Open Letter of Apology to the Patient I Saw Last Night
You came into the hospital hoping to deliver a baby. In fact you weren't pregnant, but you wouldn't believe that; so the ER called me. We had a pretty nice conversation. I didn't challenge your belief that you were pregnant despite a negative urine pregnancy test and an ultrasound showing a normal nongravid uterus; and in turn you loosened up just a little bit. You were still clearly mistrustful - and who wouldn't be in your situation? as you said you'd been in and out of psychiatric hospitals more often than you could remember - but you were willing to talk. You definitely didn't want to come into the hospital, you said.
I was ready to send you home, really I was. Sure you were delusional, but it was a pretty benign delusion, as delusions go. You weren't suicidal. You weren't homicidal. You had a place to stay and seemed reasonably well groomed and nourished. I wasn't worried about your ability to take a cab back to your apartment, the same way you had come. You even had a psychiatrist, you knew your medications and doses (unlike 95% of the patients who come through the ER), you were carrying the pills in your purse, and you had an appointment in less than a week. There are thousands of people out there with worse delusions than yours - more severe, more pervasive, more dangerous - who manage to survive from day to day and to find a little pleasure in life, which is about all anyone can ask for anyway.
Unfortunately for you, things weren't that easy. Since I'm still a resident, I work under the supervision of an attending physician. At night the attending physician is at home, offering advice by phone; but she bears the ultimate responsibility for the patient care decisions that we make. See where this is going? I made you sound as good as I could - as good as you were - but she wasn't having it. She said you were delusional and wouldn't be safe at home, and that unless we could find someone to come get you at 4 AM, we would have to bring you into the hospital even though you didn't want to come.
But you didn't have anyone who could come get you. Like a lot of mentally ill people, you'd burned your bridges. You weren't close with your family, and the 'friend' you named at first turned out to be someone you hadn't spoken with in ten years. And while I was calling around to area hospitals trying to find a case manager, a psychiatrist, someone - anyone - who knew you and could help you out, or at least vouch for your ability to care for yourself - you decided you'd been waiting around in the ER long enough and it was time to leave.
After that things happened quickly. Four big ER security guys pounced on you to stop you from walking out the door. I heard your screams from the doc-box where I was dialing number after unresponsive number, and my heart sank. By the time I got out there you were already in restraints. At that point I was boxed in, and I had no choice but to write out a legal hold.
It was clear you'd been through this before. Other than telling me you hoped I'd die in a traffic accident, you took it all pretty calmly - much more calmly than I would have in your position. You were evidently familiar with the laws governing this kind of thing. You pointed out that you weren't dangerous to yourself or to others and that the legal basis for me to keep you was pretty thin. There wasn't really anything I could say. I acknowledged that you had a point, apologized to you and thanked you for staying (comparatively) calm. I told you I had no choice but to admit you to the hospital. Then I wrote out some weak excuse for the legal hold, which I knew probably wouldn't stand up to the judicial review that would likely take place in a few days. I hoped someone with more power than I had would let you out before then.
We walk the line between safety and liberty every day. When is it justified to deprive someone of his personal liberty? I think the law has it about right in theory - you should be physically dangerous or unable to assure your own care and safety. Seems straightforward; but in practice the latitude is wide and depends heavily on the judgement of the individuals involved. To me, this case lay far over on one side of the line; to my attending, it was far to the other. This time, the unfortunate patient got caught in the middle.
*****Addendum: the view from the other side - please read before commenting*****
You show up in the ER at 4 AM with no accompaniment, clearly delusional. We have no information about you other than what you choose to share with us. You cannot or will not give us the names of any family or friends whom we could contact. Are we going to take your word for it that you can get home safely? Are we just going to say, okay, you're not dangerous, you can go, and bundle you into a cab alone at 4 AM - without speaking to a single other person who knows you? What if you do go home and (as teendoc suggested) try to self-perform a C-section? Our job is not to concern ourselves with the legal fine print, but to do what is best for the patient. The legal fine print is the job of the hearing officer who will come to the unit and review our decision. For now, for tonight, the safest thing we can do for you is *not* to let you go home alone at 4 AM.
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You did all you could.
