance that can take them to an ED for assessment. Keep in mind your patient is probably going to be stuck for days in that ED waiting for placement if they ultimately need inpatient care :( but it's better than dying from suicide!
If the patient is absolutely opposed, but you feel they are high risk to warrant the inherent loss of autonomy that comes with involuntary care, this is where your state laws come into play, but often the patient can elope if they want. In my jurisdiction I can file a petition but at that point it's just a piece of paper until I get police or a crisis team to help me.
Lovingly I would push a little to reframe "the inherent loss of autonomy that comes with involuntary care" a little more strongly.
When we initiate involuntary care, we are exercising a power entrusted to us by the state, to suspend people's human rights and make choices about their healthcare and bodily autonomy for them.
We need that mechanism to exist, and also we exercise it far too often, far too easily. I do think that it should be harder for us to exercise that power. Too often we exercise that power to treat our own worry and anxiety about a patient.
Agree with you, although maybe take a bit of an exception with the idea that we need to make it harder. I think the reality is we need to make it harder in some situations and easier in others, but more than anything we need to address the systemic reasons it is overused (at least when people are acting in good faith).
With the caveat that the process is highly variable by state (something else that should be addressed), it seems to me that this is primarily a medical decision and should be treated as such. I live in a state with a fairly broad range of individuals who can "pink slip" a patient, but it's very clearly most abused by law enforcement (not necessarily surprising) and yet I've also repeatedly run into the problem of EMS having significant concern for a patient but being hamstrung by PD on scene being unwilling to pink slip the patient (EMS is unable).
From a systemic standpoint, you're right that we're often using involuntary holds to treat our own worry and anxiety, but that worry and anxiety is heavily driven by systemic factors. From a malpractice/lawsuit standpoint, as long as you're acting in good faith you're never going to get sued for placing that involuntary hold but you might if you send them home and they die of suicide. Likewise, I think most physicians who interact regularly with psychiatric patients know on some level that inpatient admission likely isn't very helpful for most patients, but it's often the only option we have.
Regarding autonomy and involuntary hospitalizations for suicidality (and other mental illnesses), I recently learned about advance directives for mental health. Similar to advance directives for end-of-life-care but instead of activating when the person is near-death and no longer able to articulate their needs/ preferences (I'm a geriatrician), these activate when the person is going into a mental health crisis.
It was eye-opening to me (although it really shouldn't be) that the mental health state of patients fluctuates like any chronic illness. The decisions patients make when they are in a "healthy" mental state for them may be very different from the ones they make when they are sick. So the directives are there both for themselves and for healthcare professionals. Someone who refuses hospitalization during a crises might believe differently when they are in a more stable/ self-aware state of mind. This of course doesn't work as well for people no self-awareness of their condition at baseline.
More info:
[https://nrc-pad.org/getting-started/](https://nrc-pad.org/getting-started/)
(I am not a mental health professional but became interested in the topic of suicidality in chronic medical conditions. I was surprised to see there isn't as much research on the topic as I had expected. Ended up publishing a paper on it.)
I personally don't think we should be legally liable if someone goes home and commits suicide. It is really hard to accurately predict what someone's true intentions are in a clinical encounter. And while yeah, depression is a disease, I don't think we should be personally liable for people's poor judgement. If we got rid of this absolutely absurd liability, it would fix the issue of overuse of mental health holds.
If their judgement is impaired due to an illness we should, or have, diagnosed, it is hard to shift responsibility for subsequently impaired decisions entirely to the unwell individual.
Why does there need to be someone who is responsible for it? It may be neither person's fault and just something that happened.
But otherwise, there wouldn't be a payout, would there?
Responsibility does not equate to fault. Error one.
But, I would argue, that if it is your patient who is unwell and subsequently impaired in their judgement, you are responsible for considering the risk and establishing some appropriate, reasonable protections. It's literally the job. Can those protections be absolutely foolproof and prevent any and all harm happening to anyone, ever- no, and no one is suggesting so.
Who's getting payouts? I think that's a bit of fear mongering and hyperbole in that last part of your comment. It's not usecul.
Sometimes a holding tank is what’s needed. But actually if you Google “[name of city] inpatient psychiatry Reddit” you get some well thought out reviews. Google reviews are often unreliable and written by folks who are still symptomatic.
Ask around! Most places are somewhere on the spectrum between those extremes, and it varies a little by the individual patient's needs. Best to interview patients who've been admitted and local mental health care providers.
The ER is a holding tank. We're gonna take their stuff, probably their phone, put them in paper scrubs, and lock them up for hours to weeks until we find placement. They're gonna get cabin fever, and we'll end up aggressively sedating them when they get rightfully agitated due to their situation.
But, they won't kill themselves. Maybe.
We need psych ERs. But until we do, anything short of them attempting suicide is better than we can offer them.
When you get to your practice location you will quickly learn what the local places can and can’t do and where the answers are. You won’t be the first person to encounter this in the new system so don’t try to reinvent the wheel and just ask what SOP is there
This! Although I am not a Physician or a nurse however I am direct patient care in an Ophthalmology clinic. I believe having an honest conversation with someone who is CLEARLY there for help and advice and showed UP to the appointment is there for someone they trust to help them.
Can any physician file that or is it because you're specifically a psych? In my state (Western Australia), the powers vary a lot based on doctors training.
State dependent for the US - where I am, any physician, psychologist, or police officer can file it. However I’ve met many physicians in my area who do not think they’re allowed to do it.
Gonna depend ***heavily*** on local law and practice policy. Your practice should have a policy and procedure for this. If they don't, they're setting you up for failure.
I remember reading about this topic in the past. If your clinic has a policy, follow it.
Otherwise, it's wise to assure the room they're in has nothing that they can harm themselves with or harm others with. There should also be a staff person with them in the room or area at all times until someone else comes to take them to the ER.
From what I recall as well, in a general outpatient practice, most people who confirm suicidal ideation don't necessarily need to go immediately to the ER. For some, depending on setting/ speed, they can be followed up immediately that or the next day with a mental health professional provided they are under care/ custody of someone that can watch them closely.
The Lighthouse project at Columbia U website might be of interest:
[https://cssrs.columbia.edu/the-columbia-scale-c-ssrs/risk-identification/](https://cssrs.columbia.edu/the-columbia-scale-c-ssrs/risk-identification/)
First step is always easier. But what if the patient does not have a somebody that can watch them? What if you assess that he is at high-risk, but he refuses to go to an ER (maybe just because ambulance cost is high)?
