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Ovid: Oxford Handbook of Psychiatry

Editors: Semple, David; Smyth, Roger; Burns, Jonathan; Darjee, Rajan; McIntosh, Andrew Title: Oxford Handbook of Psychiatry, 1st Edition Copyright ©2005 Oxford University Press > Table of Contents > Chapter 22 – Difficult and urgent situations Chapter 22 Difficult and urgent situations P.890
Dealing with psychiatric emergencies It is a common misconception that there are no real emergencies in psychiatry. The billowing white coat may be gone, but then so is the backup of the arrest team. Dealing with acute situations can feel like a lonely business, and doubts about the best management of given situations may prevent you getting that much needed rest period. As a psychiatrist, you are primarily a doctor, and you should ensure that you are up to date with basic resuscitation procedures. Familiarise yourself with the procedures in place for the management of medical emergencies in your hospital, as the level of on-site facilities will vary. There is no substitute for experience, but hopefully some of the guidance in the following section (and the other pages they refer to) will allow a rational approach to a number of common (and not so common) difficult and urgent situations in a psychiatric setting. Keep the following principles in mind: Primum non nocere (‘Above all, do no harm’)

  • Always ensure your own and other staff’s safety.
  • Remember—patient confidentiality does not override issues of threatened harm to themselves or other individuals.
  • Always suspect (and as far as possible eliminate) potential organic causation for psychiatric presentations.
  • If necessary facilities or expertise are not available, make appropriate arrangements to get the patient to them as soon as possible.

Assess

  • Always make the fullest assessment possible—do not fail to ask about important issues just because you feel a person may not wish to talk about them.
  • Ensure that you have the best quality information available. If other sources of information are available (e.g. previous notes, 3rd party information), use them!
  • Don’t dawdle—if a situation requires immediate action, act.

Consult

  • Do not assume anything. If in doubt, consult a senior colleague. Remember you are part of a team, and if there is a difficult decision to make, do not make it alone.

Keep contemporaneous records

  • Clearly record your assessment, decisions made (and reasons), and the names of any other colleagues involved or consulted. Legally, if it’s not been recorded, it’s not been done.

P.891
P.892
What to do if summoned to a crisis situation/negotiation principles First principles

  • Speak to the staff who originated the call.
  • Obtain as much information as possible about the situation prior to seeing the patient.
  • Establish what your expected role is.
  • Keep your own safety uppermost in your mind (no heroics).

General aims

  • Attempt to put the patient at their ease; explain who you are and why you have been asked to speak to them.
  • Be clear in any questions you need to ask.
  • Elicit useful information.
  • Achieve a safe, dignified resolution of the situation.

Important communication principles

  • Be conscious of both verbal and non-verbal language.
    • Listen actively—assimilate and understand what is actually being said and interpret the various underlying meanings and messages.
    • Feedback—go back over what the patient has said with them to assure them that you understand what they are saying.
    • Empathy—show you appreciate them sharing their thoughts, feelings, and motives.
    • Content and feeling—note any difference between what is said verbally and what message is really being given.
  • Use checkpoint summaries—brief reviews of the main points discussed, about issues, and any demands.

Important suggestions

  • Use open questions to give the patient an opportunity to ventilate what is on their mind (this may help relieve tension, keep the patient talking, and allow you to assess the mental state).
  • Listen carefully to what the patient is saying.
    • This may provide further clues as to their actions.
    • It also demonstrates concern for the patient’s problem.
  • Be honest, upfront, and sincere—try to develop a trusting relationship.
  • Be neutral—avoid approval or disapproval unless absolutely necessary.
  • Orient the patient to looking for alternative solutions together, without telling them how to act (unless asked).
  • Try to divert any negative train of thought.
  • Check with other team members before making any commitments.
  • If the police have been called, present the reason for their presence realistically, but neutrally.
  • Do not involve family members in negotiations.

Some suggestions for dealing with particular patients (See opposite) P.893
The patient responding to paranoid ideas/delusion

  • Avoid prolonged eye contact and do not get too close.
  • The patient’s need to explain may allow you to establish a degree of rapport. Allow them to talk, but try to stay with concrete topics.
  • Do not try to argue them out of their delusions—ally yourself with their perspective without sounding insincere (e.g. ‘What you are saying is that you believe…x…y…z’)
  • Avoid using family members who may be part of the delusional system.
  • Try to distance yourself from what may have happened in the past (e.g. ‘I’m sorry that was your experience before…maybe this time we could manage things better…’).
  • Be aware that your offer of help may well be rejected.

The patient with antisocial traits

  • A degree of flattery may facilitate discussion of alternative solutions (e.g. you understand their need to communicate, how important their opinions are to you, your desire to work together to resolve things).
  • Encourage them to talk about what has led up to this situation.
  • Try to convince them that other ways of achieving their aims will be to their advantage—keep any negotiation reality-oriented.
  • Focus their attention on you as the means to achieve their aims.

The patient with borderline traits

  • Provide ‘understanding’ and ‘uncritical acceptance’.
  • Help them find a way to sort things out without having ‘failed again’.
  • Try to build self-esteem (e.g. ‘You have done well coping with everything up to now…’.)
  • Once trust has been gained, it may be possible to be more directive.
  • Use the patient’s desire to be accepted (e.g. ‘I really think it would be best if we…’).
  • Bear in mind that often the behaviour will be attention-seeking, and it may be worth asking: ‘What is it you feel you need just now?’
  • Do not be surprised if the patient acts impulsively.

