There is no substitute for experience, but hopefully some of the guid- ance in the followin g section (and the other pages they refer to) will allow a rational approach to a number of common (and not so common) dif- \201 cult and urgent situations in a psychiatric setting . Keep the following principles in mind: \200\230Primum non nocere \200\231: above all, do no harm \200 Always ensure your own an d other staff \200\231s safety. \200 If necessary facilities or expertise are not availab le, make appropriate arrangements to get the patient to them as soon as possible. Always su spect (and as far as possible exclude) potential organic causes for psychiatric presentatio ns. Remember \200\224patient con \201 dentiality does not override issues of threatened ha rm to themselves or other individuals. Assess \200 Always make the fullest assessment possible \200\224do not fail to ask about important issu es 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. pr evious notes, third-party information), use them! Don \200\231t dawdle \200\224if a situati on requires immediate action, act. Consult \200 assume anything. If in doubt, consult a senior colleague. Do not Remember yo u are part of a team, and if there is a dif \201 cult decision to make, do not make it alo ne. Keep contemporaneous records \200 Clearly record your assessment, decisions made ( and reasons), and the names of any other c olleagues involved or consulted. Legally, if it \200\231s not been recorded, it \200\231s n ot been done. 24_Semple_Chap24.indd 982 12/7/2012 5:42:55 PM This page intentionally left blank CHAPTER 24 Dif \201 cult and urgent situations 984 What to do if summoned to a crisis situation/negotiation principles First principles \200 \200 Speak to the staff who originated the call. Obtain as much information as possible about th e situation prior to seeing the patient. Establish what your expected role is. Keep your ow n safety uppermost in your mind (no heroics). \200 General aims \200 Attempt to put the patient at their ease; explain who you are and why you have been asked t o speak to them. Be clear in any questions you need to ask. Elicit useful information. Achi eve a safe, digni \201 ed resolution of the situation. \200 \200 Important communication principles \200 Be conscious of both verbal and non-verbal language. \200 Listen actively \200\224assimilate and understand what is actually being said and interpret the various underlying meanings and messages. Feedback \200\224go back over what the patie nt has said with them to assure them that you understand what they are saying. Empathy \200 \224show you appreciate them sharing their thoughts, feelings, and motives. Content and fee ling \200\224note any difference between what is said verbally and what message is really b eing given. Use checkpoint summaries \200\224brief reviews of the main points discussed, about issues, and any demands. Important suggestions \200 Use open questions to give the patient an opportunity to ventilate what is on their mind (t his 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 t o their actions. It also demonstrates concern for the patient \200\231s problem. Be honest, up front, and sincere \200\224develop a trusting relationship. Be neutral \200\224avoid ap proval or disapproval unless necessary. Orientate the patient to looking for alternative so lutions together, without telling them how to act (unless asked). Try to divert any negativ e train of thought. Check with other team members before making any commitments. If the pol ice have been called, present the reason for their presence realistically, but neutrally. D o not involve family members in negotiations. \200 \200 \200 \200 24_Semple_Chap24.indd 984 12/7/2012 5:42:55 PM CRISIS SITUATION/NEGOTIATION PRINCIPLES 985 Some suggestions for dealing with particular patients The patient responding to paranoid id eas/delusions \200 \200 Avoid prolonged eye contact and do not get too close. The patient \200\231s need to explain may allow you to establish a degree of rapport. Allow them to talk, but try to stay with c oncrete topics. Do not try to argue them out of their delusions \200\224ally yourself with their perspective without sounding insincere (e.g. \200\230What you are saying is that you believe x y z \200\231). Avoid using family members who may be part of t he delusional system. Try to distance yourself from what may have happened in the past (e.g . \200\230I \200\231m sorry that was your experience