A colleague forwarded me the following excellent question posted to a listserv:
One question that has been raised is how to handle an individual who reports willingness to voluntarily go to the ER for psychiatric assessment. Since trusting a questionably unstable and suicidal individual to present for treatment opens our agency and the patient up to considerable risk, I wanted to get input on this issue from professionals in the field.
My questions are: What is the process that you use when you genuinely believe an adult patient will voluntarily present her/him self for possible commitment/assessment? How do you manage patient risk and your own liability in this instance? (e.g . requiring family members to be involved; or requiring a signed written contract to present at the hospital, etc) What do you do to ensure/confirm that they do indeed go to the hospital? What do you do when they do not go to the hospital, as agreed?
I'm looking for both a description of specific steps that you take and what variables you take into consideration as you decide what to do in this case.
This is an excellent question for several reasons:
- the writer wants to support patient agency, preferring in principle to go with the patients voluntary wishes, rather than become unnecessarily coercive.
- the writer is correctly concerned about putting all eggs in the self-report basket. A person at risk who is not stable may not be able to follow through with intentions to get help. It is central to both really listen people in our care AND understand that self-report has limitations and has to be considered in context
- the writer has shared honestly her concern about both patient safety and his/her own liability—almost everyone who works with individuals at risk has these dual concerns and needs to think openly about how to balance them.
This is such a good question that I wish I had put it on my docket of questions to blog about
. And it relates as a follow-up question to one that is on that docket, "When it comes to hospitalizing isn’t it always best to “err on the side of caution”?
Here is my attempt to offer some principles for the assessment and documentation of a patient's agreement to voluntary actions:
- Document assessment of reliability of self-report. When assessing and documenting self-report the following should be considered and noted:
- past experience, if any with the patient as a reliable reporter or not. “Pt. has reliably followed through on medical decisions and plans in the past.”
- evidence of psychosis, thought disorder, intoxication, extreme agitation or other factor that would put the person’s capacity to make decisions in question. If not, “Pt’s thinking is logical, coherent, and reasonable. Judgment is intact. No indication of impaired capacity to make decisions and follow through with them.”
- degree of patient cooperation. Explicitly note that the person volunteered information, though s/he didn’t have to. “The patient has been open, cooperative, and collaborative in the assessment and planning process. There is little reason to doubt his/her sincerity in agreeing to seek help and additional evaluation.”
- impulsivity. The greatest risk here would be that the person would all of a sudden feel overwhelmed with pain and impulsively kill him/herself. If there is not strong evidence of that kind of impulsivity (even if there has been some in the past) note that. “The patient has a past history of mild impulsive behavior, however, this was several years ago and under very different circumstances..."
- Show your reasoning. The key to great documentation is to state each of the factors considered, then show that the plan came as a result of synthesizing these factors. This can come in a statement like “In light of these factors, the plan for voluntary self-transport seems reasonable and prudent.”
- Say what you didn't do. Related to the previous point, it as as important to document the road NOT taken. This shows that you took the situation seriously and considered the full range of options.
- A corollary to this principle is to note risks associated with alternative courses of action. “Involuntary transport has potential of violating the patient’s rights and of harming the patient’s opportunity to benefit from hospitalization. The risk associated with involuntary transport outweigh the relatively small risk that the patient will precipitously abandon our plan and harm him/herself.”
- Document consultation. Much more consultation occurs in primary care than is ever documented. This would be a time to do it. One line is sufficient: “Discussed case with Dr. X who concurred with the plan.”
Note that each of these points needs only a sentence or bullet-point, and not all will be applicable in every circumstance.
I'd be interested in feedback and ideas from who employs these principles in their documentation. I would also be interested in reading comments with other ideas about how to address the situation the questioner described.