The depressed patient

  • Psychomotor retardation may make response time slow—be patient.
  • The presence of friends or relatives may worsen their feelings of worthlessness and guilt.
  • Focus on the ‘here and now’—avoid talking abstractly.
  • Acknowledge that they probably cannot imagine a positive future.
  • Be honest and straightforward—once rapport has been established, it may be appropriate to be explicitly directive.
  • Try to postpone the patient’s plans, rather than dismiss them (e.g. ‘Let’s try this…and see how you feel in the morning…’).
  • Be prepared to repeat reassurances.

The patient experiencing acute stress

  • Allow ventilation of feelings.
  • Try to get them to describe events as objectively as possible.
  • Have them go back over the options they have ruled out.
  • Review the description of events, and present a more objective, rational perspective.

P.894
Managing suicide attempts in hospital Attempted overdose In psychiatric wards, the most likely means of attempted self-poisoning involves building up a stock of prescribed medication or bringing into the ward tablets to be taken at a later date (e.g. while out on pass). Often patients will volunteer to trusted nursing staff that they have taken an overdose, or staff will notice the patient appears overtly drowsy and when challenged the patient admits to overdose.

  • Try to ascertain the type and quantity of tablets taken (look for empty bottles, medication strips, etc.)
  • Establish the likely time-frame.
  • If patient is unconscious or significantly drowsy, arrange immediate transfer to emergency medical services.
    • Inform medical team of patient’s diagnosis, current mental state, current status (informal/formal), any other regular medications.
  • If patient asymptomatic, but significant overdose suspected, arrange immediate transfer to emergency services.
    • Do not try to induce vomiting.
    • If available, consider giving activated charcoal (single dose of 50g with water) to reduce absorption (esp. if NSAIDs/paracetamol).
  • If patient asymptomatic, and significant overdose unlikely:
    • Monitor closely (general observations, level of consciousness, evidence of nausea/vomiting, other possible signs of poisoning).
    • If paracetamol or salicylate (aspirin) suspected: perform routine bloods (FBC, U&Es, LFTs, HCO3, INR) and request specific blood levels (4h post-ingestion for paracetamol).
    • If other psychiatric medications may have been taken, consider urgent blood levels (e.g. lithium, anticonvulsants—see p. 888).
    • Be aware that LFTs may be abnormal in patient on antipsychotic or antidepressant medication.
  • If in doubt, get advice, or arrange for medical assessment.

Deliberate self-harm Most episodes of deliberate self-harm involve superficial self-inflicted injury (e.g. scratching, cutting, burning, scalding) to the body or limbs. These may be easily treated on the ward with little fuss (to avoid secondary reinforcement of behaviour).

  • Any more significant injuries (e.g. stabbing, deep lacerations) should be referred to emergency medical services, with the patient returning to the psychiatric ward as soon as medically fit.
  • Medical advice should also be sought if:
    • You do not feel sufficiently competent to suture minor lacerations.
    • Lacerations are to the face/other vulnerable areas (e.g. genitals) or where you cannot confirm absence of damage to deeper structures (e.g nerves, blood vessels, tendons).
    • The patient has swallowed/inserted sharp objects into their body (e.g. vagina, anus).
    • The patient has ingested potentially harmful chemicals.

P.895
Attempted hanging Most victims of attempted hangings in hospitals do not use a strong enough noose or sufficient drop height to cause death through spinal cord injury (‘judicial hanging’). Cerebral hypoxia through asphyxiation is the probable cause of death and should be the primary concern in treatment of this patient population. On being summoned to the scene

  • Support the patient’s weight (if possible enlist help).
  • Loosen/cut off ligature.
  • Lower patient to flat surface, ensuring external stabilisation of the neck and begin usual basic resuscitation (ABCs, IV access, etc.)
  • Emergency airway management is a priority:
    • Where available, administer 100% O2
    • If competent and indicated: use nasal or oral endotracheal intubation.
  • Assess conscious level, full neurological examination, and degree of injury to soft tissues of the neck.
  • Arrange transfer to emergency medical services as soon as possible.

Points to note

  • Aggressive resuscitation and treatment of post-anoxic brain injury is indicated even in patients without evident neurological signs.
  • Cervical spine fractures should be considered if there is a possibility of a several foot drop or evidence of focal neurological deficit.
  • Injury to the anterior soft tissues of the neck may cause respiratory obstruction. Close attention to the development of pulmonary complications is required.

Attempted asphyxiation

  • Remove source (ligature, polythene bag, etc.)
  • Give 100% O2
  • If prolonged period of anoxia, or impaired conscious level, arrange immediate transfer to emergency medical services.

After the event Patient

  • Once the patient is fit for interview, formally assess mental state and conduct assessment of further suicide risk (pp. 730, 731, 732, 733).
  • Establish level of observation necessary to ensure patient’s safety, clearly communicate your decision to staff and make a record in the patient’s notes. (NB Hospitals policy may vary, but levels of observation will range from timed checks (e.g. every 15mins) to having a member of staff within arm’s length of the patient 24hrs/day).

