Does your OB patient have a psychiatric complaint? And can you manage it?
Here’s how to handle 5 challenges, including postpartum depression, an attempt to leave the hospital against advice, and denial of pregnancy
IN THIS ARTICLE
Sometimes a patient must be held against her will
Some mothers lack the capacity to refuse treatment. They may be unable to verbalize an understanding of the situation and its risks. Their reasoning may be abnormal, with disorganized or delusional thinking, or both. The patient may be tangential or talk “in circles” rather than answer your questions.
Try to ascertain whether mood symptoms are contributing to her irrational thinking. For example, is her rationale for going home—“just to be with my husband because I don’t want to be alone”—due to her depression, despite the risk to herself and the fetus? Try to be flexible and creative. For example, you could call the husband and ask him to come to the hospital to sit with the patient.
Is the patient psychotic? For example, does she believe she has to leave now because the staff has been replaced by aliens who plan to kill her and her fetus? If so, you have the authority to continue her hospitalization—but contact the psychiatry department for medication recommendations. A urine toxicology screen would also be prudent.
If the patient is irrational and lacks the capacity to decide whether to stay or leave, document your conversation with her, as well as the reasoning behind your decision to intervene further. Other steps include:
- contacting the hospital’s attorney
- completing an emergency detention form
- calling security
- ensuring that the patient’s environment is safe for her and others (TABLE 2).13
TABLE 2
5 steps to sound management of a patient who wants to leave
against medical advice
| 1. Ask the patient why she wants to leave now |
| 2. Inform her of the risks to herself and to her fetus |
| 3. Ask her to verbalize the risks to herself and to her fetus |
4. Determine whether the patient’s request is rational
|
| 5. Document the medical explanation and reasoning in the chart |
CASE 2 RESOLVED
After building some rapport with the patient, you ask why she wants to leave right now. During this conversation, the patient reveals that she has not slept in three nights, and says she believes that the insulin is keeping her up. You are able to assure her that this is not the case and offer her something to help her sleep. She decides not to leave against medical advice.
Unexplained agitation
CASE 3: Patient becomes abusive
At 1 AM, you are called to the seventh floor, where a 20-year-old G2P1 at 26 weeks’ gestation is yelling at staff and hitting anyone who comes near. She was admitted earlier in the day for management of threatened abortion and a dilated cervix. She has no documented psychiatric history, but is flushed, disheveled, and hostile, accusing the staff of sabotaging her life, and is seen picking at imaginary things. You notify psychiatry, but no one is available.
What do you do?
Determining the origin of these symptoms will help determine the appropriate course of action. Among the possibilities are:
- drug intoxication or withdrawal
- delirium
- psychosis
- a chronic problem such as a personality disorder (TABLE 3).
Psychosis means that a patient is out of touch with reality. A psychotic patient may experience delusions, auditory and visual hallucinations, and gross disorganization. Brief psychotic episodes usually last for 1 day to 1 month, with eventual recovery to premorbid functioning.7
Substances such as medications or illicit drugs also can induce psychosis. Major offenders include steroids and narcotic agents. Alternatively, sudden withdrawal of illicit substances (due to hospitalization) could manifest as delirium or psychosis.
Personality disorder. If the patient’s behavior is not new but a long-term problem, she may have a chronic personality disorder rather than acute illness. Personality problems involve pervasive response patterns and dysfunctional coping patterns that affect daily life. For example, a patient who has borderline personality disorder may have emotional instability presenting as intense episodic dysphoria or irritability. Such patients have a hard time empathizing with others, poor impulse control, and a desire for instant gratification. They may also misinterpret the behavior of other people and take offense easily as a result. Lacking stress-management skills, they regress to unhealthy defense mechanisms such as acting out, complaining, passive aggressiveness, and splitting of the staff (thinking that people are all good or all bad).
