Ethics with psych patients

[HLxDrummer]

So how do you guys handle physical and chemical restraints? As an intern I feel uncomfortable deciding when it is legally and ethically cool. Like when do you call security vs. kick them out vs. chemical vs. physical.

For example what if they are drunk and aggressive. They are a threat to others so I'm guessing you can restrain?

What about an aggressive kid getting in fights at school/spitting at people/fighting with staff?

What if that person wasn't a minor? Seems like it would be unethical to restrain them but at the same time unethical to kick them out.

Do you ever give anything if they are just really disruptive/screaming? Nurses ask me for this all the time and I don't because they aren't a threat but it does scare the **** out of the 6 year old girl and her mom next door for a sore throat lol!

I guess I understand chemical vs. physical but how do you decide between those and just having security kick them out?

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[BoardingDoc]

So how do you guys handle physical and chemical restraints? As an intern I feel uncomfortable deciding when it is legally and ethically cool. Like when do you call security vs. kick them out vs. chemical vs. physical.

For example what if they are drunk and aggressive. They are a threat to others so I'm guessing you can restrain?

What about an aggressive kid getting in fights at school/spitting at people/fighting with staff?

What if that person wasn't a minor? Seems like it would be unethical to restrain them but at the same time unethical to kick them out.

Do you ever give anything if they are just really disruptive/screaming? Nurses ask me for this all the time and I don't because they aren't a threat but it does scare the **** out of the 6 year old girl and her mom next door for a sore throat lol!

I guess I understand chemical vs. physical but how do you decide between those and just having security kick them out?

Minors: if they aren't there for involuntary eval, ask if mom/dad wants them restrained or if they want to leave. If they're on a hold, tell the parents your plan for chemical sedation if the kid doesn't calm down.

Adults:
-On a psych hold, assaulting people or too drunk to leave? Haldol as needed.
-Sober, not SI/HI and just an dingus? Tell them they will be escorted out by security if they don't calm down. If they don't, have them escorted out. If they calm down, make it clear that you are there to help them, but if they have any further outbursts, they will be escorted out.

 

[namethatsmell]

So how do you guys handle physical and chemical restraints? As an intern I feel uncomfortable deciding when it is legally and ethically cool. Like when do you call security vs. kick them out vs. chemical vs. physical.

For example what if they are drunk and aggressive. They are a threat to others so I'm guessing you can restrain?

What about an aggressive kid getting in fights at school/spitting at people/fighting with staff?

What if that person wasn't a minor? Seems like it would be unethical to restrain them but at the same time unethical to kick them out.

Do you ever give anything if they are just really disruptive/screaming? Nurses ask me for this all the time and I don't because they aren't a threat but it does scare the **** out of the 6 year old girl and her mom next door for a sore throat lol!

I guess I understand chemical vs. physical but how do you decide between those and just having security kick them out?

This is a good question. Everybody is going to have a different take on this as there are often many shades of gray in these situations.

I always approach these patients by asking myself what's the safest option (for both them and staff).

Assuming you need to work the patient up for something/need to keep them in the ED for whatever reason, my algorithm is usually: Jedi the patient/try to talk them down -> offer food /comfort measures -> PO meds -> IM/IV meds -> physical restraints (last resort). Most of the time I can get patients to calm down with the first three options.

All others who demonstrate capacity to understand risks/benefits/alternatives to care can leave AMA. Committing time/resources to these patients exposes them (and staff) to safety risks (med reactions, getting hurt in scuffle w/security, etc) and takes away care from others.

Over time the decision of when to escalate things in these situations is kinda like porn- you'll know it when you see it.


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[GeneralVeers]

I don't have time for games. I give them one chance to change their behavior. I give them the options to behave....or not. 75% of the patients take the latter. Subsequently it results in chemical and/or physical restraints. Belligerent, aggressive patients who are not psychotic or otherwise intoxicated get escorted out immediately with police called if their is any resistance.

 

[n2b8me]

As an intern it is appropriate to feel uncomfortable about a lot of things that happen in the hospital... especially the ER.
As an attending my first (sometimes only) thought is what is this person's dispo? Can they go back to the street or are they gonna get 5150'd or admitted for something. If they aren't leaving the ER because they are too psychotic or unstable in any way then it is easy to use chemical and physical restraints. If they stable enough to leave the ER now then friends, family and PD can help them get to where they need to be - no meds or restraints please.

Also I would support the nurses if they are getting agitated about a patient screaming incessantly --> find a room with a door we have a couple of these in my 20 bed ER, then give meds as needed. Nobody wants to be in an ER with somebody screaming and suffering. including those working, those visiting, and of course the other sick people.