before maybe this time we could manage things better \200\231). Be aware that your offer of help may well be rejected . \200 The patient with antisocial traits \200 A degree of \202 attery may facilitate discussion of alternative solutions (show you unde rstand their need to communicate, how important their opinions are, your desire to work tog ether to resolve things). Encourage them to talk about what has led up to this situation. T ry to convince them that other ways of achieving their aims will be to their advantage \200 \224keep any negotiation reality-oriented. Focus their attention on you as the means to ach ieve their aims. \200 The patient with borderline traits \200 \200 \200 Provide \200\230understanding \200\231 and \200\230uncritical acceptance \200\231. Help t hem \201 nd a way to sort things out without having \200\230failed again \200\231. Try t o build self-esteem (e.g. \200\230You have done well coping with everything up to now \200\231) Once trust is gained, it may be possible to be more directive. Use the patient \200\231s desire to be accepted (e.g. \200\230I really think it would be best if we \200\231). Bear in mind that often the behavior will be attention-seeking, and it may be wo rth asking: \200\230What is it you feel you need just now? \200\231 Do not be surprised if the patient acts impulsively. \200 The depressed patient \200 \200 Psychomotor retardation may slow response time \200\224be patient. The presence of friends or relatives may worsen their feelings of worthlessness and guilt. Focus on the \200\230he re and now \200\231 \200\224avoid talking abstractly. Acknowledge that they probably cannot imagine a positive future. Be honest and straightforward \200\224once rapport has been est ablished, it may be appropriate to be explicitly directive. Try to postpone the patient \200\231s plans, rather than dismiss them (e.g. \200\230Let \200\231s try this and s ee how you feel in the morning \200\231). Be prepared to repeat reassurances. \200 \200 The patient experiencing acute stress \200 \200 \200 \200 Allow ventilation of feelings. Try to get them to describe events as objectively as possibl e. Have them go back over the options they have ruled out. Review the description of events , and present a more objective, rational perspective. 24_Semple_Chap24.indd 985 12/7/2012 5:42:55 PM CHAPTER 24 Dif \201 cult and urgent situations 986 Managing suicide attempts in hospital Attempted overdose In psychiatric wards, the most lik ely 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). Of ten patients will volunteer to trusted nursing staff that they have taken an overdose, or s taff will notice the patient appears overtly drowsy and when challenged the patient admits to overdose. \200 Try to ascertain the type and quantity of tablets taken (look for empty bottles, medication strips, etc.). Establish the likely timeframe. If patient is unconscious or signi \201 ca ntly drowsy, arrange immediate transfer to emergency medical services. Inform medical team of patient \200\231s diagnosis, current mental state, current status (informal/ formal), an y other regular medications. If patient asymptomatic, but signi \201 cant overdose suspect ed, arrange immediate transfer to emergency services: \200 \200 \200 Do not try to induce vomiting. If available, consider giving activated charcoal (single dos e of 50g with water) to reduce absorption (esp. if NSAIDs or paracetamol). If patient asymptomatic, and signi \201 cant overdose unlikely: \200 Monitor closely (general observations, level of consciousness, evidence of nausea/vomiting, other possible signs of poisoning). If paracetamol or salicylate (aspirin) suspected: perf orm routine bloods (FBC, U&Es, LFTs, HCO3, INR) and request speci \201 c blood levels (4hr post-ingestion level for paracetamol). If other psychiatric medications may have been take n, consider urgent blood levels (e.g. lithium, anticonvulsants \200\224see b p. 928). Be aw are 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 super \201 cial self-in \202 icted injury (e.g. scratching, cutting, burning, scalding) to the body or limbs. The se may be easily treated on the ward with little fuss (to avoid second- ary reinforcement o f behavior). \200 Any more signi \201 cant injuries (e.g. stabbing, deep lacerations) should be referred to emergency medical services, with the patient returning to the psychiatric ward as soon as m edically \201 t. Medical advice should also be sought if: \200 \200 You do not feel suf \201 ciently competent to suture minor lacerations. Lacerations are to the face/other vulnerable areas (e.g. genitals) or where you cannot con \201 rm absence o f damage to deeper structures (e.g. nerves, blood vessels, tendons). The patient has swallo wed/inserted sharp objects into their body (e.g. vagina, anus). The patient has ingested po tentially harmful chemicals. 