The Tyranny of the “Collateral” Information
Rounding on the inpatient unit with residents and medical students we stop to talk to Mr. X. He is a 50 year old white man. Never been in the hospital before. The first question he asks me is “when do I leave, I do not belong here”. I ask the standard questions. He denies any problem that he feels would lead to being in the hospital and during the examination there is no evidence of any severe mental illness. I give the usual response, I will need to review his record further and talk more to the team, and I will then get back to him.
In the nursing station, the resident reports that he was brought to the Emergency Room because he was suicidal. The information was gathered by “collateral” sources including family and his outpatient psychiatrist. We dive into the information, most of it vague. He never tried to kill himself. He never told the psychiatrist that he had a plan, but did say that sometimes he wishes that he was dead. The sister insists that he has become increasingly suicidal but cannot give any other history. In the Emergency Room they decided to commit him to the inpatient unit. This is a common occurrence. It is often decided to punt the long term decision to someone else rather than make a decision in the middle of the night. There are many logistical problems that prevent these types of decisions from being made. There are no clinics open, no ability to send patients to an appropriate level of care immediately. As such, the inpatient unit is the “safest” bet.
After examining the patient and reading through the pages of collateral information I felt “pretty sure” that this patient was not in fact a high risk of suicide, but what do I do with the 5 pages of collateral information saying otherwise. Who do I believe? This is when I realize that the collateral has become the tyrannical force that it is. The “collateral” uses the word “suicide” and it is now in the center of the discussion. There is no need to prove this was actually said, although in today’s day and age there is often a text message or some posting on social media that speaks to it. But even if the text message states “sometimes I do not feel like living”, does this mean that the individual is suicidal.
The discussion by the clinicians veers off the road of clinical decision making, and hops onto the legal-risk management highway. Despite there being no evidence that locking patients up actually decreases suicide, we are stuck with one intervention which is to lock the person up until we can develop a “safe discharge plan”. Like amateur detectives we sift through evidence to find out who is “lying”. The protagonist “House” would say “everybody lies”, and I then realize in the end I will never learn the truth, just bits and pieces of information that will amount to nothing definitive.
We are now in a struggle between the patient and the “collateral” both attempting to convince the psychiatrist of their veracity. Both have an agenda but it is a different one. One wants out and the other wants that person in. I am no longer a doctor treating a patient. I am a judge, hearing evidence and making a decision about whether or not to incarcerate this person. I have been given the authority by the state of New York to have this person committed for up to 60 days. The patient can ask to see an actual judge, but that will take some time and the outcome is not guaranteed. Although he feels that he should be released the “collateral” believes otherwise. If the patient is released and harms himself or others, the blame comes back to the doctor. After all, there was so much collateral information and you “ignored it”. The new role is “risk manager”. I now need to fill out “evidenced based forms” to prove that the patient is right and not the collateral. The major problem is that the “evidence based forms” are based on information given by the patient.
As the morning went on I realized that something was missing from the entire discussion. Is this person actually being treated for anything? What is the psychological issue that actually brought him to the hospital? We dig further, and confront the patient. We dig further and confront the collateral. We take an actual history. We develop a narrative and in the end we identify the multiple conflicts that led to this day. It is a rich tapestry of familial dysfunction, with sibling rivalry, parental exhaustion, marital discord and budding adolescence. Yet the “collateral” remains. Although we might develop a formulation that seems clinically sound, we still have to contend with family members calling us stating that the patient is in fact suicidal. They further add that they do not feel “safe” allowing them home.
The idea of a “safe discharge” was meant to protect the rights of individuals with severe mental illnesses who were at times discharged to shelters and would be victimized in such settings. The “collateral” provider however can use the same word, “safe”, to further bind the hands of the provider.
In the end the patient will be discharged and more likely than not, be safe. The issue at hand is the inherent adversarial tone that is set. The patient is not seeking treatment, they are seeking freedom. The doctor is providing “safety” but does not engage in a therapeutic manner since the tone has been set to be one of an adversarial nature. The patient is taught that there are words not to be stated or you might be committed. The family now knows the words to use to have a problematic relative removed. In the end the opportunity to create a supportive and trusting therapeutic relationship is harmed by the natural adversarial nature of the first contact. The family which has long been frustrated by watching the problematic and socially unacceptable deviates more from the practice of medicine due to this process. We treat behaviors or alleged behaviors that are unacceptable to society. People no longer present to the hospital seeking treatment for an illness, but are sent due to such behaviors. We follow laws and regulations and often forget the patient before us. We speak of autonomy and yet often must take the side of others against the patient in order to “protect them”.
In the end we try to engage the individual. We try to work with them and attempt to help them understand what is occurring. We use the admission as a call to action, pointing to interventions that can be done in the community which bring the individual in for admission. We educate the individual about a variety of factors that interfere with the ability of the individual to just be “let go”.
By the day of discharge, the patient has probably already made a decision about what their plan is. They often will not be forthright with us, lest we extend the stay. They will smile, tell us they feel well and thank us for our help. I want to believe them when they say these things, but in the words of Gregory House M.D, everybody lies.