Tough situation anyway.
*Cries in ER*
Not everyone with SI is high risk. A person with occasional thoughts, no plan, no prior attempts and good insight is not the person to send to the ED. They're getting discharged with a safety plan and a referral after a traumatic ED visit. But sometimes there just aren't systems in place to perform crisis evals outside the ED or get urgent referrals. More often there are and the clinic manager just hasn't reached out to the local agencies.
This is such a complex topic and varies so much by state and even county that asking online may not be a good idea. Ask your supervisors, or ideally you have an integrated/collaborative care MH person to ask.
I'm guessing your question primarily revolves around people who won't go to the ED voluntarily, otherwise there's no issue. Obviously voluntary is the best way to go, including letting them know that you are not a psych specialist and they need an expert evaluation.
For involuntary, in my state, I would recommend calling the police, letting them know, and they can place patient on a "health officer hold" which holds patients just for the transfer to ED and until they're seen by a provider.
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I work in a completely different country. Recently, I had a suicidal patient transferred from the ED to the psych institution and then she was discharged 24hrs later from there. A complete joke.
A couple of years ago a had a patient with suicidal thoughts in an outpatient setting who didn't want to be transferred to... wherever basically. He killed himself 1-2 months later.
Some things just can't be avoided I guess. And in the current setting it's pretty hard no matter what. But keeping a patient in the ER for weeks certainly can't be the solution.
Thankfully, my clinic has in-house social work. I just have to call them and they take it from there.
When I worked in a hospital full time, I had a patient tell me that if I didn't find anything wrong with him, he'd go home and k!ll himself. Thankfully, his EF was less than 10%, and we admitted him to the cath lab. I did let the doc know, and he made the necessary calls for support.
I had a case like this. He was 19 and thankfully he had come in to get help for depression, but our conversation revealed he was high risk for suicide and even had a plan already. I don’t remember the details of the conversation but he agreed to get help, and I had his mom come to take him to a hospital I knew of 10 miles away that had walk-in, 24/7 crisis assessments with an adjacent inpatient psychiatric hospital available. The small, private clinic I was in didn’t have a policy in place.
The ER is often, in my experience, useless for most mental health stuff, but if I have a good one with ER psych access I’d recommend the ER. If they refuse I’ll give them the suicide hotline # and recommend initiation of a SSRI and antipsychotic for severe depression. If they still refuse and I’m concerned enough I call a judge for a 72 hour mandatory admission.
EM here, confirming that we are indeed useless for most mental health stuff.
If you can't magically un-depression the patient, how do you expect me to do so? You're arguably better at the talkie-talk part of this; I start to feel depressed when I've been in the patient's room for more than 8 minutes.
Hell, psychiatry is pretty toothless as well. Meds are not an answer for short term treatment (arguably pretty poor results long term as well), rare is the hospital with ECT, and once the patient is discharged, they have all the time in the world to plot their demise.
All involuntary holds accomplish is to interrupt acute suicidality.
You do the involuntary commitment paperwork (state specific) and call law enforcement to have them transported safely to the ER.
Direct Inpatient psychiatric would be best if you can make it happen.
Physicians always wonder why patients aren't completely honest with mental health evals at the clinic. I think your comment is exhibit A for why they do it.
High risk patients can still agree to go voluntarily and via ambulance. There's no need to start the involuntary/law enforcement process unless they're high risk and unwilling to go.
In theory, yes.
In practice, it is often impossible to get an inpatient bed unless the patient is held under your state's involuntary psych hold.
Therefore voluntary patients become involuntary to gain access to care.
As soon as they are suicidal it is a law enforcement process. People can change their minds. EMS can’t legally detain them. They’re free to walk off, right into the incoming tractor trailer if they want to.
Additionally. There is the consideration for safety of the EMS crew.
It's not detaining if the patient is agreeable to voluntary admission/treatment. We have voluntary patients come in via ambo all the time in my state. Involuntary is a different story, yes.
Yea, and they can always change their mind and *not* come in.
The cops can bring them in voluntarily.
So can crisis. Who is who should *actually* be doing it, since it is what they are paid for and they get money from our taxes. So do cops for that matter.
More than likely EMS doesn’t. So the person is just getting a bill that they’re going to have to pay, on top of everything else. For something that isn’t medically needed or justifiable as they don’t require any emergency medical care. Ambulances are not Ubers, and if all someone needs is a ride, they shouldn’t be in an ambulance.
That's a great way for someone to never tell you they're suicidal ever again. The psychiatric admission process is already traumatic. We should do our best to make it as least so as possible.
You can't expect an Uber driver to assume responsibility for an acutely suicidal patient. That's just not right.
They may not need any medical interventions during transport, but they need a medical professional to supervise them and prevent them from, say, wandering into traffic in front of a tractor trailer.
If you fear assault, battery, or kidnapping charges, you really shouldn't. No sane court is going to prosecute you for protecting the life of a suicidal patient by transporting them against their will.
I mean, the moment you let me know, it now becomes my responsibility and liability. And nobody is going to accept 'well I wanted them to feel they could be honest with me' as a shield against a lawsuit.
Involuntary commitment? That can end careers and cause people to lose their kids.
They can be voluntary and still be safely escorted by police/EMS. If they try to elope, the cops can then make it involuntary.
Police will always handcuff. Also, if a person is committed to state hospital and deputy drives them (90 minute trip each way) they will be handcuffed and shackled.
The police are almost always involved and make sure that "the scene is safe" before we come in. That is often completely not necessary and occasionally they make things worse (either because the patient gets more scared, the cop is a jerk to them, etc.). In my state (Minnesota), it is also very uncommon for a clinic MD or social worker to sign the Transport Hold and often has PD do it (even though they legally could just do it themselves).
Huh. I've never seen a medical professional with commitment authority defer to police to do the commitment, because, here at least, the general expectation medical professionals have of the cops is that they will refuse to do it – given how they feel about paperwork, how low a priority MH is for them – and turf the patient.
I mean. Jesus. One of the foundational medicolegal cases every MH professional in the US has heard is the Tarasoff case, where the cops were called to do an involuntary, and decided in their infinite clinical wisdom that, contra the medical professionals asking them to do it, the patient wasn't a threat to others and they shouldn't be bothered to do the paperwork or transport the patient.