24_Semple_Chap24.indd 986 12/7/2012 5:42:55 PM MANAGING SUICIDE ATTEMPTS IN HOSPITAL 987 Attempted hanging Most victims of attempted hangings in hospitals do not use a strong enoug h noose or suf \201 cient drop height to cause death through spinal cord injury ( \200\230 judicial hanging \200\231). 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 \200 \200 \200 Support the patient \200\231s weight (if possible enlist help). Loosen/cut off ligature. Lo wer patient to \202 at surface, ensuring external stabilization of the neck and begin usu al basic resuscitation (ABCs, IV access, etc.). Emergency airway management is a priority: \200 \200 Where available, administer 100% O 2. If competent and indicated: use nasal or oral endotra cheal 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 \200 Aggressive resuscitation and treatment of post-anoxic brain injury is indicated even in pat ients 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 de \201 ci t. 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 \200 \200 \200 Remove source (ligature, polythene bag, etc.). Give 100% O If prolonged period of anoxia, o r impaired conscious level, arrange immediate transfer to emergency medical services. 2. After the event Patient \200 Once the patient is \201 t for interview, formally assess mental state and conduct assess ment of further suicide risk (b p. 784). Establish level of observation necessary to ensure patient \200\231s safety, clearly communicate your decision to staff, and make a record in the patient \200\231s notes. (Note: Hospital policy may vary, but levels of observation wi ll range from timed checks (e.g. every 15mins to having a member of staff within arm \200 \231s length of the patient 24hrs/day). Staff For particularly traumatic events, it may be necessary to arrange a \200\230critical incident review \200\231 (at a later date) where all staff involved participate in a con \201 dential debrie \201 ng session. This is not to apportion blame, but rather to review policy and to consider what measures (if any) might be taken to prevent similar events occu rring in the future. 24_Semple_Chap24.indd 987 12/7/2012 5:42:55 PM CHAPTER 24 Dif \201 cult and urgent situations 988 Severe behavioral disturbance This covers a vast range of presentations, but will usually r epresent a qualitative acute change in a person \200\231s normal behavior, that manifests p ri- marily as antisocial behavior \200\224e.g. shouting, screaming, increased (often disrup tive/intrusive) activity, aggressive outbursts, threatening violence (to others or self). In extreme circumstances (e.g. person threatening to commit suicide by jumping from a heigh t [out of a window, off a roof], where the person has an offensive weapon, or a hostage sit uation), this is a police matter and your responsibility does not extend to risking your ow n or other people \200\231s lives in trying to deal with the situation. Common causes \200 \200 \200 b p. 790). Acute confusional states (see delirium Drug/alcohol intoxication. Acute symptoms of psychia tric disorder (anxiety/panic, mania, b p. 310, schizophrenia/other psychotic disorders, b p . 186). \200\230Challenging behavior \200\231 in brain-injured or LD patients ( Behavior u nrelated to primary psychiatric disorder \200\224this may re \202 ect personality disorder , abnormal personality traits, or situational stressors (e.g. frustration). b p. 358, \200 b p. 766). General approach \200 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 behavior has arisen. b p. 990. Follow the general principles outlined on Look for evidence of possib le psychiatric disorder. Look for evidence of possible physical disorder. Try to establish any possible triggers for the behavior \200\224 environmental/interpersonal stressors, use of drugs/alcohol, etc. \200 \200 \200 Management This will depend upon assessment made: \200 If physical cause suspected: \200 \200 b p. 790). Follow management of delirium ( Consider use of sedative medication (see examination, facil itate transfer to medical care (if indicated), or to allow active (urgent) medical manageme nt. b p. 990) to allow proper If psychiatric cause suspected: \200 Consider pharmacological management of acute behavioral disturbance (see b p. 990). Conside r need for compulsory detention. Review current management plan, including observation leve l. \200 If no physical or psychiatric cause suspected, and behavior is dangerous or seriousl y irresponsible, inform security or the police to have person removed from the premises (an d possibly charged if a criminal offense has been committed, e.g. assault, damage to proper ty). 