Such a hard, and ever-changing, line to walk. Or toe.
but in that case we would have missed the compassion and the kindness of those with at least limited authority - specifically you
(who i side with by the way)
wonderful post
And by the way, it's good to see you around. Just so you know. :)
You can disagree all you want OR, but she and the attending violated the law. While this patient is imprisoned against her will due to Pontificatrix and the attending's malfeasance, she will probably be doped with controlled substances that have negative side effects which is yet another assault.
How would you like to be locked up in a mental ward against your will in violation of the law and injected?
She gave you no reason to think she was a danger to herself or others.
Shame.
But so great to read you again, P. We've missed you around here.
I almost wish I had not read this. I was having a relaxing Sunday morning and am now agitated.
However, when you become the main doctor ponti, my friend, I'm expecting great things from you, including the way to reform on some of these issues.
Here is why I did not do that. It is because not I, but the other doctor and the staff, would have had to bear the responsibility for that decision.
Assuming that it was possible for me to let the patient go against my attending's wishes (in fact it probably was not, as the ER attending would have backed her up even though he also disagreed with her, and he would likely have written the hold had I not), that decision would have stood as hers. If the patient had left the ER and come to some harm through being too insane to care for herself (this was the attending's view), the attending - not I - would have been held legally liable.
Personally I think the whole system of having someone who is not there carry ultimate responsibility for the patient is ridiculous. But as someone noted, that's sort of empty at the moment that a decision has to be made.
In retrospect, if I had told the attending I wouldn't write the hold, perhaps that would have forced her to come in and write it herself, or forced the ER attending to write it. I don't know how realistic that scenario would be (it sure would have created havoc), but at the time it frankly didn't occur to me. It's a lot easier to think about that in hindsight.
(By the way the attending was spitting mad when I told her I thought her decision was not right. Again in retrospect the judgement seems clearer but at the time she was screaming at me that I was going to be an attending myself soon and I had better learn to care about my patients' safety. Thinking about it now I am more convinced that the patient should have been let go, but she was so emphatic that I was halfway convinced she might be right.)
ChrisK said:
"Unfortunately, pontificatrix, coming on here to salve your conscience doesn't absolve you"
Heh heh. If I wanted to salve my conscience I would have complained quietly to my fellow residents, who would be unconditionally sympathetic and supportive. I came on here because I knew I would get this discussion, and I wanted it. Believe me when I say I could have written this story in a way that made both me and the attending sound much better than they do in the version I posted.
"While this patient is imprisoned against her will due to Pontificatrix and the attending's malfeasance, she will probably be doped with controlled substances that have negative side effects which is yet another assault.
How would you like to be locked up in a mental ward against your will in violation of the law and injected?"
Just to clarify, in my state under most circumstances it is illegal to give a patient on a psych unit any psychotropic medication (injected or otherwise) without the patient's express written consent. In fact the nurses on the floor won't give the med - even if the pt is asking for it - unless there is a written consent filed in the chart.
The exceptions are 1) a true emergency situation in which the patient is attempting to harm others on the unit, and 2) a lengthy and extended process of legal appeal in which you thoroughly document why the patient is too insane to be able to make his own decisions about medication. This takes a couple of weeks and isn't very common because the case is hard to prove.
Sure, all those who excoriate about the abuse of power here, would be singing a different tune if this seemingly reasonable, yet delusional woman decided to perform her own c/section after returning home to get out the baby she knew to be there.
As we know, its all a crapshoot. With human beings, predicting what they will do is impossible. And after said c/section, you can be sure that the malpractice lawyers will be all over what should have been done with a delusional patient in such a situation. So you get more risk-averse and defensive in your practice of medicine since you know that any misstep with find you in a courtroom explaining why you thought it was fine to let a delusional woman go home alone at 4 AM. Behind Blue Eyes will not be able to be called as a witness for your having done the right thing, despite the outcome.
So yeah it all really sucks. We have to spend too much time anticipating the worst possible consequences of our decisions. And in fairness, it was much much different when I was a resident and a fellow. But realizing as an attending that any and all consequences of your decision fall solely on you (you get this as a trainee, but the weight and gravitas of it really smacks you when you sign on as the academic attending yourself), it is so very tough.
But I do have one question. You mentioned that she had a psychiatrist. Were you able to contact his/her service and discuss how s/he wanted to manage follow up? That might have calmed your attending a bit more if she knew that the woman's regular psychiatrist was involved and follow up had been arranged.