Staff

  • For particularly traumatic events, it may be necessary to arrange a “critical incident review” (at a later date) where all staff involved participate in a confidential debriefing session. This is not to establish blame, but rather to review policy and to consider what measures (if any) might be taken to prevent similar events occurring in the future.

P.896
Severe behavioural disturbance This covers a vast range of presentations, but will usually represent a qualitative acute change in a person’s normal behaviour, that manifests primarily as antisocial behaviour—e.g. shouting, screaming, increased (often disruptive/intrusive) activity, aggressive outbursts, threatening violence (to others or self). In extreme circumstances (e.g. person threatening to commit suicide by jumping from a height (out of a window, off a roof), where the person has an offensive weapon, or a hostage situation), this is a police matter and your responsibility does not extend to risking your own or other people’s lives in trying to deal with the situation. Common causes

  • Acute confusional states (see delirium p. 734).
  • Drug/alcohol intoxication.
  • Acute symptoms of psychiatric disorder (anxiety/panic—p. 344, mania—p. 318, schizophrenia/other psychotic disorders—p. 198).
  • ‘Challenging behaviour’ in brain-injured or LD patients (pp. 716, 717, 718).
  • Behaviour unrelated to primary psychiatric disorder—this may reflect personality disorder, abnormal personality traits, or situational stressors (e.g. frustration).

General approach

  • Sources of information will vary depending on the setting (e.g. on the ward, in outpatients, emergency assessment of new patient). Try to establish the context in which the behaviour has arisen.
  • Follow the general principles outlined on pp. 890, 891, 892, 893.
  • Look for evidence of possible psychiatric disorder.
  • Look for evidence of possible physical disorder.
  • Try to establish any possible triggers for the behaviour—environmental/inter-personal stressors, use of drugs/alcohol, etc.

Management This will depend upon assessment made:

  • If physical cause suspected:
    • Follow management of delirium (p. 734)
    • Consider use of sedative medication (see opposite) to allow proper examination, facilitate transfer to medical care (if indicated), or to allow active (urgent) medical management.
  • If psychiatric cause suspected:
    • Consider pharmacological management of acute behavioural disturbance (see opposite).
    • Consider need for compulsory detention.
    • Review current management plan, including observation level.
  • If no physical or psychiatric cause suspected, and behaviour is dangerous or seriously irresponsible, inform security or the police to have person removed from the premises (and possibly charged if a criminal offence has been committed e.g. assault, damage to property).

P.897
Pharmacological approach to severe behavioural disturbance Numerous local guidelines are available. Be aware of these and ensure that, if involved in control and restraint, you are adequately trained to carry out these duties responsibly. The following is a suggested aid to pharmacological management. The doses quoted are appropriate for young, physically fit patients who have previously received antipsychotic medication. In patients who are elderly, have physical health problems, or are ‘antipsychotic naïve’, dosage should at least be halved (refer to BNF for further guidance). First-line treatments:

Option 1: Intramuscular haloperidol 10–20mg and 1–2mg lorazepam
Intramuscular olanzapine may also be an alternative1
Repeat if necessary
Option 2: Diazepam 10mg by slow intravenous bolus
Repeat if necessary. N.B. Ensure flumazenil available.

Second-line treatments:

Option 3: Intramuscular chlorpromazine 25–100mg N.B. Danger of postural hypotension and fatality if given inadvertently by intravenous injection.
Option 4: Zuclopenthixol acetate 50–150mg. (This is rapidly acting, sedating, depot antipsychotic which is best avoided in antipsychotic naïve or inexperienced patients because of long half-life.)

Third-line treatments Other treatments (e.g. paraldehyde) or combinations of the above may be suggested in some centres. Always consult senior medical advice before administering these interventions. The evidence base is relatively weak for the superiority of any compound over another, although benzodiazepines may have a shorter time to onset and are generally safe2. Aftercare Respiration, pulse, and blood pressure should be monitored within an hour of drug administration and regularly thereafter. Look for extrapyramidal side-effects, particularly acute dystonia. Remember: fatalities have occurred in the context of emergency restraint. Note on consent: Giving emergency medication for acute behavioural disturbance is essentially treatment under common law (p. 822). The justification rests on the judgement that no other management options are likely to be effective, and that tranquillisation will prevent the patient harming themselves or others. Harm may include behaviour that is likely to endanger the physical health of the patient (e.g. not consenting to urgent treatment or investigations that are likely to be life-saving) when capacity to give consent is judged to be impaired (p. 822). References 1 http://www.nice.org.uk 2 TREC Collaborative Group (2003) Rapid tranquillisation for agitated patients in emergency psychiatric rooms: a randomised trial of midazolam versus haloperidol plus promethazine. BMJ 327, 708–13. P.898
The catatonic patient Catatonia is certainly less common in current clinical practice, thanks to the advent of effective treatments for many psychiatric disorders and earlier interventions. Nonetheless the clinical presentation may be a cause for concern, particularly when a previously alert and oriented patient becomes mute and immobile. The bizarre motor presentations (e.g. posturing) may also raise concerns about a serious acute neurological problem (hence these patients may be encountered in a medical/liaison setting), and it is important that signs of catatonia are recognised. Equally, the ‘excited’ forms may be associated with sudden death (‘lethal’ or ‘malignant’ catatonia), which may be preventable with timely interventions. Clinical presentation Characteristic signs