24_Semple_Chap24.indd 988 12/7/2012 5:42:55 PM This page intentionally left blank CHAPTER 24 Dif \201 cult and urgent situations 990 Pharmacological approach to severe behavioral disturbance There are often local protocols f or rapid tranquillization and for control and restraint and these should be followed where available. In situations requiring rapid tranquillization or control and restraint, discuss manage- ment with a senior colleague as soon as possible. In the guide (Box 24.1) the doses quoted are appropriate for young, physically \201 t pat ients who have previously received antipsychotic medica- tion. In patients who are elderly, have physical health problems, or are \200\230antipsychotic na ve \200\231, dosage sho uld at least be halved (refer to BNF for further guidance). Potential risks \200 \200 \200 Over-sedation causing loss of consciousness or alertness. Compromise of airway. Cardiovascu lar or respiratory collapse (raised risk where there is stress or extreme emotion or extrem e physical exertion). Interaction with prescribed or illicit medication. Damage to therapeu tic relationship. Other (related or coincidental) physical disorders (e.g. congenital prolo nged QTc syndromes, patient on medication lengthening QTc). \200 \200 Dos and don \200\231ts \200 \200 \200 \200 \200 Follow local protocols where these are available. Document all decisions/actions. Have a lo w threshold for obtaining senior advice. Always prescribe oral and IM doses separately to a void confusion. Do not use two different drugs of the same class for rapid tranquillization . Document maximum total daily dose and maximum dosage frequency on the prescription kardex . Do not mix medications in the same syringe. Aftercare \200 Respiration, pulse, and blood pressure should be monitored within an hour of drug administr ation and regularly thereafter. Look for extra-pyramidal side-effects, particularly acute d ystonia (see b p. 954); possible NMS (see b p. 956). Remember: fatalities have occurred dur ing emergency restraint. Issues of consent Giving emergency medication for acute behavioral disturbance is essen- ti ally treatment under common law (b p. 874). The justi \201 cation rests on the judgment th at no other management options are likely to be effective, and that tranquillization will p revent the patient harming them- selves or others. Harm may include behavior 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 (b p. 872). 24_Semple_Chap24.indd 990 12/7/2012 5:42:55 PM PHARMACOLOGICAL APPROACH 991 Box 24.1 A guide to rapid tranquillization First-line treatments (allow suf \201 cient time between doses for assessing clinical resp onse) Non-psychotic context: Consider oral lorazepam 1 \200\2232mg. Psychotic context: Consider oral lorazepam 1 \200\2232mg and oral anti- psychotic, e.g. hal operidol 10 \200\22320mg, chlorpromazine 50 \200\223100mg. Second-line treatments \200\224oral medication failed/refused/not indicated (allow suf \201 cient time between doses for assessing clinical response) Non-psychotic context: Consider IM lorazepam 1 \200\2232mg. Psychotic context \200 \200 Consider IM lorazepam 1 \200\2232mg + IM haloperidol 10 \200\22320mg. Consider IM olanzapin e for moderate disturbance (do not give IM lorazepam within 1hr of IM olanzapine). Consider IM chlorpromazine 25 \200\223100mg ( hypotension and fatality if given inadvertently by IV injection. Consider IM depot zuclopenthixol acetate (Clopixol acuphase 50 \200\223150mg \200\224repeat every 2 \200\2233 days if necessary up to max total dose 400mg. (This is a r apidly acting, sedating, depot antipsychotic which is best avoided in antipsychotic-na v e or inexperienced patients because of long half-life.) Note: danger of postural ) Exceptional circumstances \200\224immediate tranquillization necessary \200 Consider IV benzodiazepines, e.g. diazepam 10mg by slow IV bolus (Note: ensure \202 umaze nil available in case of respiratory depression). Consider IV haloperidol 2 \200\22310mg (h igh risk of dystonia \200\224max daily dose 18mg may sometimes be given as single dose). Third-line treatments \200 Other treatments (e.g. paraldehyde) or combinations of the above may be suggested in some c enters. Always consult senior medical advice before administering these interventions. 