Psychiatrists and other mental health professionals leave voice mail messages on their office phones advising patients what to do in case of an emergency. But when a suicidal patient in crisis calls the psychiatrist and hears the recorded message, "If you have a 'true' emergency, go to your nearest emergency room or call 911," the patient's risk of suicide may increase.
Psychiatrists and other mental health professionals must be accessible to suicidal patients or be able to provide for adequate coverage in their absence, because the psychiatrist may be the only person with whom the suicidal patient has a life-affirming relationship.
What, exactly, is a "true" emergency? Who can define it? "True" emergency is devoid of meaning, but the suicidal patient may perceive the intent of the above message as: "Don't bother me!" The "true" emergency message erects a barrier between the patient and the psychiatrist. Does this now increasingly heard message reflect an erosion of the doctor-patient relationship wrought by changes in mental health care delivery? Is it also a misguided effort at risk management?
Leaving the message, "If you have a 'true' emergency, go to your nearest emergency room," or the variant "call 911," leaves a patient with few options. Suicidal patients are often reluctant to call 911. The police and rescue squad will arrive at the door with sirens blaring. A crowd of inquisitive neighbors will gather. The street scene is embarrassing and humiliating. Alternatively, the patient may be too impaired or unwilling to follow the message directives, instead choosing to attempt or complete suicide.
The general hospital emergency department (ED) is the main venue for suicidal patients who require immediate care. Based on a consultative model of care, the patient is first evaluated by the ED physician. If psychiatric consultation is requested, a crisis counselor usually sees the patient. An attending psychiatrist is available on- call for consultation, usually by phone. In most instances, general hospital EDs provide adequate care.
The ED experience, however, can add to the patient's distress. Psychiatric patients report enduring long waits to be evaluated in busy general hospital EDs—the patient may not be seen for hours or even a day or more. Hours of waiting in mental misery may only confirm the patient's feelings of hopelessness and abandonment, thereby increasing suicide risk. A suicidal patient with agitated depression or a psychotic patient with auditoryhallucinations that command suicide may leave the ED before being seenand attempt or complete suicide.
Psychiatric emergency services (PESs), staffed by psychiatrists and a full complement of other mental health professionals, are usually based at large medical centers or universities. They are open 24 hours a day, 7 days a week, andprovide "full service" comprehensive emergency psychiatric services.1 Provision of "around-the-clock" service prevents patients from leaving before being evaluated.
Generally, a phone call to the patient by the psychiatrist is an intermediary step to determine an initial course of action. The psychiatrist may be able to assess the severity of a patient's suicidal crisis over the phone and, if necessary, arrange an emergency appointment. If possible, the patient may be managed by means other than referral to the ED. A return call from the psychiatrist can stabilize a suicidal patient until he or she can be seen on the same ornext day. Thus, the therapeutic alliance is preserved and strengthened.
It may be necessary to send a suicidal patient in need of immediate care to the ED or the patient may go to the ED without calling the psychiatrist. In the first instance, the psychiatrist should determine whether the patient is able to go to the ED alone or needs someone to take them. Clinicians have escorted patients to the ED. The suicidal patient may be so disturbed that he is unable to come to the psychiatrist's office or to speak coherently on the phone. The psychiatrist should try toenlist the assistance of others (eg, a family member, partner, friend, or the police) before sending the patient to the ED. If none are available, the psychiatrist may have no recourse but to call 911 or community crisis management services. A phone call to the PES or general hospital ED in advance of the patient's arrival will alert and inform the staff about the suicidalpatient. It also may help decrease the waiting time in the ED.
The psychiatrist or the covering clinician (who should be informed about suicidal patients who might call) must be available to respond within a reasonable period. Although hard-and-fast rules do not exist, if possible, an emergency call from a suicidal patient should be responded to within the hour. Cell phones facilitate accessibility and rapid response. For a patient in a suicide crisis, evenwaiting an hour may seem like an eternity.