 

[Venko]

So how do you guys handle physical and chemical restraints? As an intern I feel uncomfortable deciding when it is legally and ethically cool. Like when do you call security vs. kick them out vs. chemical vs. physical.

For example what if they are drunk and aggressive. They are a threat to others so I'm guessing you can restrain?

What about an aggressive kid getting in fights at school/spitting at people/fighting with staff?

What if that person wasn't a minor? Seems like it would be unethical to restrain them but at the same time unethical to kick them out.

Do you ever give anything if they are just really disruptive/screaming? Nurses ask me for this all the time and I don't because they aren't a threat but it does scare the **** out of the 6 year old girl and her mom next door for a sore throat lol!

I guess I understand chemical vs. physical but how do you decide between those and just having security kick them out?

I quickly sketched my decision tree as I can Imagine it. Maybe I forgot something just let me know. Hopefully it helps.

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[Arcan57]

I think there's a pretty uniform consensus on the mentally ill and the non-intoxicated belligerent jackhole. I think the intoxicated patient requires some more nuance. If it's an intoxicated patient with a severe acute health problem (I've never seen someone drunk with a STEMI but it could happen) and you judge the patient not to have medical decision making capacity then you're looking at chemical restraint. If it's someone without an obvious acute medical problem and they're not an immediate danger to themselves or others then individual management is going to vary. Some people will toss on the restraints anyway out of either medicolegal concern or actual concern for a missed injury/condition. Others will say "pt brought it on themselves, peace out". I think for most of us it's a case by case thing. The higher our gestalt for serious injury/condition and the less the patient is able to comprehend about their situation, the more likely restraint is used.

 

[HLxDrummer]

Thanks for the advice guys, definitely helpful!

 

[gman33]

What is the dispo?

If they need to stay to be evaluated, you do whatever is necessary to make that happen.
Talk, tie, takedown.

If they have capacity, throw out.

Just don't be the doc that tries to make everyone stay, but won't sedate anyone.
The staff will hate you (although there are some cases where this is appropriate)

 

[WilcoWorld]

Lots of good points above. I only have a legal/linguistic/documentation point to add:

Do not refer to it as "chemical restraint" in your chart. "Sedation" or "treatment of delirium" or "treatment of agitation" are all appropriate medical interventions while "restraint" is better left to law enforcement.

 

[Venko]

Lots of good points above. I only have a legal/linguistic/documentation point to add:

Do not refer to it as "chemical restraint" in your chart. "Sedation" or "treatment of delirium" or "treatment of agitation" are all appropriate medical interventions while "restraint" is better left to law enforcement.

Are you referring to only medicinal or also to physical limb restraints? The physical restraint is part of our EMR and I cannot readily think of a different way to say it.




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[WilcoWorld]

Are you referring to only medicinal or also to physical limb restraints? The physical restraint is part of our EMR and I cannot readily think of a different way to say it.




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I was referring to medicinal treatments of agitation. I agree that it's hard to call physical restraints something different.

 

[shoal007]

Lots of good points thus far. In addition a jackhole disrupting the ER are a danger to others (patients and staff). I do not tolerate it. I give one chance as well -- either d/c or treatment of delirium ;-).

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[Stagg737]

I quickly sketched my decision tree as I can Imagine it. Maybe I forgot something just let me know. Hopefully it helps.

View attachment 216720


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A little off-topic, but what app is that chart from? Seems like something that would have made my life infinitely easier in pre-clinical years...

 

[TooMuchResearch]

Good advice. I have nothing to add. You're still pretty new, the nurses might know these patients and know that yelling is about 90 seconds from the violent takedown you're trying to avoid. Some of the agitated psychotic patients give you a good window of opportunity to get meds in them without anyone getting hurt. Don't miss that window.

 

[GeneralVeers]

Good advice. I have nothing to add. You're still pretty new, the nurses might know these patients and know that yelling is about 90 seconds from the violent takedown you're trying to avoid. Some of the agitated psychotic patients give you a good window of opportunity to get meds in them without anyone getting hurt. Don't miss that window.

My philosophy, which I explain to nurses is that: "Anyone who is yelling and screaming either: 1. Gets discharged immediately, or 2. Gets a hefty dose of IM meds to knock them out".

 

[Venko]

A little off-topic, but what app is that chart from? Seems like something that would have made my life infinitely easier in pre-clinical years...