24_Semple_Chap24.indd 991 12/7/2012 5:42:55 PM CHAPTER 24 Dif \201 cult and urgent situations 992 The catatonic patient Catatonia is certainly less common in current clinical practice, than ks to the advent of effective treatments for many psychiatric disorders and ear- lier inter ventions. Nonetheless, the clinical presentation may be a cause for concern, particularly w hen a previously alert and oriented patient becomes mute and immobile. The bizarre motor pr esentations (e.g. posturing) may also raise concerns about a serious acute neurological pro blem (hence these patients may be encountered in a medical/liaison setting), and it is impo rtant that signs of catatonia are recognized. Equally, the \200\230excited \200\231 forms may be associated with sudden death ( \200\230lethal \200\231 or \200\230malig- nant \200 \231 catatonia), which may be preventable with timely interventions. Clinical presentation Characteristic signs \200 \200 \200 \200 \200 \200 Mutism Posturing Negativism Staring Rigidity Echopraxia/echolalia Typical forms \200 \200 Stuporous/retarded Excited/delirious Common causes \200 Mood disorder up to 50% of cases) than depression. Often referred to a s manic (or depressive) stupor (or excitement). General medical disorder \200 Metabolic d isturbances \200 Endocrine disorders \200 Viral infections (including HIV) \200 Typho id fever \200 Heat stroke \200 Autoimmune disorders Drug-related (antipsychotics, dopam inergic drugs, recreational drugs, \200 BDZ withdrawal, opiate intoxication) More commonly associated with mania (accounts for Often associated with delirium: Neurological disorders \200 Postencephalitic states \200 Parkinsonism \200 Seizure di sorder (e.g. non-convulsive status epilepticus) \200 Bilateral globus pallidus disease \200 Lesions of the thalamus or parietal lobes \200 Frontal lobe disease \200 General paresis Schizophrenia posturing, and mutism (see catatonic schizophrenia, b p. 179). (10 \200\22315% of cases) Classically catalepsy, mannerisms, 24_Semple_Chap24.indd 992 12/7/2012 5:42:56 PM THE CATATONIC PATIENT 993 Differential diagnosis \200 Elective mutism disorder, clear stressor, no other catatonic features, unresponsive to lora zepam. Stroke Mutism stroke risk factors. \200\230Locked-in \200\231 syndrome (lesions of ventral pons and cerebellum) is characterized by mutism and total immobility (apart from ve rtical eye movements and blinking). The patient will often try to communicate. Stiff-person syndrome or emotional stimuli (may respond to baclofen, which can induce catatonia). Malig nant hyperthermia and muscle relaxants in predisposed individuals (b p. 956). Akinetic Park insonism Usually in patients with a history of Parkinsonian symptoms and dementia \200\224m ay display mutism, immobility, and posturing. May respond to anticholinergics, not BDZs. Usually associated with pre-existing personality associated with focal neurological signs and other Painful spasms brought on by touch, noise, Occurs following exposure to anesthetics Other recognized catatonia (and catatonia-like) subtypes \200 Malignant catatonia autonomic instability, and catalepsy \200\224may be fatal. Neuroleptic malignant syndrome (NMS) Serotonin syndrome (SS) Acute onset of excitement, delirium, fever, \200 \200\224 b p. 956. \200\224 b p. 960. Management Assessment \200 Full history (often from third-party sources), including recent drug exposure, recent stres sors, known medical/psychiatric conditions. Physical examination (including full neurologic al). Investigations \200\224temperature, BP, pulse, FBC, U&Es, LFTs, glucose, TFTs, cortiso l, prolactin, consider CT/MRI and EEG. \200 Treatment \200 Symptomatic treatment of catatonia will allow you to assess any underlying disorder more fu lly (i.e. you will actually be able to talk to the patient). Best evidence for use of BDZs (e.g. lorazepam 500 mcg \200\2231mg oral/ IM \200\224if effective, given regularly thereaft er), barbiturates (e.g. amobarbital [amytal] 50 \200\223100 mg), and ECT. Alone or in combi nation these effectively relieve catatonic symptoms regardless of severity or etiology in 7 0 \200\22380% of cases.1,2 Address any underlying medical or psychiatric disorder. 