  • Mutism
  • Posturing
  • Negativism
  • Staring
  • Rigidity
  • Echopraxia/echolalia

Typical forms

  • Stuporous/retarded
  • Excited/delirious

Common causes

  • Mood disorder More commonly associated with mania (accounts for up to 50% of cases) than depression. Often referred to as manic (or depressive) stupor (or excitement).
  • General medical disorder Often associated with delirium:
    • Metabolic disturbances
    • Endocrine disorders
    • Viral infections (including HIV)
    • Typhoid fever
    • Heat stroke
    • Autoimmune disorders
    • Drug-related (antipsychotics, dopaminergic drugs, recreational drugs, BDZ withdrawal, opiate intoxication)
  • Neurological disorders
    • Postencephalitic states
    • Parkinsonism
    • Seizure disorder (e.g. non-convulsive status epilepticus)
    • Bilateral globus pallidus disease
    • Lesions of the thalamus or parietal lobes
    • Frontal lobe disease
    • General paresis
  • Schizophrenia (10–15% of cases) Classically catalepsy, mannerisms, posturing, and mutism (‘Catatonic schizophrenia’, p. 185).

P.899
Differential diagnosis

  • Elective mutism (p. 596) Usually associated with pre-existing personality disorder, clear stressor, no other catatonic features, unresponsive to lorazepam.
  • Stroke Mutism associated with focal neurological signs and other stroke risk factors. ‘Locked-in’ syndrome (lesions of ventral pons and cerebellum) is characterised by mutism and total immobility (apart from vertical eye movements and blinking). The patient will often try to communicate.
  • Stiff-person syndrome Painful spasms brought on by touch, noise, or emotional stimuli (may respond to baclofen, which can induce catatonia).
  • Malignant hyperthermia Occurs following exposure to anaesthetics and muscle relaxants in predisposed individuals (p. 868).
  • Akinetic parkinsonism Usually, in patients with a history of parkinsonian symptoms and dementia—may display mutism, immobility, and posturing. May respond to anticholinergics, not BDZs.

Other recognised catatonia (and catatonia-like) subtypes

  • Malignant catatonia Acute onset of excitement, delirium, fever, autonomic instability, and catalepsy—may be fatal.
  • Neuroleptic malignant syndrome (NMS)—p. 868.
  • Serotonin syndrome (SS)—p. 870.

Management Assessment

  • Full history (often from 3rd party sources), including recent drug exposure, recent stressors, known medical/psychiatric conditions.
  • Physical examination (including full neurological).
  • Investigations—T°, BP, pulse, FBC, U&Es, LFTs, glucose, TFTs, cortisol, prolactin, consider CT/MRI and EEG.

Treatment

  • Symptomatic treatment of catatonia will allow you to assess any underlying disorder more fully (i.e. you will actually be able to talk to the patient).
  • Best evidence for use of BDZs (e.g. lorazepam 500mcg-1mg oral/IM—if effective, given regularly thereafter), barbiturates (e.g. amobarbital [amytal] 50–100mg), and ECT.
  • Alone or in combination these effectively relieve catatonic symptoms regardless of severity or aetiology in 70–80% of cases1,2.
  • Address any underlying medical or psychiatric disorder.

References 1 Bush G, Fink M, Petrides G, et al. (1996) Catatonia II: treatment with lorazepam and electroconvulsive therapy. Acta Psychiatr Scand 93, 137–43. 2 Ungvari GS, Kau LS, Wai-Kwong T, Shing NF (2001) The pharmacological treatment of catatonia: an overview. Eur Arch Psychiatry Clin Neurosci 251 (suppl 1), 31–4. P.900
Medication or drug-related problems requiring immediate action There are a number of presentations related to both prescribed and recreational drugs that may present acutely and require urgent attention. These include: Prescribed medication

  • Acute dystonic reaction (p. 866)
  • Neuroleptic malignant syndrome (p. 868)
  • Serotonin syndrome (p. 870)
  • Lithium toxicity (p. 330)
  • Clozapine ‘red’ result (p. 220)
  • Paradoxical reactions to benzodiazepines (p. 875)

Recreation drugs

  • Acute opiate withdrawal (p. 538)
  • Acute benzodiazepine withdrawal (p. 540)
  • Acute alcohol withdrawal (p. 518)

P.901
P.902
The manipulative patient (1) Manipulation is a term that is generally used pejoratively, although some ethologists regard manipulative behaviour as ‘selfish but adaptive’ (i.e. the means by which we use others to further our own aims—which may be entirely laudable). In the context of psychiatric (and other medical) settings, manipulative behaviours are usually maladaptive and include:

  • Inappropriate or unreasonable demands
    • More of your time than any other patient receives.
    • Wanting to deal with a specific doctor.
    • Only willing to accept one particular course of action (e.g. admission to hospital, a specific medication or other form of treatment).
  • Behavioural sequelae of failing to have these demands met
    • Claims of additional symptoms they failed to mention previously.
    • Veiled or explicit threats of self-harm, lodging formal complaints, litigation, or violence.
    • Passive resistance (refusing to leave until satisfied with outcome of consultation).
    • Verbal or physical abuse of staff/damage to property.
    • Actual formal complaints relating to treatment (received or refused), or false accusations of misconduct against medical staff.