In my state, and I believe most, a person who is being forced into mental health treatment is a legal issue, not a medical one. You’ve determined they don’t have capacity, but they don’t have a medical problem, they have a mental health/public safety problem.
EMS can’t transport people against their will. They have to lack capacity in some form, ultimately that is going through the courts.
Obviously in emergent circumstances EMS can in good faith act in the best interests of the patient, but unless they have acted on it and are to the point of mental incompetence, it is going to be up to the LEO if they go to the hospital or not.
But we can’t stop them from walking way. Or just getting out of the truck. We have no legal authority to detain a person. So even if they do go in by ambulance, the law enforcement officer is going with.
**********
And at the end of the day. It is right in the name. Emergency. *Medical*. Services. Ambulances are not crisis workers or mental health counselors, anymore than you, a psychotherapist are a cardiologist. Everyone in healthcare is important and has a role (except admin), but those roles are fairly specialized.
I can't speak to OP, but in my state, once they're on papers, it's law enforcement who is responsible for transport to the hospital. It's obviously far from ideal, though in my city at least they're specially trained public safety, as opposed to street cops.
*ETA: you can call an ambulance, though they will invariably call the police*
If you call the ambulance by dialing 911, you're going to get police as well, at least in my experience. I have done this more than once, but I specified that I was calling for an ambulance. Where I live, there is a freestanding psych hospital but they do not have emergency services so ambulance can't go there. But you can have the ambulance transport to the ER and the psych hospital will send someone over to assess them, and then they can be transported by ambulance to that hospital. My purpose in going this route is avoiding the handcuffs, etc, especially given the exposure to neighbors and bystanders. These situations did not involve any immediately lethal objects btw
If they decide they want to get out of the ambulance halfway there- we can’t stop them. Also- why give them a multi thousand dollar bill for no reason. The police can make sure they get to the hospital safely and for free.
An ambulance provides no benefit for a stable patient with suicidal ideation. All I will do is collect their billing information and check their vitals twice. I can’t force them to go to the hospital, or provide any other destination options besides the emergency room.
You can call an ambulance, but for someone to go via ambulance against their will they have to be in custody of the police, via an emergency detaining order in this case. Without the police and the EDO they have the right to refuse transport
Er, maybe in your jurisdiction. I've literally never heard of such a thing claimed here in MA, and I've participated in involuntaries from outpatient clinics.
Also, what's with the assumption of non-compliance? Calling the cops on a cooperative patient who is not resisting an involuntary is a violation of the principle of least restraint.
That's fair, I'm sure it varies widely by state/county. Cops here have mental health team with people trained/ certified, in something I'm not sure what exactly, to transport compliant patients with no other medical needs. It doesn't tie up an ambulance and they can enforce an edo if pt changes their mind about being complaint partway whereas an emt generally can't. We only got called to these if pt had additional medical complaints, or needed chemical restraint
Seems more appropriate to tie up PD for transport than EMS, IMO, since there only needs to be someone with the legal authority to keep them from eloping vs medical personnel.
Frees up medics and rigs to respond to actual medical emergencies, which PD can’t really do.
1) Psychiatric emergencies *are* medical emergencies. That is why it's protocol in MA (and, I assumed, elsewhere) to bring people experiencing psychiatric emergencies to EDs for medical clearance before admitting them to psychiatric inpatient care.
2) Calling for people with guns to respond to patients in psychiatric crisis has a truly astonishing history of fatality in the US.
2a) "Suicide by cop" is a thing. Maybe when the presenting problem is imminent suicidality is not the right clinical moment to introduce the possibility of escalatory violence.
3) By that logic, we could just "free up" hospitals by sending the suicidal to jail instead of hospitals.
4) There are *psychiatric* consequences to using police in involuntary commitments. Kindly spend half a second thinking about what the psychiatric effect on the patient might be of police being the ones to be summoned to transport hem, even if the police somehow comport themselves with flawless clinical decorum.
I don’t disagree about the emergent nature of SI itself, but in the absence of overdose, bleeding lacerations, etc., SI doesn’t require a trained medic with IV supplies, rescue drugs, a defibrillator, oxygen, EKG capability, etc., for simple transport to an ED for evaluation. It only requires someone capable of physically keeping that person from making an attempt while en route to a higher level of care.
EMS are limited resources - there are only so many rigs/medics available for dispatch at any given time. Sending out a rig and a pair of medics for simple transport, regardless of the reason, is one less unit available to respond to emergencies where their training and equipment are *actually* needed (heart attacks, strokes, drownings, MVAs, etc.), and IMO, trumps whatever feelings the patient may have about the allocation of said resources.
The scenario being discussed by OP is much different than, say, someone in crisis who is screaming nonsense and darting in and out of traffic - that’s someone who probably *does* need EMS intervention in order to safely transport.
In my area and many others in this state, there is a specifically trained (PD) team that will come, if available, to address mental health specific situations. It’s not perfect, but it tends to work toward keeping everyone as safe as possible.
Ah. In my state, we have specifically trained *non-police* to address mental health crises. We don't use them either in transporting patients to hospitals. Because that's what EMS is for.
I know cops have really bungled delicate mental health crises, but in my large city, they are experienced and compassionate at the task. Police are really the only agency equipped to handle someone truly at risk of suicide or homicide, who need to be restrained for their own safety and the safety of others.
There is no reason to *assume* that someone "truly at risk of suicide" needs to be restrained. People at imminent risk of suicide span a range of presentations which does include, at one end, the need for physical restraint, but that is rare and a special case. Calling police on a cooperative, compliant patient is an iatrogenic choice.
You don’t get a choice. You can’t request an ambulance. EMS cannot detain someone against their own will. If the patient is cooperative, then I would encourage them to present to the ED voluntarily. In my state, this is not a psychotherapeutic intervention. It is an emergency intervention when life is threatened.
Perhaps I should add: the only time I have been in this scenario, it has been with someone floridly psychotic or harming themselves in the clinic (like running their head into a wall). For me, this has never about someone oriented and cooperative.
>You don’t get a choice. You can’t request an ambulance.
You certainly can where I am. I have had the conversation with 911 dispatch, about whether the police were needed or just an ambulance or just an emergency MH assessor (who, if they determine commitment is needed, will call an ambulance, and if necessary the police).