I used coggle.it

I love it for mind mapping


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[Venko]

My philosophy, which I explain to nurses is that: "Anyone who is yelling and screaming either: 1. Gets discharged immediately, or 2. Gets a hefty dose of IM meds to knock them out".

Do you apply this only for patients or does the occasional consulting service get the same treatment?



(I am blessed that it has been many many years since I had any such conflict, so many thanks to the teams I work with, I am only joking here)


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[Tenk]

I usually ask the patient to sit down for a second and chat with me. If they are AAO and deny SI/HI and can tell me exactly why they want to leave or don't want X treatment then I usually won't do it. If they can't do all those things I have found these people usually need your help and more often if you just act calm you can talk a lot of them down. If there is no talking down then they get the B52. If they are violent I go straight to ketamine. Just document your reasons and you will be fine.

 

[Aker]

I give them the options to behave....or not. 75% of the patients take the latter.

Jedi the patient/try to talk them down -> offer food /comfort measures -> PO meds -> IM/IV meds -> physical restraints (last resort).

These two comments do basically resume the general professional attitude towards disrupting behaviour at the ER, no matter its cause; either confront the patient (with very little success) or "Jedi" him -the "magical" stressed.

Now, my own take on this is to assume first my own responsibility on patient communication at the ER. And second to train in dealing (with) and leading patient-doctor communication -so that to "Jedi" the patient becomes a professional tool/technique much more than a wish-set of actions/attitudes.

There are many useful communication tools for the ER professional. I mostly use Ericksonian (hypnotic) techniques to rapidly de-activate disruptive behaviour, build up rapport and basically transform an aggressive patient into a collaborative one (obviously enough the process, which includes an ongoing evaluation of patient psychological/psychiatric problems, is more complex -and interesting- than what can be described here). But there are many other psychological tools just as useful -and not hard to learn and practice. For example, you can take a look at the Verbal De-escalation of the Agitated Patient, a Consensus Statement of the American Association for Emergency Psychiatry Project BETA De-escalation Workgroup (Q1).

Q1
Agitation is an acute behavioral emergency requiring immediate intervention. Traditional methods of treating agitated patients, ie, routine restraints and involuntary medication, have been replaced with a much greater emphasis on a noncoercive approach. Experienced practitioners have found that if such interventions are undertaken with genuine commitment, successful outcomes can occur far more often than previously thought possible. In the new paradigm, a 3-step approach is used. First, the patient is verbally engaged; then a collaborative relationship is established; and, finally, the patient is verbally de-escalated out of the agitated state. Verbal de-escalation is usually the key to engaging the patient and helping him become an active partner in his evaluation and treatment; although, we also recognize that in some cases nonverbal approaches, such as voluntary medication and environment planning, are also important. When working with an agitated patient, there are 4 main objectives: (1) ensure the safety of the patient, staff, and others in the area; (2) help the patient manage his emotions and distress and maintain or regain control of his behavior; (3) avoid the use of restraint when at all possible; and (4) avoid coercive interventions that escalate agitation. The authors detail the proper foundations for appropriate training for de-escalation and provide intervention guidelines, using the “10 domains of de-escalation.”

I particularly dislike most agitation rule-of-action charts, specially because of their naive and many times counterproductive psychological recommendations (here you have an example). And yet I understand one should be familiar with some rule of thumb for restraint use (chemical/physical) at the ER (this is an interesting approximation -in Spanish though).

Anyhow, from a pragmatical point of view -even above basic ethical considerations- I believe psychological [Jedi/"restraint"] techniques should almost always be considered first in most cases of disruptive behavior at the ER.

 

[namethatsmell]

I have found these people usually need your help and more often if you just act calm you can talk a lot of them down.

Just want to re-emphasize this for the interns. The second you get worked up or agitated yourself the likelihood of successfully talking down the agitated patient drops considerably.

 

[Venko]

I usually ask the patient to sit down for a second and chat with me. If they are AAO and deny SI/HI and can tell me exactly why they want to leave or don't want X treatment then I usually won't do it. If they can't do all those things I have found these people usually need your help and more often if you just act calm you can talk a lot of them down. If there is no talking down then they get the B52. If they are violent I go straight to ketamine. Just document your reasons and you will be fine.

If there is a question about SI or HI, you should probably need some corroboration rather than taking the patient at their word when they deny it. A safety assessment for a person suspected of suicidality includes gathering outside source data, assessment of outpatient support structures, weapons assessments, etc.

I agree with your plan for the agitated person who is not ever being accused or suspected of making suicidal gestures or statements.


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