Key points

  • Patients DO have the right to expect appropriate assessment, care, and relief of distress.
  • Doctors DO have the right to refuse a course of action they judge to be inappropriate.
  • Action should always be a response to clinical need (based on a thorough assessment, diagnosis, and best evidence for management), NOT threats or other manipulative behaviours.
  • It is entirely possible that a patient who demonstrates manipulative behaviour DOES have a genuine problem (it is only their way of seeking help that is inappropriate).
  • Some of the most difficult patients tend to present at ‘awkward’ times (e.g. the end of the working day, early hours of the morning, weekends, public holidays, intake of new staff)—this is no accident!
  • Admitting a patient to hospital overnight (when you are left with no other option) is not a failure—some patients are very good at engineering this outcome. At worst it reinforces inappropriate coping behaviours in the patient. (Critical colleagues would probably have done the same themselves in similar circumstances.)
  • If you have any doubts about what course of action to take, consult a senior colleague and discuss the case with them.

Management principles: 1. New case

  • Make a full assessment to establish:
    • Psychiatric diagnosis and level of risk (to self and others).
    • Whether other agencies are required (e.g. specific services: drug/ alcohol problems; social work: housing/benefits/social supports; P.903
      counseling: for specific issue—debt/employment/bereavement/ alleged abuse).
  • Ask the patient what they think is the main problem.
  • Ask the patient what they were hoping you could do for them, e.g.:
    • Advice about what course of action to take.
    • Wanting their problem to be ‘taken seriously’.
    • Wanting to be admitted to hospital (below).
    • Wanting a specific treatment.
  • Discuss with them your opinion of the best course of action, and establish whether they are willing to accept any alternatives offered (e.g. other agencies, outpatient treatment).

2. The ‘frequent attender’/chronic case

  • Do not take short cuts—always fully assess current mental state and make a risk assessment.
  • When available—always check previous notes, any written care plan, or ‘crisis card’.
  • Establish the reason for presenting now (i.e. what has changed in their current situation).
  • Ask yourself ‘Is the clinical presentation significantly different so as to warrant a change to the previously agreed treatment plan?’
  • If not, go with what has been laid out in the treatment plan.

Pitfalls (and how to avoid them)

  • Try not to take your own frustrations (e.g. being busy, feeling ‘dumped on’ by other colleagues, lack of sleep, lack of information, vague histories) into an interview with a patient—your job is to make an objective assessment of the person’s mental state and to treat each case you see on its own merits.
  • Try not to allow any preconceptions or the opinions of other colleagues colour your assessment of the current problems the patient presents with (people and situations have a tendency to change with time, and what may have been true in the past may no longer be the case).
  • Watch out for the patient who appeals to your vanity by saying things like: ‘You’re much better than that other psychiatrist I saw…I can really talk to you…I feel you really understand…’ They probably initially said the same things to ‘that other psychiatrist’ too!
  • Do not be drawn into being openly critical of other colleagues; remember you are only hearing one side of the story. Maintain a healthy regard for the professionalism of those you work beside—respect their opinions (even if you really don’t agree with them).
  • If you encounter a particularly difficult patient, enlist the support of a colleague and conduct the assessment jointly.
  • NEVER acquiesce to a ‘private’ consultation with a patient of the opposite sex; do not make ‘special’ arrangements; and NEVER give out personal information or allow patients to contact you directly.

P.904
The manipulative patient (2) Specific situations Patient demanding medication

  • There are really only two scenarios where there is an urgent need for medication:
    • The patient who is acutely unwell and requires admission to hospital anyway (e.g. with acute confusion, acute psychotic symptoms, severe depression, high risk of suicide).
    • The patient who is known and has genuinely run out of their usual medication (for whom a small supply may be dispensed to tide them over until they can obtain a repeat prescription).

Patient demanding immediate admission

  • Clarify what the patient hopes to achieve by admission, and decide whether this could be reasonably achieved, or if other agencies are better placed to meet these requests (see p. 6).
  • If the patient is demanding admission due to drug/alcohol dependence, emphasise the need for clear motivation to stop, and offer to arrange outpatient follow-up (the next day) (see p. 514).
  • Always ask about any recent trouble with the police; it is not uncommon for hospital to be sought as a ‘sanctuary’ from impending court appearance (but remember this can be a significant stressor for patients with current psychiatric problems).

Additional complications Demanding relatives/other advocates

  • Assess the patient on their own initially, but allow those attending with the patient to have their say (this may clarify the ‘why now’ question, particularly if it involves the breakdown of usual social supports).
  • Ask the patient for their consent to discuss the outcome of your consultation with those accompanying them (to avoid misunderstandings and improve compliance with the proposed treatment plan).

Patient ‘raising the stakes’

  • If a patient is dissatisfied with the outcome of your consultation, they may try a number of ways to change your mind (see p. 902); They may even explicitly say: What do I have to do to convince you… before resorting to other manipulative behaviours.
  • This type of response only serves to confirm any suspicions of attempted manipulation and should be recorded as such in the notes (verbatim if possible).
  • Stick to your original management plan, and if the behaviour becomes passively, verbally or physically aggressive, clearly inform them that unless they desist, you will have no other option than to have them removed (by the police, if necessary).
  • Equally, any threats of violence towards individuals present during the interview or elsewhere should be dealt with seriously and the police (and the individual concerned) should be informed—patient confidentiality does not take precedence over ensuring the safety of others.