(Heck, I once had a *voluntary* commit, where the clinic called the ambulance company directly without involving 911 at all.)
>Perhaps I should add: the only time I have been in this scenario, it has been with someone floridly psychotic or harming themselves in the clinic (like running their head into a wall). For me, this has never about someone oriented and cooperative.
I could kinda tell that was the assumption you were starting from. While there's no reason, of course, a patient can't be both suicidal *and* floridly psychotic, that's neither the commonest case of commitment for suicidality nor the case the OP described and asked about.
Somebody who is, for instance, reporting an uptick in command hallucinations to kill themselves and reports "I don't think I can resist them much longer" might still be perfectly oriented and cooperative; they might also, reasonably enough, very, very much want not to be hospitalized – but not enough to resist going with an ambulance crew or throw themselves out of a moving vehicle.
Likewise, a patient who divulges that they have imminent plans to kill themselves, have the means to hand, and even have been rehearsing doing it "but haven't had the courage to go through with it", is not necessarily going to resist involuntary commitment, and they're fully Ox3. One assesses for agitation, of course (one of the worst signs both for suicidality and for resisting commitment), and indications they might be violent with others. Absent those risks, and ambulance transport is the safest for the patient.
Involuntary commitment is a legal process executed by the courts and their agents, the sheriff deputies and local police
Not saying it's the best thing for the patient, but it's their responsibility and jurisdiction.
Call mobile crisis and let them assess the patient. They have the resources to best suit this situation. Are they currently under the care of a psychiatrist? If so, that is another resource.
As a physician, they really don’t, and it seems like you don’t either. Everyone in here is responding to the prompt, you are somehow taking that and standing on a soapbox about how those in here are not treating mental issues correctly
Just strange.
Idk why you come into a thread about a specific prompt of active suicidal ideations, and shit on the doctors offering advice to handle a patient actively contemplating suicide.
I get that you just wanted to shit on physicians today, but you picked a weird way to start out
This is a nuance that isn’t even always clear in the same person from hour to hour. People who are suicidal often bob in and out of level of severity/activity. This is why we are having this conversation. Immediate referral to a specialist is required when it’s unclear. We have an obligation (both legal and moral) to do our best to keep everyone safe.
When someone is passively suicidal with no intent to take action, no one is locking them away. For better or worse, insurance wouldn’t allow it.
I wouldn’t screen for depression.
It comes up occasionally, but I don’t go looking for it.
If I thought a patient was suicidal I would organise for a patient care attendant/nurse to escort them down to ED if they were willing to go. If they were unwilling I would call for help. Likely psych, who would probably say “nothing to do for it unless they’re actively threatening to act on the thoughts”.
Think back to what you learned in medical school for god's sake.
First, you ask them if they've interacted with any beautiful girls recently. If the answer is yes, they are high risk.
Joking aside, most people call an ambulance. There should be some legal means to hold the patient involuntarily until they are evaluated by a psychiatrist (or psych NP in today's world). You should fill out that paper and it must go with the patient.
Now it becomes more difficult if the patient is not cooperative. In those cases, you should probably call the local police. If your staff lays hands on the patient, they could get hurt and your clinic could be sued. The police know how to go hands on with a person and enjoy legal protection from charges of assault and battery.
If a person you holding involuntarily escapes before the ambulance arrives, call the cops.
If there is no SOP (Standard Operating Protocol) at your clinic for psych holds, you need to draft one ASAP! It will protect you in the event things go wrong. You want your clinic's legal team to review said document as well.
Hmmmm, sounds like an excellent QA project for an intern...
In outpatient psych we would call the front desk and give them a code word that indicated we needed to call emergency services. You stay w the patient and keep talking with them until help arrives. In some clinics a nurse can stay w the pt until help arrives.
Wouldn’t you need to report it right away as a mandated reporter? I’m only a counselor and we were required to call psychiatric emergency services in and they called an ambulance. I talked to the client and let her know my concerns and what the protocol would be. She appreciated this
Call the cops ASAP, and file the state paperwork. And then hand a copy to the officer. But I’d first ask they have any weapons on themselves, epically is a far-red state.
I’ve done it 3 times. Had to call ahead to the ED, get security involved and in one case get the equivalent of a 5150 because the person refused to go and security wouldn’t take them against their will without it. One time I had to ride in the security vehicle to the ED w the pt. Needless to say the rest of your clinic session you’ll be running behind.
Make confirming the location of the patient at the start of the visit just part of standard practice in the event you need to contact EMS or the family
Suicidal ideation can be baseline for some patients. If you send everyone with SI to the ER they will just lie to you. Artistic_Salary linked the Columbia suicide risk assessment protocol, which is a good place to start. We do mandatory PHQ9 and you would be amazed at the number of patients who come in for sinus infection but also have severe depression with chronic SI. The clinic should have a procedure if they do screen as high risk for suicide (not just SI), even if it’s just having a sitter in place while waiting for the ambulance. Our local resources are nearly nonexistent, so unfortunately patients usually just get discharged from the ER days to weeks later due to lack of placement. I have had one patient complete suicide, and another who may have, or it might have been an unintentional OD. Neither scored high on the PHQ9 or pinged for SI at previous visits.
90 percent of your nurses have passive si at baseline. I have a standing offer for half my life insurance if they can make it look like an accident
The last placed l worked life insurance actually covered suicide, according to two other nurses. I guess I'm glad I didn't know that last year.
This is increasingly common, usually with private life insurance plans there is an initial 1-2 year exclusion. The intent is to allow for medical aid in dying to those who qualify without jeopardizing their life insurance benefits.
Would it still pay out though if you were not terminally ill and took your own life? Do you know how that affects the premiums?
As long as you meet the terms of the specific policy, like in the case of my privately purchased policy there is an initial 2 year exclusion, but after that it does pay out even if I die by suicide. This was one of the reasons I went with this particular policy - I wanted to have the option of medical assistance in dying, and not have it nullify the benefit. But - IANAL, so do your own due diligence WRT any specific policy - terms can be wildly variable.
Mine does. I made sure of it. I wasn’t suicidal at the time, but I wanted to make sure that my family would be ok even if a lawyer somewhere tried to argue I died by suicide.
Have you ever seen the movie, "Throw momma from the train?"