1 Bush G, Fink M, Petrides G, et al. (1996) Catatonia II: treatment with lorazepam and elec trocon- vulsive therapy. Acta Psychiat Scand 93: 137 \200\22343. 2 Ungvari GS, Kau LS, Wai- Kwong T, et al. (2001) The pharmacological treatment of catatonia: an overview. Eur Arch Ps ychiat Clin Neurosci 251(Suppl. 1): 31 \200\2234. 24_Semple_Chap24.indd 993 12/7/2012 5:42:56 PM CHAPTER 24 Dif \201 cult and urgent situations 994 The manipulative patient 1 Manipulation is a term that is generally used pejoratively, alth ough some ethologists regard manipulative behavior as \200\230sel \201 sh but adaptive \200\231 (i.e. the means by which we use others to further our own aims \200\224which may b e entirely laudable). In the context of psychiatric (and other medical) set- tings, manipul ative behaviors are usually maladaptive and include: \200 Inappropriate or unreasonable demands: \200 \200 \200 More of your time than any other patient receives. Wanting to deal with a Only willing to a ccept one particular course of action (e.g. admission to hospital, a speci \201 c medicati on or other form of treatment). speci \201 c doctor. Behavioral sequelae of failing to have these demands met: \200 \200 Claims of additional symptoms they failed to mention previously. Veiled or explicit threats of self-harm, lodging formal complaints, litigation, or violence. Passive resistance (refu sing to leave until satis \201 ed with outcome of consultation). Verbal or physical abuse of staff/damage to property. Actual formal complaints relating to treatment (received or re fused), or false accusations of misconduct against medical staff. \200 Key points \200 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. Acti on should always be a response to clinical need (based on a thorough assessment, diagnosis, and best evidence for management), NOT threats or other manipulative behaviors. It is enti rely possible that a patient who demonstrates manipulative behavior DOES have a genuine pro blem (it is only their way of seeking help that is inappropriate). Some of the most dif \201 cult patients tend to present at \200\230awkward \200\231 times (e.g. the end of the working day, early hours of the morning, weekends, public holidays, intake of new staff) \200\224this is no accident! Admitting a patient to hospital overnight (when you are left w ith no other option) is not a failure \200\224some patients are very good at engineering th is outcome. At worst it reinforces inappropriate coping behaviors 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 \200 Make a full assessment to establish: \200 \200 Psychiatric diagnosis and level of risk (to self and others). Whether other agencies are re quired (e.g. speci \201 c services: drug/ alcohol problems; social work: housing/bene \201 ts/social supports; 24_Semple_Chap24.indd 994 12/7/2012 5:42:56 PM THE MANIPULATIVE PATIENT 1 995 counseling: for speci \201 c issue \200\224debt/employment/bereavement/ alleged abuse). \200 Ask the patient what they think is the main problem. Ask the patient what they were hoping you could do for them, e.g. \200 \200 \200 \200 Discuss with them your opinion of t he best course of action, and establish whether they are willing to accept any alternatives offered (e.g. other agencies, outpatient treatment). Advice about what course of action to take. Wanting their problem to be \200\230taken seri ously \200\231. Wanting to be admitted to hospital. Wanting a speci \201 c treatment. 2. The \200\230frequent attender \200\231/chronic case \200 Do not take short cuts \200\224always fully assess current mental state and make a risk ass essment. When available \200\224always check previous notes, any written care plan, or \200\230crisis card \200\231. Establish the reason for presenting current situation). Ask y ourself \200\230Is the clinical presentation signi \201 cantly different so as to warrant a change to the previously agreed treatment plan? \200\231 If not, go with what has been l aid out in the treatment plan. now (i.e. what has changed in their See Box 24.2 for pitfalls and how to avoid them. Box 24.2 Pitfalls (and how to avoid them) \200 Try not to take your own frustrations (e.g. being busy, feeling \200\230dumped on \200\231 by other colleagues, lack of sleep, lack of information, vague histories) into an intervie w with a patient \200\224your job is to make an objective assessment of the person \200\231 s mental state and