In solo practice, the psychiatrist or covering clinician must be accessible to calls from suicidal patients 24 hours a day, 7 days a week, by cell phone, pager, or other means of direct communication (excluding e-mail). Twenty-four-hour coverage for patient emergencies is an established medical practice and standard of care.
Psychiatrists in group practice or institutional settings have on-call schedules that provide continuous coverage for patients. Some psychiatrists provide their home phone number to patients during a period of increased suicide risk.
The Opinions of the Ethics Committee on the Principles of Medical Ethics With Annotations Especially Applicable to Psychiatry2 takes a firm position on the emergency coverage of patients.
Question: One of our members is concerned that psychiatrists in his area do not routinely check in with their answering machines after hours, leave no number where they may be reached, or leave a message for patients to contact the local emergency department in case of emergency. Is this member's concern about the ethics of these psychiatrists warranted?
Answer: Yes. Ethical psychiatrists are obliged to render competent care to their patients. That competent care would include either being available for emergencies at all times or making appropriate arrangements. Certainly, a message telling patients to call an emergency department is not adequate coverage. Even in rather stable practices, including analytic practices with relatively stable patients, emergencies do arise. Care must be taken that, if and when such emergencies do arise, the patient is not abandoned.
Patient education: a prearranged safety plan
With the current limitations on access to hospital services, most patients at risk for suicide, even long-term high-risk patients, are treated as outpatients. Some psychiatrists provide and discuss with new patients a safety protocol to be followed in an emergency. The spirit of the discussion is, "We're in it together." Alliance-building encourages the patient, who might not do so otherwise, to call the psychiatrist during a crisis. Psychiatrists must explain how they can be reached in an emergency.
The psychiatrist or covering clinician, however, may not be able to return the patient's call in time when an acutely suicidal patient needs immediate assistance. In the prearranged plan, the patient will leave a message with a phone number for the psychiatrist indicating that he has gone to a safe "holding place" to await the psychiatrist's call (eg, at home, with family or a friend, or other) or if necessary, to a predetermined ED. The psychiatrist will call the ED at the first opportunity to assist in the patient's assessment and management. If a PES is accessible to the patient, the address and phone number should be provided.
Some patients at risk for suicide do not have family, partners, friends, or other supportive resources. If unable to wait for a callback from the psychiatrist, the patient should be provided with suicide prevention hot- line numbers as a source of assistance. The National Suicide Prevention Lifeline (800-273-TALK; or www. suicidepreventionlifeline.org) can refer the patient to local hotlines and other sources of help.
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2. American Psychiatric Association. The Opinions of the Ethics Committee on the Principles of Medical Ethics With Annotations Especially Applicable to Psychiatry. Section 1-AA. Washington, DC: American Psychiatric Association; 2001.
3. Meyer DJ, Simon RI. Split treatment. In: Simon RI, Hales RW, eds. The Textbook of Suicide Assessment and Management. Arlington, Va: American Psychiatric Publishing; 2006.
4. Simon RI, Shuman DW. Clinical Manual of Psychiatry and Law. Arlington, Va: American Psychiatric Publishing; 2007.
5. Mains J. Medical abandonment. Med Trial Tech Q. 1985;31:306-328.
6. Bolles v Kinton, 83 Colo 147,153, 263, p 28 (1928).
7. Fochtmann LJ. Emergency services. In: Simon RI, Hales RE, eds. The American Psychiatric Publishing Textbook of Suicide Assessment and Management. Arlington, Va: American Psychiatric Publishing; 2006.
8. Simon RI. Assessing and Managing Suicide Risk: Guidelines for Clinically Based Risk Management. Arlington, Va: American Psychiatric Publishing; 2004.
9. Simon RI. Clinically based risk management of the suicidal patient: avoiding malpractice litigation. In: Simon RI, Hales RE, eds. The American Psychiatric Publishing Textbook of Suicide Assessment and Management. Arlington, Va: American Psychiatric Publishing; 2006.