On Call Psychiatry: A Review of Some Cases

Of note, this article does mention and discuss suicide

I was on call recently over the weekend.  What this means at the hospital where I work is that I go into the psychiatric emergency unit for 830-9am to review any admissions that took place overnight.  The staff on call the night before would have reviewed these cases over the phone with the psychiatry resident who was on call also and would have approved of the admissions for me to reassess the following day.

Luck would have it, there were no patients admitted over night!  But there were 2 consults waiting to be seen who had been medically cleared by the emergency physician.  This means, no medical issues requiring attention from other specialists was needed and so their presentations are deemed 100% psychiatric or psychological in nature.

I was fortunate enough to have 2 psychiatric residents with me for the day, and so they set about working on the 2 consults that were waiting in the emergency room.

With these taken care of, I started working on the issues on the psychiatric unit, of which there were 2 cases needing my attention.  Both were elderly patients with psychosis and varying stages of dementia who were refusing medications for their medical issues as well as for their psychiatric conditions.  The questions being asked of me were the following: do their medical conditions, if untreated, make them medically unstable such that it is unsafe to have them on a psychiatric ward?  (where on the weekend there is little support and less comfort for medically urgent matters?)  In both cases, their decompensated mental illness were major contributors in their refusal for medical treatment, so how can medication for their mental illness be started, and if needed, enforced?  Lastly, in their present state, are they capable of making these medical decisions?  Who is to determine this and if they are not capable, then what?

In both these cases, though I pride myself on forming a therapeutic alliance to get to the heart of things, these skills were utterly useless.  Both patients were either too disoriented or too paranoid to be able to engage in any productive conversation with me about anything let alone the reasons why they were in hospital.  So then it becomes about what the hospital is allowed to do, and who in the hospital is allowed to do it.  There is a formal process in cases like these, to ensure the rights of the patient have not been infringed upon.  The formal process goes as follows:

1. Determining if the patient is capable of making a specific treatment decision.  This means, if we are asking if the patient is able to make a decision about a medical issue or procedure, this capacity assessment must be done by the physician who would know most about what is being proposed.
2. Once they are deemed incapable, for mental health issues, we file a form 33 and we must wait for the patient to receive advice about their right to contest this finding.  This involves another individual called the rights advisor.  If the patient chooses to contest, no new treatment can be started until a hearing has been completed on the issue.  This hearing will involve more people including a panel of 3 individuals who make the final judgement, the psychiatrist, the patient and any legal counsel the patient has obtained.
3. In mental health, when someone is deemed incapable and the panel at the hearing agrees, a substitute decision maker is then appointed to make the decision on the patient's behalf.  It usually is a family member or partner, but if there is no one, one is appointed by the office of the Public Guardian & Trustee.

But do I deal with this on a weekend?  When I am only seeing these patients for one day?  Certainly I can defer for a couple of days, and perhaps in that time, more education can be given to the patients to see if they can develop the capacity to make these decisions over time.

It is when I am mulling over the many options that I realize how many factors go into each and every decision as well as the time that is required to reach a decision I think is responsible, good care.  And so much of my ability to do this depends on the bandwidth I have.  Because these are my first cases of the morning and the workload in the emergency room was very manageable, I had the energy to dive in.  I was able to do a thorough chart review and review the notes of the other medical specialists involved that helped me determine that the medical issues for both patients were not deemed as urgent or needing attention over the weekend.  I was also able to gather history about these patients' mental health and both had documented prior diagnoses of a psychotic disorder that responded to treatment.  Both also had clearly documented that once their psychosis was better treated, the patients were more amenable to medical treatment.

And so it was my opinion that the mental health treatment was to be prioritized.  Fortunately for one of the patients, she had had the rights advice given and she opted not to challenge the finding of her incapacity.  This gave me legal grounds to administer treatment right away, and because she was refusing oral medications, we provided the treatment intramuscularly.

The other patient was earlier on in his hospitalization and so capacity for his mental illness was still being assessed.  The result here is that no psychiatric treatment could start yet, unfortunately.  Medically he was deemed incapable and so the medical team would have to take things from there.

Back in the emergency department, the two consults had been seen by the residents and they were ready to review them with me.

What was notable about both consults is that though there is no denying a significant psychological issue was present, the question we faced is whether or not hospitalization and medication would help.  Both cases involved patients with questionable reliability voicing suicidal thinking and being brought to hospital by police. 

Suicidal thinking is often taught as a symptom, but it is so much more than that.  In training we are taught to screen for major psychiatric illnesses and for safety risk.  In having many of these conversations with many types of people, what I have learned is that suicidal thoughts can be anything from a true desire to end one's life, and/or it can be an expression of pain and suffering.  It can be a thought one holds for a short time when intoxicated or in crisis, and it can be a thought that recurs over time.  These thoughts can bring about significant distress or distress in others in how they are expressed (we see these a lot in the emergency department) or they can be experienced in a detached or foreign way.  Patients can have these thoughts but no urge or want to act on them.  So in our assessment this is what we are trying to gauge.  What happened to bring about these thoughts?  And is this a symptom of something reversible with treatment in hospital?  Or, and there are special circumstances, will this symptom worsen in hospital where one is removed from his/her life and supports? 

One of these patients expressed suicidal thinking in the heat of an argument and when she was given a chance to settle down, completely denied she had any of these thoughts or plans anymore.  There was nothing else acute on the psychiatric assessment and so even though there were stressors present and this patient was vulnerable, given that there was no role for psychiatric medication management, and this patient wanted to return home to be at work the following day, she was discharged.

The second patient was more complicated.  He had been in and out of the emergency department with suicidal thinking for many years now and though he voiced having overdosed on medication today, he refused all medical treatment for the overdose and the emergency physician noted his physical exam and bloodwork had no abnormalities.  When this patient was assessed by our team, he could not engage in the assessment or the emotional support we tried to provide to better understand the situation and how we might be able to help.  We determined this patient's presentation was both acute and chronic with regards to his suicidal thinking, and so far, our interventions had been refused or unhelpful.  Do we admit this patient?  What would happen then?  From past documentation, he did not do well when admitted to hospital.  When the threats he made on his life warranted an involuntary hospitalization, he would often escalate when a rule was being enforced on the unit and required both physical and chemical restraint.  Unfortunately, it is not uncommon for certain patients to do worse and not better when admitted.  Because we had this insight, and there was nothing else treatable by a hospital stay, he stayed in the emergency department for some time. Following a period of being more settled, he denied any suicidal thinking and requested to leave.  There were no grounds to place this patient on a form 1 to admit against his will and so he too was discharged.