to treat each case you see on its own merits. Try not to allow any preco nceptions or the opinions of other colleagues color 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 w ho appeals to your vanity by saying things like: \200\230You \200\231re much better than t hat other psychiatrist I saw I can really talk to you I feel you really underst and \200\231. They probably initially said the same things to \200\230that other psychiatr ist \200\231 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 professionali sm of those you work beside \200\224 respect their opinions (even if you really don \200 \231t agree with them). If you encounter a particularly dif \201 cult patient, enlist the support of a colleague and conduct the assessment jointly. NEVER acquiesce to a \200\230pr ivate \200\231 consultation with a patient of the opposite sex; do not make \200\230specia l \200\231 arrangements; and NEVER give out personal information or allow patients to conta ct you directly. 24_Semple_Chap24.indd 995 12/7/2012 5:42:56 PM CHAPTER 24 Dif \201 cult and urgent situations 996 The manipulative patient 2 Speci \201 c situations Patient demanding medication \200 There are really only two scenarios where there is an urgent need for medication: \200 The patient who is acutely unwell and requires admission to hospital anyway (e.g. with acut e confusion, acute psychotic symptoms, severe depression, high risk of suicide). The patien t who is known and has medication (for whom a small supply may be dispensed to tide them ov er until they can obtain a repeat prescription). genuinely run out of their usual Patient demanding immediate admission \200 Clarify what the patient hopes to achieve by admission, and decide whether this could be re asonably achieved, or if other agencies are better placed to meet these requests (see b p. 6). If the patient is demanding admission due to drug/alcohol dependence, emphasize the nee d for clear motivation to stop, and offer to arrange outpatient follow-up (the next day) (s ee b p. 556). Always ask about any recent trouble with the police; it is not uncommon for h ospital to be sought as a \200\230sanctuary \200\231 from an impending court appearance (b ut remember this can be a signi \201 cant stressor for patients with current psychiatric p roblems). Additional complications Demanding relatives/other advocates \200 Assess the patient on their own initially, but allow those attending with the patient to ha ve their say (this may clarify the \200\230why now \200\231 question, particularly if it i nvolves the breakdown of usual social supports). Ask the patient for their consent to discu ss the outcome of your consultation with those accompanying them (to avoid misunderstanding s and improve compliance with the proposed treatment plan). Patient \200\230raising the stakes \200\231 \200 If a patient is dissatis \201 ed with the outcome of your consultation, they may try a num ber of ways to change your mind (see b p. 994); they may even explicitly say: \200\230What do I have to do to convince you? \200\231 before resorting to other manipulative behaviors . This type of response only serves to con \201 rm any suspicions of attempted manipulatio n and should be recorded as such in the notes (verbatim if possible). Stick to your origina l management plan, and if the behavior becomes passively, verbally, or physically aggressiv e, 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 indivi duals present during the interview or elsewhere should be dealed with seriously and the pol ice (and the individual concerned) should be informed \200\224patient 24_Semple_Chap24.indd 996 12/7/2012 5:42:56 PM THE MANIPULATIVE PATIENT 2 997 con \201 dentiality does not take precedence over ensuring the safety of others. Suspected factitious illness \200 Try to obtain corroboration of the patient \200\231s story (or con \201 rmation of your su spicions) from third-party sources (e.g. GP, relative, previous notes, including other hosp itals they claim to have been seen at). If your suspicions are con \201 rmed, directly fee d this information back to the patient, and clearly inform them of what course of action yo u plan to take (e.g. recording this in their notes, informing other agencies, etc.). Do not feel \200\230defeated \200\231 if you decide to admit them to hospital. Record your suspi cions in the notes and inform the psychiatric team that the reason for admission is to asse ss how clinically signi \201 cant the reported