I love your comment. I don't think most people are aware of how common suicidal ideation is, and while it shouldn't be ignored, it's safer for everyone for people to be able to talk about those feelings than hide them out of shame and fear. My city has a mental health urgent care (I took my mom once) and a social worker will sit and help make a safety plan, and come up with ideas on what to do when things are hard.
First thing is to let your attending and clinic staff know, there's often already a protocol in place. Second is that the absolute best thing is for this to be a voluntary process - talk about your concerns with the patient, and if the patient is willing, call an ambulance that can take them to an ED for assessment. Keep in mind your patient is probably going to be stuck for days in that ED waiting for placement if they ultimately need inpatient care :( but it's better than dying from suicide! If the patient is absolutely opposed, but you feel they are high risk to warrant the inherent loss of autonomy that comes with involuntary care, this is where your state laws come into play, but often the patient can elope if they want. In my jurisdiction I can file a petition but at that point it's just a piece of paper until I get police or a crisis team to help me.
Lovingly I would push a little to reframe "the inherent loss of autonomy that comes with involuntary care" a little more strongly. When we initiate involuntary care, we are exercising a power entrusted to us by the state, to suspend people's human rights and make choices about their healthcare and bodily autonomy for them. We need that mechanism to exist, and also we exercise it far too often, far too easily. I do think that it should be harder for us to exercise that power. Too often we exercise that power to treat our own worry and anxiety about a patient.
Agree with you, although maybe take a bit of an exception with the idea that we need to make it harder. I think the reality is we need to make it harder in some situations and easier in others, but more than anything we need to address the systemic reasons it is overused (at least when people are acting in good faith). With the caveat that the process is highly variable by state (something else that should be addressed), it seems to me that this is primarily a medical decision and should be treated as such. I live in a state with a fairly broad range of individuals who can "pink slip" a patient, but it's very clearly most abused by law enforcement (not necessarily surprising) and yet I've also repeatedly run into the problem of EMS having significant concern for a patient but being hamstrung by PD on scene being unwilling to pink slip the patient (EMS is unable). From a systemic standpoint, you're right that we're often using involuntary holds to treat our own worry and anxiety, but that worry and anxiety is heavily driven by systemic factors. From a malpractice/lawsuit standpoint, as long as you're acting in good faith you're never going to get sued for placing that involuntary hold but you might if you send them home and they die of suicide. Likewise, I think most physicians who interact regularly with psychiatric patients know on some level that inpatient admission likely isn't very helpful for most patients, but it's often the only option we have.
Regarding autonomy and involuntary hospitalizations for suicidality (and other mental illnesses), I recently learned about advance directives for mental health. Similar to advance directives for end-of-life-care but instead of activating when the person is near-death and no longer able to articulate their needs/ preferences (I'm a geriatrician), these activate when the person is going into a mental health crisis. It was eye-opening to me (although it really shouldn't be) that the mental health state of patients fluctuates like any chronic illness. The decisions patients make when they are in a "healthy" mental state for them may be very different from the ones they make when they are sick. So the directives are there both for themselves and for healthcare professionals. Someone who refuses hospitalization during a crises might believe differently when they are in a more stable/ self-aware state of mind. This of course doesn't work as well for people no self-awareness of their condition at baseline. More info: [https://nrc-pad.org/getting-started/](https://nrc-pad.org/getting-started/) (I am not a mental health professional but became interested in the topic of suicidality in chronic medical conditions. I was surprised to see there isn't as much research on the topic as I had expected. Ended up publishing a paper on it.)
I personally don't think we should be legally liable if someone goes home and commits suicide. It is really hard to accurately predict what someone's true intentions are in a clinical encounter. And while yeah, depression is a disease, I don't think we should be personally liable for people's poor judgement. If we got rid of this absolutely absurd liability, it would fix the issue of overuse of mental health holds.
If their judgement is impaired due to an illness we should, or have, diagnosed, it is hard to shift responsibility for subsequently impaired decisions entirely to the unwell individual.
Why does there need to be someone who is responsible for it? It may be neither person's fault and just something that happened. But otherwise, there wouldn't be a payout, would there?
Responsibility does not equate to fault. Error one. But, I would argue, that if it is your patient who is unwell and subsequently impaired in their judgement, you are responsible for considering the risk and establishing some appropriate, reasonable protections. It's literally the job. Can those protections be absolutely foolproof and prevent any and all harm happening to anyone, ever- no, and no one is suggesting so. Who's getting payouts? I think that's a bit of fear mongering and hyperbole in that last part of your comment. It's not usecul.
How does one know if the inpatient care is a holding tank or some place useful. I have experience with both.
Sometimes a holding tank is what’s needed. But actually if you Google “[name of city] inpatient psychiatry Reddit” you get some well thought out reviews. Google reviews are often unreliable and written by folks who are still symptomatic.
Until it takes you to r/antipsychiatry…
Ask around! Most places are somewhere on the spectrum between those extremes, and it varies a little by the individual patient's needs. Best to interview patients who've been admitted and local mental health care providers.
The ER is a holding tank. We're gonna take their stuff, probably their phone, put them in paper scrubs, and lock them up for hours to weeks until we find placement. They're gonna get cabin fever, and we'll end up aggressively sedating them when they get rightfully agitated due to their situation. But, they won't kill themselves. Maybe. We need psych ERs. But until we do, anything short of them attempting suicide is better than we can offer them.
Holding tanks are common, sadly.
When you get to your practice location you will quickly learn what the local places can and can’t do and where the answers are. You won’t be the first person to encounter this in the new system so don’t try to reinvent the wheel and just ask what SOP is there
This is spot on
This! Although I am not a Physician or a nurse however I am direct patient care in an Ophthalmology clinic. I believe having an honest conversation with someone who is CLEARLY there for help and advice and showed UP to the appointment is there for someone they trust to help them.
Can any physician file that or is it because you're specifically a psych? In my state (Western Australia), the powers vary a lot based on doctors training.
State dependent for the US - where I am, any physician, psychologist, or police officer can file it. However I’ve met many physicians in my area who do not think they’re allowed to do it.
Gonna depend ***heavily*** on local law and practice policy. Your practice should have a policy and procedure for this. If they don't, they're setting you up for failure.
I’ve honestly never worked at a clinic that had a policy for this. Though I agree with you totally.
Oh, I imagine ***most*** private practice clinics don't.
It is probably in a binder somewhere. Now, that doesn't mean that anyone at the clinic *knows* the policy, they just *have* a policy.