Regarding the patient's psychiatrist, no, he was not reachable at 4 AM. I did get the on-call doc at his practice (which is totally atypical - usually what you get is the doc's answering machine telling you to call 911 or go to the ER in an emergency), but that person a) did not know the patient at all, and b) did not have access to her records.
And then I would have gone back to sleep, pager next to my head.
Your attending erred on the side of caution, and I understand that as well. I wish the psychiatrist who pulled me off the benzodiazapenes I had been on for a year and a half had erred on the side of caution, but she did not. She tried to do in six days. That went quite poorly for my 19-year-old brain. But I had the opposite experience of Redstocking Grandma, and met many compassionate, knowledgeable people at the hospital I went to. Ten years later, and I'm still thankful for the attention that they paid and the interest that they took in me. They understood that I was still really a kid, who had no idea what was going on, or why she seemed to have suddenly gone crazy, because of course the psychiatrist hadn't warned me of any side effects other than, "you might not be able to sleep." You strike me as one of those compassionate people, because you felt the need to write this post in the first place.
But I think that the more salient point is that she didn't present with this symptom in an office, she showed up to a hospital. So one question might be: is part of the reason she showed up in the ER ready to give birth because some part of her knew what might happen (that she would get hospitalized or get some other kind of help she wasn't getting at the time)? Someone with the delusion that she is pregnant and about to give birth may well have "carried" this delusional pregnancy for some time. There may have been some precipitating event to set off her labor (so to speak), some kind of crisis. And so it is hard to say what how risky it might be to send her back home without any help.
On the other hand, she seemed lucid enough to know the details of her medications and to promise to follow up with her own psychiatrist (though the next day would have been better than less than a week). I imagine in your situation I would have done the same thing, tried to send her home, allowed the attending to make the call if she disagreed.
I guess the other question in this case is: is the hospital where she was sent the kind of place where she had no hope of getting real help (either in the form of revisiting how effective her medications were or a good referral to a therapist who could help her with her emotional distress)? Some places are, many are not.
Although anyone can have an opinion on anything, of course. But I strongly feel that if you haven't had to deal, up-close and personal, with a delusional person who's actively struggling with those delusions, you're really in no position to make a lot of sweeping generalities about "freedom."
And Ponti, if you had been able to get hold of a friend or family member of this patient at 4:00 in the morning, do you really think they would have been happy to take her home, when she's absolutely convinced she's about to give birth? I think no matter how much they loved her, they would have begged you to admit her, to keep her safe. Of course, admission to what, to where ... but that's the subject of another post.
(Good to see you back here!)
Is there anything you can do at this point by way of changing things so that the staff of your hospital is more aware of the law regarding patients' rights?
On the basis of the information posted here, I suspect she did not feel safe in some way. She may have come to the hospital aware that she might be admitted as a psychiatric patient. She had no social supports, no other place to go.
It's a shame there was no in-between available. She needed someone to talk to at length, someone who could hear her out. The resident did the best she could--calling all around to find someone who could fill that need.
I don't know what the best course of action would have been in this case. I'm just sharing my own reasoning. I would have been on the better-safe-than-sorry side of things.
And of course blood tests to see if she were really taking her medication, or counting pills to see if the right number remained in the bottle from the time of her last prescription being filled. But you probably did all these things.
And of course, if the patient hadn't sensed what might happen (get hospitalized) and tried to bolt from the ER you could have waited until 7 AM and interview the patient together with the attending AND reach her treaters to make a more solid decision.
But the patient didn't exactly allow that did she? How many medical patients get up and walk out in the middle of an interview about a potentially serious problem in the ER? That's right, zero-or next to zero.
So that behavior in itself was a sign of her being unstable and not using good judgment. Right?
Of course, if she had been willing to wait around a few hours the hospital could have sent her directly to her psychiatrist or therapist and ensure she was cared for without hospitalizing her against her will...but it was the patient who played the card that you had to respond to.
Getting used to exercising judgment and making decisions that patients don't like is part of why residency last so long and is often so painful. Disagreements with attendings sometimes are about concrete patient matters, but more often about countertransference in my experience (having been on both sides) just sayin.