symptoms are (it will soon become clear in a ward environment and it may take time to obtain third-party sources). Patient threatening suicide by telephone \200 \200 b p. 984). Keep the person talking (see 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 b e at high risk of suicide, encourage them to come to hospital \200\224if they refuse or are unable to do so, organize 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 ha ve 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 Closure). Closure \200 Clearly document your assessment, any discussion with senior colleagues, the outcome, and a ny treatment plan. Record the agreement/disagreement of the patient and any other persons a ttending with them. If appropriate, provide the patient with written information (e.g. appo intment details, other contact numbers) to ensure clear communication. Ensure that you have informed any other necessary parties (e.g. keyworkers/psychiatric team already involved wi th the patient, source of referral \200\224which may be the GP, other carers, social worker s, etc.). If the assessment occurs out of hours, make arrangements for information to be pa ssed on to the relevant parties in the morning (ideally try to do this yourself). If you ha ve suggested outpatient follow-up for a new patient, make sure you have a means of contacti ng 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 you r contact with the patient and the outcome of your assessment. 24_Semple_Chap24.indd 997 12/7/2012 5:42:56 PM CHAPTER 24 Dif \201 cult and urgent situations 998 Issues of child protection The treating doctor has a responsibility to consider the welfare not only of their patient, but also of the patient \200\231s dependants (in most cases, th eir children). Where there are concerns relating to the welfare of children, this responsib ility may be discharged both through actions you take your- self (e.g. admitting the patien t to hospital), and through involvement of appropriate statutory agencies (e.g. child and f amily social services). Each case should be individually assessed; however, a number of sce narios can be recognized: \200 Necessary absence When a patient is brought into hospital (e.g. for emergency assessment) t he admitting doctor should clarify whether they have dependent children, and if so, what ar rangements have been made for their care. If these are unsatisfactory, or are disconcerting ly vague (e.g. \200\230with a friend \200\231), child and family social services should be consulted. Neglect of childcare responsibilities result of mental disorder, patients \200 \231 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 d oes not preclude being a parent \200\224what is important is that individual patients recei ve appropriate assessment to ascertain the type of additional support they may need and the level of monitoring required. Risk of positive harm to child to the child by acts of commi ssion, rather than omission. These include: Psychotic disorders in which the patient holds abnormal beliefs \200 about their child. Severe depressive disorder with suicidal ideas, which involve killing the child (usually for altruistic reasons). Drug misuse where there a re drugs or drug paraphernalia left carelessly in the child \200\231s environment. In some circumstances, as a Certain disorders carry the risk of harm In these cases, a joint approach should be adopted involving mental health (optimizing the patient \200\231s management) and social services (addressing issues of child protection an d welfare). 24_Semple_Chap24.indd 998 12/7/2012 5:42:56 PM This page intentionally left blank CHAPTER 24 Dif \201 cult and urgent situations 1000 Patients acting against medical advice 1: guiding principles In certain situations, doctors are faced with deciding whether or not to act against a patient \200\231s stated wishes. T his most commonly occurs when: \200 \200 A patient does not consent to a particular treatment plan. A patient wishes to leave hospit al, despite medical advice that this is not in their best interests. Some common clinical s cenarios are discussed in Box 24.3 (see b p. 1002). Fundamental principles \200 An adult has the right to refuse treatment or to leave hospital should they wish. Doctors h ave a responsibility to discuss what they are proposing with the patient fully, to ensure t hat 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 pati ent \200\231s consent or override a patient \200\231s expressed wishes when: \200 