A 52-year-old man is brought to the emergency department by his roommate after threatening to commit suicide. He is angry about being taken to the hospital and says, "I just want to go home and sleep." His roommate says, "I can't take it anymore; I thought he was going to jump out of the car on the way to the hospital." The patient has a history of recurrent major depression, post-traumatic stress disorder, and alcohol abuse. He describes increasing depression since his divorce 5 years ago. He feels hopeless, has difficulty getting out of bed, and eats only one meal a day. The patient ruminates about his failed marriage and blames himself for his heavy drinking and losing contact with his 2 grown children. He has always owned a gun, which he usually keeps in a locked drawer in a bedside table. However, in the last week he has taken the gun out and held it before going to sleep "because it feels like a security blanket, it's reassuring." The patient has suicidal thoughts but does not think he will act on them. He says, "I just need to know I have a way out." His medical record indicates that he tried to overdose 3 months ago by taking a handful of sleeping pills and drinking 2 liters of vodka. Last year, he tried to hang himself in his garage but was discovered by his roommate. The patient has been followed by a psychiatrist in an outpatient clinic. He felt better when taking duloxetine but has not taken the medication for the past few months as he can no longer afford it. He insists that he is not feeling suicidal now and demands to leave. The patient is placed on 1:1 observation, and arrangements are made to hospitalize him. He is upset and tearful and starts to pace. He says angrily, "You can't keep me here against my will. If I wanted to kill myself, I would have done it already. I just want to go home so I can finally get some rest." The nursing staff attempts to calm the patient down and offers him water and a sandwich, which he refuses. The physician approaches the patient to explain the treatment plan. Which of the following is the most appropriate statement?

Question

A 52-year-old man is brought to the emergency department by his roommate after threatening to commit suicide.  He is angry about being taken to the hospital and says, "I just want to go home and sleep."  His roommate says, "I can't take it anymore; I thought he was going to jump out of the car on the way to the hospital."  The patient has a history of recurrent major depression, post-traumatic stress disorder, and alcohol abuse.  He describes increasing depression since his divorce 5 years ago.  He feels hopeless, has difficulty getting out of bed, and eats only one meal a day.  The patient ruminates about his failed marriage and blames himself for his heavy drinking and losing contact with his 2 grown children.  He has always owned a gun, which he usually keeps in a locked drawer in a bedside table.  However, in the last week he has taken the gun out and held it before going to sleep "because it feels like a security blanket, it's reassuring."  The patient has suicidal thoughts but does not think he will act on them.  He says, "I just need to know I have a way out."  His medical record indicates that he tried to overdose 3 months ago by taking a handful of sleeping pills and drinking 2 liters of vodka.  Last year, he tried to hang himself in his garage but was discovered by his roommate.  The patient has been followed by a psychiatrist in an outpatient clinic.  He felt better when taking duloxetine but has not taken the medication for the past few months as he can no longer afford it.  He insists that he is not feeling suicidal now and demands to leave. The patient is placed on 1:1 observation, and arrangements are made to hospitalize him.  He is upset and tearful and starts to pace.  He says angrily, "You can't keep me here against my will.  If I wanted to kill myself, I would have done it already.  I just want to go home so I can finally get some rest."  The nursing staff attempts to calm the patient down and offers him water and a sandwich, which he refuses.  The physician approaches the patient to explain the treatment plan.  Which of the following is the most appropriate statement?

Quizplus · Accepted Answer

Explanation: Physicians must be clear and decisive when there is concern about patient safety. Hospitalization, voluntary or involuntary, on a locked psychiatric unit is required when a patient has suicidal ideation with a potentially lethal plan. Physicians should be aware that the process of involuntary admission can be a traumatizing experience. The best way to communicate this decision is a patient-centered approach in which the physician explains that the primary goals of hospitalization include alleviating the patient's suffering and providing treatment in a safe environment. This approach offers hope, acknowledges the patient's pain, and does not place the physician in the adversarial position of focusing solely on thwarting the patient's desire to harm himself. (Choices A and D) These statements focus on preventing suicide and may further antagonize the patient who, at this point, appears to want to die. A patient-centered approach that acknowledges the patient's suffering and need for treatment would be more appropriate. (Choice B) It is inappropriate to offer false reassurance by implying that the patient might be discharged after speaking with the outpatient psychiatrist. Although contacting the outpatient psychiatrist is important, the decision to discharge the patient rests with the inpatient team. In addition to being inaccurate, this statement also has the potential to damage the patient's relationship with the outpatient psychiatrist. (Choice E) Although this statement is true, it focuses on the physician's responsibilities and not the patient's needs. Educational objective: Once a physician has made the decision to involuntarily hospitalize a suicidal patient, this plan should be communicated clearly but empathically to the patient. Acknowledging the patient's suffering can help minimize the trauma of involuntary admission. References: How to increase quality of care during coercive admission? A review of literature. (http://www.ncbi.nlm.nih.gov/pubmed/23937606)

A 52-Year-Old Man Is Brought to the Emergency Department by His