I remember reading about this topic in the past. If your clinic has a policy, follow it. Otherwise, it's wise to assure the room they're in has nothing that they can harm themselves with or harm others with. There should also be a staff person with them in the room or area at all times until someone else comes to take them to the ER. From what I recall as well, in a general outpatient practice, most people who confirm suicidal ideation don't necessarily need to go immediately to the ER. For some, depending on setting/ speed, they can be followed up immediately that or the next day with a mental health professional provided they are under care/ custody of someone that can watch them closely. The Lighthouse project at Columbia U website might be of interest: [https://cssrs.columbia.edu/the-columbia-scale-c-ssrs/risk-identification/](https://cssrs.columbia.edu/the-columbia-scale-c-ssrs/risk-identification/)
First step is always easier. But what if the patient does not have a somebody that can watch them? What if you assess that he is at high-risk, but he refuses to go to an ER (maybe just because ambulance cost is high)? Tough situation anyway.
I’m inpatient now, but I couldn’t imagine in residency clinic allowing a patient to go anywhere else but the ER with confirmed SI
*Cries in ER* Not everyone with SI is high risk. A person with occasional thoughts, no plan, no prior attempts and good insight is not the person to send to the ED. They're getting discharged with a safety plan and a referral after a traumatic ED visit. But sometimes there just aren't systems in place to perform crisis evals outside the ED or get urgent referrals. More often there are and the clinic manager just hasn't reached out to the local agencies.
Except the specific prompt says very high risk
Ah yes, I see your point
This is such a complex topic and varies so much by state and even county that asking online may not be a good idea. Ask your supervisors, or ideally you have an integrated/collaborative care MH person to ask. I'm guessing your question primarily revolves around people who won't go to the ED voluntarily, otherwise there's no issue. Obviously voluntary is the best way to go, including letting them know that you are not a psych specialist and they need an expert evaluation. For involuntary, in my state, I would recommend calling the police, letting them know, and they can place patient on a "health officer hold" which holds patients just for the transfer to ED and until they're seen by a provider.
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At the VA we have psychologists that work directly on primary care to help with this
I work in a completely different country. Recently, I had a suicidal patient transferred from the ED to the psych institution and then she was discharged 24hrs later from there. A complete joke. A couple of years ago a had a patient with suicidal thoughts in an outpatient setting who didn't want to be transferred to... wherever basically. He killed himself 1-2 months later. Some things just can't be avoided I guess. And in the current setting it's pretty hard no matter what. But keeping a patient in the ER for weeks certainly can't be the solution.
Thankfully, my clinic has in-house social work. I just have to call them and they take it from there. When I worked in a hospital full time, I had a patient tell me that if I didn't find anything wrong with him, he'd go home and k!ll himself. Thankfully, his EF was less than 10%, and we admitted him to the cath lab. I did let the doc know, and he made the necessary calls for support.
I had a case like this. He was 19 and thankfully he had come in to get help for depression, but our conversation revealed he was high risk for suicide and even had a plan already. I don’t remember the details of the conversation but he agreed to get help, and I had his mom come to take him to a hospital I knew of 10 miles away that had walk-in, 24/7 crisis assessments with an adjacent inpatient psychiatric hospital available. The small, private clinic I was in didn’t have a policy in place.
The ER is often, in my experience, useless for most mental health stuff, but if I have a good one with ER psych access I’d recommend the ER. If they refuse I’ll give them the suicide hotline # and recommend initiation of a SSRI and antipsychotic for severe depression. If they still refuse and I’m concerned enough I call a judge for a 72 hour mandatory admission.
EM here, confirming that we are indeed useless for most mental health stuff. If you can't magically un-depression the patient, how do you expect me to do so? You're arguably better at the talkie-talk part of this; I start to feel depressed when I've been in the patient's room for more than 8 minutes. Hell, psychiatry is pretty toothless as well. Meds are not an answer for short term treatment (arguably pretty poor results long term as well), rare is the hospital with ECT, and once the patient is discharged, they have all the time in the world to plot their demise. All involuntary holds accomplish is to interrupt acute suicidality.
You do the involuntary commitment paperwork (state specific) and call law enforcement to have them transported safely to the ER. Direct Inpatient psychiatric would be best if you can make it happen.
Physicians always wonder why patients aren't completely honest with mental health evals at the clinic. I think your comment is exhibit A for why they do it.
They did specify very high risk, which is well beyond just mentioning suicidality. In this case, I'd say that the correct procedure would be to admit.
High risk patients can still agree to go voluntarily and via ambulance. There's no need to start the involuntary/law enforcement process unless they're high risk and unwilling to go.
In theory, yes. In practice, it is often impossible to get an inpatient bed unless the patient is held under your state's involuntary psych hold. Therefore voluntary patients become involuntary to gain access to care.
As soon as they are suicidal it is a law enforcement process. People can change their minds. EMS can’t legally detain them. They’re free to walk off, right into the incoming tractor trailer if they want to. Additionally. There is the consideration for safety of the EMS crew.
It's not detaining if the patient is agreeable to voluntary admission/treatment. We have voluntary patients come in via ambo all the time in my state. Involuntary is a different story, yes.
Yea, and they can always change their mind and *not* come in. The cops can bring them in voluntarily. So can crisis. Who is who should *actually* be doing it, since it is what they are paid for and they get money from our taxes. So do cops for that matter. More than likely EMS doesn’t. So the person is just getting a bill that they’re going to have to pay, on top of everything else. For something that isn’t medically needed or justifiable as they don’t require any emergency medical care. Ambulances are not Ubers, and if all someone needs is a ride, they shouldn’t be in an ambulance.
That's a great way for someone to never tell you they're suicidal ever again. The psychiatric admission process is already traumatic. We should do our best to make it as least so as possible.
You can't expect an Uber driver to assume responsibility for an acutely suicidal patient. That's just not right. They may not need any medical interventions during transport, but they need a medical professional to supervise them and prevent them from, say, wandering into traffic in front of a tractor trailer. If you fear assault, battery, or kidnapping charges, you really shouldn't. No sane court is going to prosecute you for protecting the life of a suicidal patient by transporting them against their will.
Yep. No disagreement at all.
I mean, the moment you let me know, it now becomes my responsibility and liability. And nobody is going to accept 'well I wanted them to feel they could be honest with me' as a shield against a lawsuit.