Having seriously mentally ill people walking the streets may be someone's view of civil rights, but I believe their human rights are being violated. It also does not make great health care to allow this poor delusional woman to tie up important health care resources with multiple visits to doctors and ERs claiming she is pregnant, right? Any ideas what the bill was for an ER visit with OB-GYN consult, labwork, ultrasound, and psych consult? I mean, money is not the main thing, but it does give you a clue something is really wrong with this picture.
Your caring heart and sensitivity to the dignity and respect every patient deserves speaks very well for you and your career. Keep questioning those in authority and don't accept decisions if you feel they are not morally right! Keep on questioning!
Ten years ago my sister refused to answer her phone when I called, she was angry with me for noticing her loosening grip on reality. I came to visit and listened as she told me that her boyfriend was Jesus who had landed in his spaceship to save her, that he would save me too...believe it or not this was mild for her. I tried to persuade her to come with me to the hospital to talk to the doctors she knows in the E.R., she wouldn't and became angry, began to yell. Eventually I was able to call the police who told me that even though she was clearly delusional she was of no harm to herself or others and they could not "make" her go to the hospital against her will. She clearly was off her meds and needed help yet until she reached out for help there wasn't much I could do. Eventually patients like my sister reach out for help but only after causing themselves untold pain.
I guess the point of my comment is...go easy on yourself. Don't lose the ability to feel for patients like my sister. There are too many doctors who dismiss them, who treat them as "crackpots" rather than the suffering human beings they are who sometimes are like children who need to be told when to take their medicine.
I have seen people much more dangerously isolated than this patiet shown the door. For example a homeless man who had a leg amputaion was delivered to a street corner 2 weeks later. Sure he had a new prosthesis but would never receive the care and nutrition for wound healing he needed. I have seen people sent away from the E.R after a fight, fall out in the bushes on the hospital grounds., the blood on the bandage of their head still growing.
And as for the psych E.R.- people who clearly state they want to die are often given some pills and sent home all the time with an appointment to see someone the next month. .All they have to do is sign a "contract"that they will hold off on their plan til they meet with their appt. Why psych doctors think a piece of paper will hold
desperate people on earth is beyond me.I guess they always say someone broke their "contract" if they kill themself and be free of respnsibility.
I think this was a case of the Dr. in charge choosing to teach the resident a lesson about the psych system , rather than giving a shxt about the real human being involved.The delusion of pregnancy is not dangerous and the person clearly seemed to understand how to seek help.
Ponti,
Great to have you back and thank you for bringing us this real slice of ER life. Hyblaean gets it.
First, I have some sympathy for doctors who, having released a patient a few times and then found that the patient hurt themselves or others, get very conservative about taking the risk of releasing a patient.
Second, I have no idea how often a patient with delusions goes on to hurt themselves or others. This would be a factor in my decision if I were in the attending's shoes.
Third, as for those who said that Pontificatrix should have followed her conscience and damn the consequences, I would respond that had she done so, a great many patients in future years would most likely be deprived of a physician in a position of authority who shows an unusual level of regard for a patient's rights.
"There were a couple of other options, that you may have explored to resolve this false dilemma. Reaching her treating psychiatrist may have helped to see if the worrisome symptom-the delusion of being pregnant-was new, or old and stable."
I tried that but could not reach him. (Not unusual, honestly I would have been surprised if he *had* happened to be answering his office phone at 4 am.)
"And of course blood tests to see if she were really taking her medication"
Blood test suggested she was taking her medication but had either skipped her last dose or was being underdosed by her dr (she was slightly below the therapeutic range).
"or counting pills to see if the right number remained in the bottle"
She had her pills rolling around freely in her purse; no bottles.
"How many medical patients get up and walk out in the middle of an interview about a potentially serious problem in the ER? That's right, zero-or next to zero."
I wouldn't agree with that. When I was working on the medical side of the ER people left early all the time, just because they were tired of waiting - especially if workup had been completed and they were just waiting for discharge instructions or whatever. It's annoying to sit around in the ER for hours waiting for something to happen.
"So that behavior in itself was a sign of her being unstable and not using good judgment. Right?"
Right. But was it *dangerous*?
"Of course, if she had been willing to wait around a few hours the hospital could have sent her directly to her psychiatrist or therapist and ensure she was cared for without hospitalizing her against her will...but it was the patient who played the card that you had to respond to."