P.905
Suspected factitious illness

  • Try to obtain corroboration of the patient’s story (or confirmation of your suspicions) from 3rd party sources (e.g. GP, relative, previous notes, including other hospitals they claim to have been seen at).
  • If your suspicions are confirmed, directly feed this information back to the patient, and clearly inform them of what course of action you plan to take (e.g. recording this in their notes, informing other agencies, etc.)
  • Do not feel ‘defeated’ if you decide to admit them to hospital. Record your suspicions in the notes and inform the psychiatric team that the reason for admission is to assess how clinically significant the reported symptoms are (it will soon become clear in a ward environment and it may take time to obtain 3rd party sources).

Patient threatening suicide by telephone

  • Keep the person talking (see advice, pp. 890, 891, 892, 893).
  • Try to elicit useful information (name, where they are calling from, what they plan to do, risk to anyone else).
  • If you judge the patient to be at high risk of suicide, encourage them to come to hospital—if they refuse or are unable to do so, organise for emergency services to go to their location and bring them to hospital.
  • If the patient refuses to give you any information, inform the police who may have other means to determine the source of the call and respond.
  • Always document ‘phone calls in the same way as you would any other patient contact (see below).

Closure

  • Clearly document your assessment, any discussion with senior colleagues, the outcome, and any treatment plan.
  • Record the agreement/disagreement of the patient and any other persons attending with them.
  • If appropriate, provide the patient with written information (e.g. appointment details, other contact numbers) to ensure clear communication.
  • Ensure that you have informed any other necessary parties (e.g. keyworkers/psychiatric team already involved with the patient, source of referral—which may be the GP, other carers, social workers, etc.)
  • If the assessment occurs out of hours, make arrangements for information to be passed on to the relevant parties in the morning (ideally try to do this yourself).
  • If you have suggested outpatient follow-up for a new patient, make sure you have a means of contacting the patient, to allow the relevant service to make arrangements to see them as planned.
  • If you think it is likely the patient will re-present to other services, inform them of your contact with the patient and the outcome of your assessment.

P.906
Issues of child protection The treating doctor has a responsibility to consider the welfare not only of their patient, but of the patient’s dependants (in most cases, their children). Where there are concerns relating to the welfare of children, this responsibility may be discharged both through actions you take yourself (e.g. admitting the patient to hospital), and through involvement of appropriate statutory agencies (e.g. child and family social services). Each case should be individually assessed, however a number of scenarios can be recognised:

  • Necessary absence When a patient is brought into hospital (e.g. for emergency assessment) the admitting doctor should clarify whether they have dependent children, and if so, what arrangements have been made for their care. If these are unsatisfactory, or are disconcertingly vague (e.g. ‘with a friend’), child and family social services should be consulted.
  • Neglect of childcare responsibilities In some circumstances, as a result of mental disorder, patients’ ability to provide the appropriate level of physical or emotional care may be impaired. This may relate to functional impairments (e.g. poor memory), continuing symptomatology (and medication side-effects), or dependence on drugs or alcohol. Having a mental disorder does not preclude being a parent—what is important is that individual patients receive appropriate assessment to ascertain the type of additional support they may need and the level of monitoring required.
  • Risk of positive harm to child Certain disorders carry the risk of harm to the child by acts of commission, rather than omission. These include:
    • Psychotic disorders in which the patient holds abnormal beliefs about their child.
    • Severe depressive disorder with suicidal ideas, which involve killing the child (usually for altruistic reasons).
    • Drug misuse where there are drugs or drug paraphernalia left carelessly in the child’s environment.

In these cases, a joint approach should be adopted involving mental health (optimising the patient’s management) and social services (addressing issues of child protection and welfare). P.907
P.908
Patients acting against medical advice In certain situations, doctors are faced with deciding whether or not to act against a patient’s stated wishes. This most commonly occurs when:

  • A patient does not consent to a particular treatment plan.
  • A patient wishes to leave hospital, despite medical advice that this is not in their best interests.

Fundamental principles

  • An adult has the right to refuse treatment or to leave hospital should they wish.
  • Doctors have a responsibility to discuss what they are proposing with the patient fully, to ensure that the patient is informed of the options, risks, and the preferred management (but not to enforce or coerce).

Special circumstances In some circumstances, doctors have the power to act without the patient’s consent or override a patient’s expressed wishes when:

  • Consent cannot be obtained in an emergency situation (pp. 821, 822) and treatment may be given under common law(p. 822).
  • A patient’s capacity is either temporarily or permanently impaired (p. 822) and they are unable to give informed consent. The responsible doctor should act in the patient’s best interest(p. 823)—use of the Adults with Incapacity Act (2002) in Scotland (p. 822).
  • They are suffering from a mental disorder and their capacity to take decisions is impaired. Use of the MHA may be necessary to ensure their own (or other persons’) safety.