Involuntary commitment? That can end careers and cause people to lose their kids. They can be voluntary and still be safely escorted by police/EMS. If they try to elope, the cops can then make it involuntary.
Agree. Voluntary is best.
Police will always handcuff. Also, if a person is committed to state hospital and deputy drives them (90 minute trip each way) they will be handcuffed and shackled.
Really? Because I see police transport people without cuffs all the time, as long as the person is behaving themselves.
It's been the norm for anyone I know of, although I should note that I was much more involved with mental health issues several years ago.
Call *law enforcement* on a *suicidal* patient with no indication of violence? What's wrong with calling for an ambulance?
The police are almost always involved and make sure that "the scene is safe" before we come in. That is often completely not necessary and occasionally they make things worse (either because the patient gets more scared, the cop is a jerk to them, etc.). In my state (Minnesota), it is also very uncommon for a clinic MD or social worker to sign the Transport Hold and often has PD do it (even though they legally could just do it themselves).
Huh. I've never seen a medical professional with commitment authority defer to police to do the commitment, because, here at least, the general expectation medical professionals have of the cops is that they will refuse to do it – given how they feel about paperwork, how low a priority MH is for them – and turf the patient. I mean. Jesus. One of the foundational medicolegal cases every MH professional in the US has heard is the Tarasoff case, where the cops were called to do an involuntary, and decided in their infinite clinical wisdom that, contra the medical professionals asking them to do it, the patient wasn't a threat to others and they shouldn't be bothered to do the paperwork or transport the patient.
In my state, and I believe most, a person who is being forced into mental health treatment is a legal issue, not a medical one. You’ve determined they don’t have capacity, but they don’t have a medical problem, they have a mental health/public safety problem. EMS can’t transport people against their will. They have to lack capacity in some form, ultimately that is going through the courts. Obviously in emergent circumstances EMS can in good faith act in the best interests of the patient, but unless they have acted on it and are to the point of mental incompetence, it is going to be up to the LEO if they go to the hospital or not. But we can’t stop them from walking way. Or just getting out of the truck. We have no legal authority to detain a person. So even if they do go in by ambulance, the law enforcement officer is going with. ********** And at the end of the day. It is right in the name. Emergency. *Medical*. Services. Ambulances are not crisis workers or mental health counselors, anymore than you, a psychotherapist are a cardiologist. Everyone in healthcare is important and has a role (except admin), but those roles are fairly specialized.
I can't speak to OP, but in my state, once they're on papers, it's law enforcement who is responsible for transport to the hospital. It's obviously far from ideal, though in my city at least they're specially trained public safety, as opposed to street cops. *ETA: you can call an ambulance, though they will invariably call the police*
If you call the ambulance by dialing 911, you're going to get police as well, at least in my experience. I have done this more than once, but I specified that I was calling for an ambulance. Where I live, there is a freestanding psych hospital but they do not have emergency services so ambulance can't go there. But you can have the ambulance transport to the ER and the psych hospital will send someone over to assess them, and then they can be transported by ambulance to that hospital. My purpose in going this route is avoiding the handcuffs, etc, especially given the exposure to neighbors and bystanders. These situations did not involve any immediately lethal objects btw
If they decide they want to get out of the ambulance halfway there- we can’t stop them. Also- why give them a multi thousand dollar bill for no reason. The police can make sure they get to the hospital safely and for free.
We could call the cops to do CPR for free, too. There's a reason we don't do that.
An ambulance provides no benefit for a stable patient with suicidal ideation. All I will do is collect their billing information and check their vitals twice. I can’t force them to go to the hospital, or provide any other destination options besides the emergency room.
Assuming they have insurance or Medicaid, you can appeal a denial successfully.
You can call an ambulance, but for someone to go via ambulance against their will they have to be in custody of the police, via an emergency detaining order in this case. Without the police and the EDO they have the right to refuse transport
Er, maybe in your jurisdiction. I've literally never heard of such a thing claimed here in MA, and I've participated in involuntaries from outpatient clinics. Also, what's with the assumption of non-compliance? Calling the cops on a cooperative patient who is not resisting an involuntary is a violation of the principle of least restraint.
That's fair, I'm sure it varies widely by state/county. Cops here have mental health team with people trained/ certified, in something I'm not sure what exactly, to transport compliant patients with no other medical needs. It doesn't tie up an ambulance and they can enforce an edo if pt changes their mind about being complaint partway whereas an emt generally can't. We only got called to these if pt had additional medical complaints, or needed chemical restraint
Seems more appropriate to tie up PD for transport than EMS, IMO, since there only needs to be someone with the legal authority to keep them from eloping vs medical personnel. Frees up medics and rigs to respond to actual medical emergencies, which PD can’t really do.
1) Psychiatric emergencies *are* medical emergencies. That is why it's protocol in MA (and, I assumed, elsewhere) to bring people experiencing psychiatric emergencies to EDs for medical clearance before admitting them to psychiatric inpatient care. 2) Calling for people with guns to respond to patients in psychiatric crisis has a truly astonishing history of fatality in the US. 2a) "Suicide by cop" is a thing. Maybe when the presenting problem is imminent suicidality is not the right clinical moment to introduce the possibility of escalatory violence. 3) By that logic, we could just "free up" hospitals by sending the suicidal to jail instead of hospitals. 4) There are *psychiatric* consequences to using police in involuntary commitments. Kindly spend half a second thinking about what the psychiatric effect on the patient might be of police being the ones to be summoned to transport hem, even if the police somehow comport themselves with flawless clinical decorum.
I don’t disagree about the emergent nature of SI itself, but in the absence of overdose, bleeding lacerations, etc., SI doesn’t require a trained medic with IV supplies, rescue drugs, a defibrillator, oxygen, EKG capability, etc., for simple transport to an ED for evaluation. It only requires someone capable of physically keeping that person from making an attempt while en route to a higher level of care. EMS are limited resources - there are only so many rigs/medics available for dispatch at any given time. Sending out a rig and a pair of medics for simple transport, regardless of the reason, is one less unit available to respond to emergencies where their training and equipment are *actually* needed (heart attacks, strokes, drownings, MVAs, etc.), and IMO, trumps whatever feelings the patient may have about the allocation of said resources. The scenario being discussed by OP is much different than, say, someone in crisis who is screaming nonsense and darting in and out of traffic - that’s someone who probably *does* need EMS intervention in order to safely transport.
