A 63‐year‐old man with a history of alcoholism and withdrawal seizures presented to the ED after a suicide attempt. The patient had persistent suicidal ideation and was placed on a psychiatric hold. In the ED, he reported irritability and “shakiness.” He was hemodynamically stable, with tremor and tongue wag noted on exam. The risks of withdrawal seizures and delirium tremens, including death, were explained, but the patient refused benzodiazepine therapy. He was oriented and understood the risks of his choice, even citing a desire to have a seizure and die. The psychiatry service agreed that he had decision‐making capacity and confirmed that the psychiatric hold did not allow forcible administration of medications except in life‐threatening situations. An increased risk of seizure was not considered life threatening, although an active seizure could be treated. The hospital's ethics and risk management services were contacted and agreed that the patient could not be compelled to take medications, although it was “important to err on the side of preserving life.” They also agreed that it was reasonable to offer the patient alcohol. Fortunately, the patient consented to benzodiazepine therapy prior to any adverse events.
Because of comorbid conditions and the medical effects of ingested substances, hospitalists often manage psychiatric patients. The care of these patients presents numerous challenges. This case highlights an ethical conflict between the goals of beneficence and respect for patient autonomy. It is complicated by the legal ramifications of a psychiatric hold, which vary by state. In general, such holds do not revoke decision‐making capacity for medical treatment, a fact of which members of the care team, including medical students and trainees, may be unaware. Although consultants can offer valuable information and opinions, the duty to evaluate decision‐making capacity and develop a comprehensive care plan ultimately rests with the hospitalist.
The care of hospitalized psychiatric patients can be medically, ethically, and legally complex. Often having the primary role in the inpatient care of such patients, it is critical that hospitalists stay informed on ethical opinions and relevant local laws. A multidisciplinary approach including psychiatric, ethics, and risk management services, communication, and negotiation with the patient, and creative solutions are important in developing an effective care plan.
J. Trambley, none.
To cite this abstract:Trambley J. Alcohol Withdrawal in a Suicidal Patient. Abstract published at Hospital Medicine 2008, April 3-5, San Diego, Calif. Abstract 184. Journal of Hospital Medicine. 2008; 3 (suppl 1). https://www.shmabstracts.com/abstract/alcohol-withdrawal-in-a-suicidal-patient/. Accessed September 22, 2019.