How an Elder Suicide Almost Happened

On a Sunday, a few years ago a situation unfolded in a Philadelphia suburb that could have ended in a suicide, but fortunately did not. It entailed a chain of events that illustrate that, in at least this one example, there are many opportunities to “do something” to prevent a suicide.

 

Mrs. S, an 80-year old widow, recently moved into a Continuing Care Retirement Community offering independent living, assisted living, and skilled nursing care. A few weeks later she was admitted to a local hospital because of an exacerbation of a chronic illness. In the course of her inpatient stay she manifested depressive symptoms and made statements indicating both suicidal ideation and a plan to take all of her medications when she returned to her residence.

 

The hospital did not have a psychiatric unit but arranged for a psychiatrist to see Mrs. S. The psychiatrist expressed concern about her risk and felt that she should not directly return to her residence. He wrote an order that she be transferred to the skilled nursing facility (SNF) at her retirement community.

 

Mrs. S was discharged the next day at 2:00 PM. For reasons that are not clear the orders were not followed and an ambulance took Mrs. S to her home. At 2:50 PM, Mrs. S called the assisted living facility (AL) in the complex and told them that she was home and that a psychiatrist had told her that she should be on a “suicide watch.” An LPN said that she would try to find out what was going on.

 

The LPN called the SNF, which knew nothing about Mrs. S. She next spoke to a nurse on the floor that had cared for Mrs. S and was told of her suicidality. The LPN relayed what she had learned to the SNF Charge Nurse who requested faxed copies of the orders. The RN called Mrs. S’s unit but there was no answer. It was now about 3:30 PM.

 

Meanwhile Mrs. S went to the AL facility and told an aide what she had been told by the psychiatrist. She said that was going to a concert in the auditorium at 4:00 PM in the hope that it would lift her spirits. The aide alerted the LPN but Mrs. S had left. The LPN contacted the SNF RN who went to the auditorium to try to find Mrs. S. What she found was an overflow crowd of 250 elderly women, many of whom fit Mrs. S’s description.

 

At 3:55 PM, the SNF RN alerted Security, which was changing shifts at 4:00 PM. Neither the outgoing or incoming security staff knew Mrs. S.  One security officer accompanied the SNF RN back to the auditorium to try to find someone on might know Mrs. S. The other security officer called the dining room and other areas where Mrs. S might be present.

 

The concert ended at 5:00 PM and Mrs. S had still not been located. At 5:15 PM, as the concertgoers cleared the lobby one of the security officers saw two women conversing on a sofa.  He inquired if either was Mrs. S. One woman said, “I guess you’re looking for me.” The security officer not wanting to run afoul of confidentiality polices returned to the front desk where he could observe Mrs. S. while the other officer called the SNF RN.

 

The SNF RN arrived five minutes later and told Mrs. S that they were ready to work on her admission. Mrs. S. readily proceeded to the SNF with the RN.

 

The SNF staff was very concerned about its ability to handle this situation. Mrs. S was admitted to a private room. The call button cord was removed and efforts were made to find a bell that Mrs. S, could used to summon help. Maintenance was contacted about securing the windows. By 6:00 PM Mrs. S was settled in and the SNF staff began checking her every hour.

 

Epilogue: When last we heard, Mrs. S was still with us and living independently at the CCCR.

 

Comment: Mrs. S voiced a potentially lethal plan with access to means and a specific timeframe. She should have been strongly encouraged to have a voluntary evaluation at a geripsychiatric facility and, if she declined, a petition for an involuntary psychiatric evaluation (“302”) should have been filed. Hopefully the hospital implemented some precautions during the last day of Mrs. S’s stay (but that is not known). The SNF seems to have taken Mrs. S’s risk seriously but did not seek an assessment. The SNF should have contacted the county crisis center for assistance. The measures taken by the SNF to assure Mrs. S’s safety were minimally adequate. It was suggested that the facility develop a suicide prevention policy for such situations but that has not been done.

Alternative to Hospitalization — Is There Such a Thing?

by Tony Salvatore, M. A.

Over the years (decades actually), I have often heard the phrase “alternative to hospitalization” used in conversations about the suitability and capability of some community-based mental health services to serve as a substitute for inpatient psychiatric care. The implication being that use of these alternatives would be less expensive, less restrictive, less stigmatizing, and less traumatizing than hospitalization while being equally effective. This phrase and the promise that it bespeaks is always taken as a valid assertion and never (in my experience) challenged by users, advocates, or providers of mental health services.

My intuition told me that there was something illogical about this phrase, but I never spoke up because I always assumed that the service in question was being presented as a means of deterring admissions involving individuals who could be safely and effectively treated in community settings. I was wrong. I have discovered that many people strongly believe that the need for inpatient psychiatric care can be met outside of a freestanding psychiatric hospital or a psychiatric unit of a community hospital. Moreover most of those espousing this view also seem to believe that inpatient psychiatric care is over-utilized because adequate substitutes are or could be available.

There are a number of misconceptions about psychiatric hospitalization. One is that it should be up to the patient who, after all, would seem to be in the best position to know if inpatient care is needed. Another is that hospitalization should follow from a determination by an outpatient provider, in the form of a referral, that this level of care is needed. Still another is that admission is solely at the discretion of the psychiatrist covering intake at the hospital. Of these, only the last has any degree of validity. A psychiatrist does indeed order an admission, but it is not based on her or his decision alone.

What is often not understood is that there are explicit criteria for an inpatient psychiatric admission that must be met. These criteria have been established by the various parties regulating, offering, or paying for inpatient psychiatric care. They are based on clinical need and appropriateness for this level of care. Satisfaction of these criteria are the primary purpose of the psychiatric evaluation that must precede any inpatient admission. The criteria of medical necessity for inpatient psychiatric care are basically clear. The individual must:

  1. Have a primary psychiatric diagnosis, excluding intellectual disability, substance abuse, or dementia, unless these conditions co-occur and are secondary to the presence of a diagnosed psychiatric disorder. (NB: Psychiatric diagnosis by itself does not equate to need for hospitalization.)
  2. Require ongoing 24-hour clinical management, monitoring, supervision, and assessment by psychiatry and nursing to develop, implement, and modify the treatment plan, which cannot be done in a less controlled care environment.
  3. Be at significant risk of harm to herself/himself or to others because of an imminent risk of suicide, assaultive behavior, or homicide, represent a risk to self because of psychosis, or demonstrate a serious inability to care for one’s self.

These criteria clearly indicate that, when strictly and correctly applied, there is, in fact, no alternative to, or substitute for, inpatient psychiatric care when that is what an individual needs. There is no single community-based program or any combination of such programs that can deliver the degree of safety, supervision, or service intensity that can be provided in an inpatient psychiatric setting. Put more plainly, someone either needs hospitalization or someone does not, yes or no.

Here is a suggestion: Use an “alternative to inappropriate hospitalization” instead of improperly using hospitalization. Inpatient care should be turned to when it is the only option capable of meeting the individual’s needs. Any other use is unnecessary, wasteful of a limited resource, and potentially harmful. Inpatient psychiatric care is not a “Plan B” for problems that cannot be otherwise resolved. It is not a stand-in for shelters or rehabs that have no beds. It is not a respite for frustrated family members or providers. It is not an alternative to incarceration when the offense is unrelated to any underlying serious mental illness.

There is no alternative to psychiatric hospitalization and psychiatric hospitalization is not an alternative to any other service.