Yeah... the more I think about it the more I think that what I neglected to do was to explain the situation more clearly to the patient. I didn't *tell* her that we thought she might need to come in unless we could find someone to contact. I did tell her we'd feel safer about her if we could find someone (this was before the attending conversation), but I didn't say we thought she'd need to come in otherwise. (I didn't go back to see her between the conversation with the attending and the time she made the break for it - I just started making phone calls.)
If she'd had a better understanding of the situation perhaps she might have made a different decision than the one she made.
Despite her added paragraph of even more excuses at the end of this blog, Pontificatrix and her attending committed malpractice and are guilty of false imprisonment. Let this be a warning to those of you who might wander into emergency rooms. You might not be allowed to come back out even if you want to leave.
Imprisoning people to "save their jobs" as suggested by Redstocking does not meet the legal standard either. The person must be about to cause PHYSICAL harm to themselves or to someone else before a shrink can lock them up. If the person did not say anything to suggest she was about to perform surgery on herself, hypothetical c-sections dreamt up in the imagination of the doctor or a doctor commentor do not qualify.
Psychiatric Malpractice by Simon and Sadoff: "Under no circumstances, not even in an apparent emergency, is it permissible for a psychiatrist to certify someone as meeting the requirements for commitment when he or she is without a good-faith basis for that determination." "The law is clear: a patient may only be committed on the basis of a good-faith determination that he or she meets all of the requirements for involuntary hospitalization. Failure to comply with this straightforward duty is sufficient grounds for a lawsuit for false imprisonment."
Not having anyone you can call at 4 AM does not make a person a danger to herself or others. Pontificatrix admitted with her "weak excuse" that she acted without good-faith.
The patient should sue the crap out of the hospital, Pontificatrix and her attending.
Easy money.
you are just another trainee doctor who makes mistakes as do all doctors from time to time
at least this time you did not kill anyone
In Denmark the mental hospitals have their own "accident and emergency" reception giving 24 hour support to this kind of patient quite separately to the usual A and E
Can you go back and visit the patient and inpatient team and let us know how it turns out, or at least let yourself know, without violating confidentiality? Follow up is always a great teacher.
These decisions are very hard and although I think the decision to hospitalize was correct there clearly is something you are wrestling with--do not ignore that (as we all see you are not)! That internal discomfort is an important signal to you that there is a lot more to learn and understand about the patient, yourself and these clinical interactions.
As for the legality and lawsuit angle, the head lawyer of a major teaching hospital gave advice early in residency that few juries or judges are going to fault a doctor who is acting in what he perceives to be the patient's best interest and there is evidence the patient is gravely disabled or at risk to themselves. It gets more complicated when the patient is in your office, may need involuntary hospitalization, and going inpatient may mean missing important income earning meetings on the West Coast and they are catching a plane in a few hours weighed against how the meetings may go in the patient is hypomanic etc etc...just saying it doesnt get easier...
We should applaud ponti for sharing the innerworkings of a psychiatric resident who is still in the process of forming the values and beliefs that will guide a lifetime of practice. Very important stuff. I hope you get to go back and talk with the attending at a clear headed time of day.
Keep writing!
Ah, there's the rub. I think this may be the crux of the matter here.
Please don't take this as a pile on. I'm speaking as an old attending here. No matter who the patient is, you've got to explain what you are thinking and what your plan is while it is going on, not after you've got it all worked out. I know that while I was a resident, I wanted to avoid the confrontation that I knew would ensue when I knew that what I wanted to do for the patient's health was in conflict with what the patient wanted for him/herself (like an anorexic who needed to be admitted for medical stabilization when she didn't think she had a problem). With all you are already dealing with in residency: the knowledge deficits, the preparation for the unexpected (Dr. So-and-So, your patient is blue. Come quick!), the procedures (the 2 month old with no veins blew his IV again), and the exhaustion, the having to deal with the potential emotional outbursts/freakouts/anger spates/accusations and other crap on top of all the rest can be just too daunting. So the tendency is to put the drama off until everything is all clear and done. You then come and present a clear plan to the patient and all the emotions get handled at once.
