You have been struggling for months to get your son, your daughter, your parent or spouse to the emergency room for a serious mental illness. Your loved one is ever more distrustful, locking, even barricading, the door and windows, not leaving home nor letting hardly anyone in, eating poorly, not bathing, and pacing incessantly. You have tried everything you can think of to get them to go for help but they refuse. Your anxiety mounts as you see their condition worsening before your eye creating a dangerous situation.
Finally, for reasons you can’t explain, your loved one agrees to go to the local hospital emergency department (ED) – and you get there as fast as you can, knowing that can change on a dime. You think, finally, a chance to get him into the hospital so treatment can begin and maybe take hold. In the ED your loved one waits for a couple of hours, grows restless but you manage to keep him there. Finally, he is seen by the doctor – after you tried unsuccessfully to get a few words in edgewise with the doctor who has 10 more people in the waiting area, and who knows what other responsibilities in the hospital.
The doctor emerges from the exam room and she signals you for a word. She tells you she is discharging your loved one since while he clearly has a mental illness he does not want admission and there is no evident “danger to self or others”, the term that captures what is legally required to admit someone who does not want to be admitted. She says she will give you the phone number of a clinic to call for an appointment. Your heart sinks. You dread what lies ahead, even if you were not sure what could be accomplished in the hospital. Your loved one pulled himself together with the doctor, however briefly, and promised to get help (a promise you know will not be kept). What awful event has to happen before he will be admitted, or will that even be too late?
What can you do to prevent this outcome? While there are no guarantees you want to convey a message that needs to be heard. To do so, you need to know what the doctor needs to know and deliver that information – short and sweet. Most important is that danger exists: you need to say that the situation is dangerous, and it is getting worse. And that there will be grave consequences to the patient, family and doctor if safety is not immediately achieved, namely by hospitalization.
Here is how one family I know succeeded in preventing the nightmare of leaving an ED without having achieved what they came for. The adult children told the doctor that their mother had left the gas on in the apartment while nailing shut the windows and barricading the door. They made a point of catching her before she went into the examining room with her patient (their mother) and saying that their mother had felt hopeless and spoke about being an increasing burden to her family. She had said that they would be better off without her. Her hopelessness, guilt and distrust meant she would not tell the doctor; in fact, she was apt to provide a cover story that would get her discharged from the ED. The family told the doctor that if their mother went home she would likely try again and die from the gas, or start a fire or an explosion, when she lit a match to smoke. They stressed that neither the family nor the doctor wanted that to happen. Their mother was admitted on an involuntary doctor’s order after she refused an offer of admission.
Involuntary admission is always the least desirable intervention. I know patients who avoid the mental health system and psychiatrists for years after such an event. Early intervention, voluntary treatment, and shared decision making (often helped by an advance psychiatric directive) are what work a lot better. But sometimes, when all fails and danger and fear mount the hospital becomes a necessary, short term and emergency action — if only you can get the mental health system to respond!
You will have a lot of explaining to do to your loved one later on. But given the choice of discharge to a dangerous situation or actively providing the doctor with information that clearly supports involuntary hospitalization, which will you choose? If you chose the latter, make a point of explaining why you did what you did to your loved one – but not until there is a good moment when you can convey your love, your fright, and your determination to help.