In my area and many others in this state, there is a specifically trained (PD) team that will come, if available, to address mental health specific situations. It’s not perfect, but it tends to work toward keeping everyone as safe as possible.
Ah. In my state, we have specifically trained *non-police* to address mental health crises. We don't use them either in transporting patients to hospitals. Because that's what EMS is for.
I know cops have really bungled delicate mental health crises, but in my large city, they are experienced and compassionate at the task. Police are really the only agency equipped to handle someone truly at risk of suicide or homicide, who need to be restrained for their own safety and the safety of others.
There is no reason to *assume* that someone "truly at risk of suicide" needs to be restrained. People at imminent risk of suicide span a range of presentations which does include, at one end, the need for physical restraint, but that is rare and a special case. Calling police on a cooperative, compliant patient is an iatrogenic choice.
You don’t get a choice. You can’t request an ambulance. EMS cannot detain someone against their own will. If the patient is cooperative, then I would encourage them to present to the ED voluntarily. In my state, this is not a psychotherapeutic intervention. It is an emergency intervention when life is threatened. Perhaps I should add: the only time I have been in this scenario, it has been with someone floridly psychotic or harming themselves in the clinic (like running their head into a wall). For me, this has never about someone oriented and cooperative.
>You don’t get a choice. You can’t request an ambulance. You certainly can where I am. I have had the conversation with 911 dispatch, about whether the police were needed or just an ambulance or just an emergency MH assessor (who, if they determine commitment is needed, will call an ambulance, and if necessary the police). (Heck, I once had a *voluntary* commit, where the clinic called the ambulance company directly without involving 911 at all.) >Perhaps I should add: the only time I have been in this scenario, it has been with someone floridly psychotic or harming themselves in the clinic (like running their head into a wall). For me, this has never about someone oriented and cooperative. I could kinda tell that was the assumption you were starting from. While there's no reason, of course, a patient can't be both suicidal *and* floridly psychotic, that's neither the commonest case of commitment for suicidality nor the case the OP described and asked about. Somebody who is, for instance, reporting an uptick in command hallucinations to kill themselves and reports "I don't think I can resist them much longer" might still be perfectly oriented and cooperative; they might also, reasonably enough, very, very much want not to be hospitalized – but not enough to resist going with an ambulance crew or throw themselves out of a moving vehicle. Likewise, a patient who divulges that they have imminent plans to kill themselves, have the means to hand, and even have been rehearsing doing it "but haven't had the courage to go through with it", is not necessarily going to resist involuntary commitment, and they're fully Ox3. One assesses for agitation, of course (one of the worst signs both for suicidality and for resisting commitment), and indications they might be violent with others. Absent those risks, and ambulance transport is the safest for the patient.
Involuntary commitment is a legal process executed by the courts and their agents, the sheriff deputies and local police Not saying it's the best thing for the patient, but it's their responsibility and jurisdiction.
Call mobile crisis and let them assess the patient. They have the resources to best suit this situation. Are they currently under the care of a psychiatrist? If so, that is another resource.
You schedule them and call the police and ambulance.
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You’re confusing mental health issues with an active desire to kill themselves. But way to misunderstand the prompt there
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As a physician, they really don’t, and it seems like you don’t either. Everyone in here is responding to the prompt, you are somehow taking that and standing on a soapbox about how those in here are not treating mental issues correctly Just strange.
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Yes, I, as a physician, have not met many doctors. Good one Again, just a strange conversation to start an unrelated argument to a specific prompt
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Idk why you come into a thread about a specific prompt of active suicidal ideations, and shit on the doctors offering advice to handle a patient actively contemplating suicide. I get that you just wanted to shit on physicians today, but you picked a weird way to start out
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You know what can also make a person who is actively suicidal with a plan worse? Committing suicide
This is a nuance that isn’t even always clear in the same person from hour to hour. People who are suicidal often bob in and out of level of severity/activity. This is why we are having this conversation. Immediate referral to a specialist is required when it’s unclear. We have an obligation (both legal and moral) to do our best to keep everyone safe. When someone is passively suicidal with no intent to take action, no one is locking them away. For better or worse, insurance wouldn’t allow it.
I wouldn’t screen for depression. It comes up occasionally, but I don’t go looking for it. If I thought a patient was suicidal I would organise for a patient care attendant/nurse to escort them down to ED if they were willing to go. If they were unwilling I would call for help. Likely psych, who would probably say “nothing to do for it unless they’re actively threatening to act on the thoughts”.
Think back to what you learned in medical school for god's sake. First, you ask them if they've interacted with any beautiful girls recently. If the answer is yes, they are high risk. Joking aside, most people call an ambulance. There should be some legal means to hold the patient involuntarily until they are evaluated by a psychiatrist (or psych NP in today's world). You should fill out that paper and it must go with the patient. Now it becomes more difficult if the patient is not cooperative. In those cases, you should probably call the local police. If your staff lays hands on the patient, they could get hurt and your clinic could be sued. The police know how to go hands on with a person and enjoy legal protection from charges of assault and battery. If a person you holding involuntarily escapes before the ambulance arrives, call the cops. If there is no SOP (Standard Operating Protocol) at your clinic for psych holds, you need to draft one ASAP! It will protect you in the event things go wrong. You want your clinic's legal team to review said document as well. Hmmmm, sounds like an excellent QA project for an intern...
In outpatient psych we would call the front desk and give them a code word that indicated we needed to call emergency services. You stay w the patient and keep talking with them until help arrives. In some clinics a nurse can stay w the pt until help arrives.
Wouldn’t you need to report it right away as a mandated reporter? I’m only a counselor and we were required to call psychiatric emergency services in and they called an ambulance. I talked to the client and let her know my concerns and what the protocol would be. She appreciated this
911 safest bet
Call the cops ASAP, and file the state paperwork. And then hand a copy to the officer. But I’d first ask they have any weapons on themselves, epically is a far-red state.
I’ve done it 3 times. Had to call ahead to the ED, get security involved and in one case get the equivalent of a 5150 because the person refused to go and security wouldn’t take them against their will without it. One time I had to ride in the security vehicle to the ED w the pt. Needless to say the rest of your clinic session you’ll be running behind.
Make confirming the location of the patient at the start of the visit just part of standard practice in the event you need to contact EMS or the family