However, when you put yourself in the patient role, you see that this is so problematic. People need to know as much information as you have as soon as you have it. And then you come back with updates. And yes, perhaps this woman might have been OK with a plan to stay here in the hospital until you could make a plan with her regular psychiatrist because you are worried about how she's doing. The best thing to do is to have her either stay in the ED or get admitted for observation until we can make a good plan for her safety with her psychiatrist. I don't know how it works with adults, but my teen patients, including those with schizophrenia and other serious mental illnesses generally respond positively when I look them in the eyes and tell them that I am worried (when I am). And this woman with no family, no friends, new to me with continued delusion would worry me without getting a good discussion and follow up plan with her therapist.
But back to my advice. What served me very well during my time in academia was always explaining my thoughts and plan after the initial interview (I'm going to review your situation with my senior doctor, but I am a bit worried about you. I'll come back in a few minutes and talk to you about what we think will be the best approach here) and then at each stage in the process. Your patients will feel more informed, involved, and not ignored.
So much great learning from this situation.
Last summer in Alger, Washington, a short distance from here, a young man went psychotic and shot and killed four of his neighbors in their homes, desecrated the bodies, and then killed a female Sheriff's Deputy when she responded to the latest of the dozens of calls for help his mother had made over the years. He then went on a freeway spree and killed another person, then wounded four more, including a State Trooper. His mother had been desperately trying to have him committed for years, but had been unsuccessful.
It is impossible to second-guess the actions of a mentally ill person. I don't envy any mental health professional in today's legal climate, and I hope this state's laws regarding commitment, and the laws of many more states, undergo significant change, and soon.
There is a third point of view: The Families have one, too.
I would appreciate if you wouldn't dissrespect your patients by assuming that they've "burned bridges". They are ill and can't help themselves, for goodness sake. Their families have no support from anyone who should be working with them.
Sometimes, the relatives and friends have to protect themselves by cutting of relationships, since they can't get help in this "Catch 22" goat rope of a mess.
Sometimes patients come from hideously abusive situations, and "family" has no business coming anywhere near them.
Many times, the family can not get information as to the patients whereabouts or well being.
I was in one of those families, and it's a miracle from God that we weren't wiped out by a violent, paranoid schizophrenic sibling who got away with one vicious attack after another for years.
When he was incarcerated, he would either be helped to escape or was let go by a one sided mental health profession. We were treated with hostility, rudness, and as if we are the enemy, with no rights whatsoever. We spent many a night in abject fear, not knowing where he was.
He died years ago, but I still wake up some nights, as I have since I've been 15 years old, in a complete panic.
Don't beat yourself up. You made the right decision, erring on the side of caution.
As a licensed psychotherapist, I think that it's really supercool that you're posting your cases anonymously here.
You know, I can understand how conflicted that you might have felt, especially since your patient had a presentation that seemed highly functional, even with the delusion. We all have false selves that we present to the world.
"The person must be about to cause PHYSICAL harm to themselves or to someone else before a shrink can lock them up."
That is not quite true. There is another criterion - the grave disability criterion - which requires that the patient be so impaired by mental illness that he is unable to meet his own basic needs. That was the criterion in question here, and the basis for the hold I wrote. And it is true that we could not verify independently that she had a place to live, an income, etc.
"I'm a bit surprised you titled this an apology. It seems to be a clear description of a situation that has no easy answers."
I guess I titled it an apology because I felt pretty deeply that I didn't do right by the patient. At the time I thought the 'not-right' was about having put the legal hold on her, and that is the perspective from which I wrote the original post. But it's not really just about the hold - she got restrained, which I expect is one of the worst, scariest, most humiliating experiences anyone can undergo.
After thinking about this a bit, I now think that what I did wrong was more about not communicating with her. I think the crucial window was the period of time after I hung up with the attending and before the patient decided to leave. I think if I had used that time to talk to her more extensively and reveal that we were thinking about bringing her in, at least she would have had a clearer idea of what was going on before she made a break for it. Maybe things would have gone differently then - e.g. the threat of hospitalization could have gotten her to reveal a contact, or she might have agreed to wait a few more hours until we could find somebody. At any rate she wouldn't have been so caught by surprise when the ER staff wouldn't let her go.
Thanks for your input everybody. This discussion has been extremely helpful.
But here's my question. You mention "delusional" as a reason to keep someone, but it seems to me the substance of the delusion is relevant. Is it not? Because thinking she's pregnant strikes me as inherently less risky (to oneself and others) than thinking the cops are after you or something like that.