Points to note

  • When a capable patient disagrees with a proposed course of action, this should be recorded clearly in the notes (with the reasons given by the patient). If this involves discharge from hospital, a ‘discharge against medical advice’ form may be useful (as a written record of the patient’s decision), even though such forms have no special legal status.
  • In emergency situations, the definition of ‘mental disorder’ is that of a layperson, not whether ICD-10 or DSM-IV criteria are satisfied.
  • Judging a person incapable does not allow for detention in hospital; equally detaining someone under the MHA does not allow for treatment (either physical or psychiatric) such emergency interventions are covered by common law.
  • Always consider the balance of risks: ask yourself ‘what am I more likely to be criticised (or sued) for?’
  • Although the final decision in non-mentally ill, capable adults rests with them, in ‘close-call’ situations it is better to err on the side of safety, and review again later. (Such situations should always be discussed with a senior colleague.)

Patient wanting to leave a psychiatric ward The duty psychiatrist is often called to psychiatric wards when patients wish to take their own discharge. Although not wanting to be in a psychiatric ward may often seem the most rational response—particularly when P.909
there are other more behaviourally disturbed patients in the same ward—a pragmatic approach should be adopted (i.e. balancing the need for assessment/inpatient treatment against the additional stress caused by admission). Follow the general principles detailed above, focusing on managing risk and acting in the patient’s ‘best interests’. Note especially:

  • Deciding whether a patient is permitted to leave the ward will be informed by both an assessment of their current mental state and knowledge of any established management plans.
  • Often decisions regarding the course of action to take will have already been discussed by the responsible consultant with nursing staff. When there are concerns, the default position is often reassessment at the time the patient is asking to leave.
  • When a patient does elect to leave against medical advice, record this clearly in the notes with, at the very minimum, an agreement for a planned review (e.g. as an outpatient, by the GP) and the recommendation that, should the patient (or their relatives) feel the situation has become unsustainable at home, they should return to the hospital.

Some examples of clinical scenarios 52-yr-old ♂ admitted with chest pain, who ought to remain in the hospital for overnight telemetry, cardiac enzymes, and repeat ECG (in the morning), but does not wish to do so. He is not incapable and not suffering from a mental disorder. The decision rests with him (he has a right to refuse—even if you think he is acting foolishly). 22-yr-old ♀ who admits to ingesting 56 aspirin, brought to GP by a concerned friend, now refusing to get in an ambulance to go to hospital. Most people would agree that she is possibly suffering from a mental disorder (suggested by her recent OD), hence there are grounds for use of MHA, with emergency treatment under common law. 18-yr-old ♀ admitted after a paracetamol overdose who needs further treatment but wishes to leave. She has some depressive features and may possibly be under the influence of alcohol. There is sufficient suspicion of mental disorder to detain under the MHA (perhaps more than in the previous scenario); treatment would be under common law. 34-yr-old ♀ with long history of anorexia nervosa, current weight under 6st, with clear physical complications of starvation (and biochemical abnormalities), refusing admission for medical management. Clear mental disorder, as well as ‘risk to themselves’—detain under the MHA; emergency treatment under common law. 53-yr-old ♂ Previously seen in A&E following a fall whilst intoxicated, brought back up to A&E 6 days later by spouse with fluctuating level of consciousness (also has been drinking heavily)—suspected extradural, but angrily refusing CT head. Capacity impaired both by alcohol and potentially serious underlying treatable physical disorder. Necessary urgent investigation warranted as in patient’s best interests—with use of sedation (if necessary) under common law. 67-yr-old ♂ with post-operative URTI who presents as confused, wishing to leave the ward because he is ‘late for his brother’s wedding’. There is a clear mental disorder and he ought to be detained under the MHA; treat under common law (sedate if necessary). 23-yr-old ♂ admitted with psychotic illness, who wants to go home to confront the neighbours whom he believes have conspired with the police to get him ‘banged up in a nut hut’. Clear mental disorder—detain under MHA; emergency treatment if required under common law. P.910
The mental health of doctors ‘Quis custodiet ipsos custodes?’ (‘Who will watch the watchmen?’) In general, doctors are in a pretty good state of health, with a lower prevalence of smoking, cardiovascular disease, cancer, and a longer life expectancy than the general population. With respect to mental health, however, the situation is reversed—with the incidence of most psychiatric disorders higher in doctors:

  • Surveys have found -25% of doctors to have significant depressive symptoms, with : = 1:2 and increased risk in: junior house officers/interns; junior doctors in O&G and psychiatry; radiologists, anaesthetists, surgeons, and paediatricians.
  • Suicide rates are high, with depression, alcohol, and drug misuse significant contributory factors. Specialties over-represented include anaesthetics, GP, psychiatry, and emergency medicine.
  • Problems of drug and alcohol dependence may affect as many as 1 in 15 doctors in the UK.

Why are doctors more likely to have mental health problems? Individual factors

  • Personality—many of the qualities that make a ‘good doctor’ may also increase the risk of psychiatric problems: (e.g. obsessionality, perfectionism, being ambitious, self-sacrifice, high expectations of self, low tolerance of uncertainty, difficulty expressing emotions).
  • Ways of thinking/coping styles e.g. being overly self-critical, denial, minimisation, rationalisation, drinking culture, need to appear competent (‘no problems’).

Occupational factors

  • Long and disruptive work hours.
  • Exposure to traumatic events—dealing with death, ethical dilemmas.
  • Lack of support (particularly from senior colleagues).
  • Competing needs of patients and family.
  • Increasing expectations with diminishing resources.
  • Professional and geographic isolation.

Barriers to seeking help Doctors are notoriously bad at seeking help for their own medical problems—particularly psychiatric problems—often only presenting when a crisis arises. Reasons for this include:

  • Symptom concealment due to fears of hospitalisation, loss of medical registration, exposure to stigmatisation.
  • Negative attitudes to psychiatry, psychiatrists, and people with psychiatric problems.
  • Lack of insight being a feature of many psychiatric disorders.

This may lead to delayed referral, misdiagnosis, and not receiving the benefits of early interventions. P.911
What to do if you suspect a colleague has a problem You have a duty to take action (see below), both in the interests of patient care and of your colleague’s health (such actions are both ethically responsible and caring). Not to do so could both put patients at risk and potentially deny your colleague treatment which might prevent further deterioration in health and performance. Usually a staged approach works best:

  • Confirm your suspicions through informal discussion with other colleagues.
  • If a clear pattern of behaviour is present, first consider discussing this observation with the colleague in question.
  • It is better if face-to-face discussion is conducted by someone of the same grade.
  • If face-to-face discussion yields no results, speak to an impartial senior colleague and/or seek further advice about local procedures (see below).
  • If the colleague is YOU, remember: responsible physicians put their patients first and take pride in looking after their own health (see p. 912).

‘If you have grounds to believe that a doctor or other healthcare professional may be putting patients at risk, you must give an honest explanation of your concerns to an appropriate person from the employing authority, such as the medical director, nursing director or chief executive, or the director of public health, or an officer of your local medical committee, following any procedures set by the employer. If there are no appropriate local systems or local systems cannot resolve the problem, and you remain concerned about the safety of patients, you should inform the relevant regulatory body [*]. If you are not sure what to do, discuss your concerns with an impartial colleague or contact your defence body, a professional organisation or the GMC for advice.’ –General Medical Council (2001) Good medical practice. London. para 27. Footnote * It is worth noting that doctors referred to the GMC because of mental health problems can continue to practice, provided their problems are not judged to affect their professional abilities, and they are suitably supervised in an agreed treatment regime. P.912
Looking after your own mental health You have a duty to yourself and your patients to act promptly if you feel there are early warning signs that your health may be affecting your performance. Signs to watch out for

  • Difficulties sleeping.
  • Becoming more impatient or irritable.
  • Difficulties concentrating.
  • Being unable to make decisions.
  • Drinking or smoking more.
  • Not enjoying food as much.
  • Being unable to relax or ‘switch off’.
  • Feeling tense (may manifest as somatic symptoms e.g. recurrent headache, aches and pains, GI upset, feeling sweaty, dry mouth, tachycardia).

Developing good habits

  • Learn to relax This can involve learning methods of progressive relaxation, or simply setting aside time when you are not working to relax with a long bath, a quiet stroll, listening to music. It also means living life less frantically—going to bed at a regular time and getting up 15–20 minutes earlier to prevent the feeling of ‘always being in a rush’.
  • Take regular breaks at work This includes regular meal breaks (away from work). Even when work is busy, try to give yourself a 5–10 minute break every few hours.
  • Escape the pager In the day and age of being always obtainable, it is a good idea to be ‘unobtainable’ once or twice a week, to give yourself time to be alone and reflect.
  • Exercise There is no doubt that regular exercise helps reduce levels of stress. It will also keep you fit, helps prevent heart disease, and improve quality of sleep.
  • Drugs Tobacco and other recreational drugs are best avoided. Caffeine and alcohol should be used only in moderation.
  • Distraction Finding a pursuit that has no deadlines, no pressures, and which can be picked up or left easily can allow you to forget about your usual stresses. This might be a sport, a hobby, music, the movies, the theatre, or books. The important point is that it is not work-related.

Organising your own medical care

  • Register with a GP ! (two-thirds of junior doctors have not done this)!
  • Allow yourself to benefit from the same standards of care (including expert assessment, if this is felt to be necessary) you would expect for your patients.
  • If you are having difficulties related to stress, anxiety, depression, or use of substances, consult your GP sooner rather than later.
  • Be willing to take advice. In particular, do not rely on your own judgement of your ability to continue working.
  • If your GP suggests speaking to a psychiatrist, and you feel uncomfortable with being seen locally, ask for an out-of-area consultation.
  • P.913

  • Utilise other sources of help and advice—both informal (friends, family, self-help books) and formal (see below). Remember you are certainly not the first doctor to have encountered these sorts of difficulties.

Sources of support and advice

  • The National Counselling Service for Sick Doctors is a confidential independent service supported by the Royal Colleges, the Joint Consultants Committee, the BMA, and other medical professional bodies. Tel: 0870 21 0535
  • The Doctors’ Support Network. Tel: 07071 223 372.
  • The BMA offers free expert advice for members who may be affected by illness through ‘Doctors for doctors’ (Tel: 020 7383 6739) and a free telephone counselling service (Tel: 0645 200 169).
  • The Sick Doctors’ Trust runs a 24 hr helpline for doctors with addiction problems. Callers are put in touch with the nearest member of the Addicted Physicians Programme (APP) an independent and free service. The British Doctors and Dentists Group is an affiliated organisation, running support groups in local areas throughout the UK and Eire. For further information contact: Isis, 126 Weybourne Road, Farnham, Surrey, GU9 9HD (Tel: 020 7487 4445; Fax: 01252 350242; Helpline: 01252 345163).

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