Patient suicidal comments

[USMC2LPN]

I had a patient of mine fall trying to transfer herself to the commode. When asked what happened, her reply was "I was just trying to kill myself". This is a new admit whom I had only met once before. She suffers from end stage liver disease and her ammonia levels are high. She was very confused at the time of the incident and could not even tell me where she was.

On the incident report and in my documentation of it, I went out of my way to point out the fact that she made this comment. Regardless of her mental status or the seriousness of it, I was under the impression that we were obligated to take ALL comments like that seriously.

When I got to work tonight I found a letter from my supervisor asking me why I documented that, and that because I did, she had to go behind me and follow up on it to "cover my butt". I thought by charting she said it I was covering my own butt. She went on to explain that this person has a very dry sense of humor and was only trying to cover up the fact that she felt stupid for falling. I pretty much got yelled at (in letter format) for doing what I thought was the right thing to do.

Was I wrong for documenting this? I feel I was completely in the right. What if she had been serious and I didn't document anything? What if someone else had heard her statement and I didn't follow up on it?

I'm really not sure what my next step should be. Any advice?

[hppygr8ful]

You were not wrong for documenting what you heard - the fact that the patient was end stage lends to the idea that she might well be suicidal. Now end stage liver disease is miserable and I don't want to start and end of life issues topic here so please understand what I am about to say.

Even if the patient was joking there is always a bit of truth in every joke in cases like this I would have called the physician and gotten an order for a psych consult. In some facilities you can do even do this without a Dr's order.

Perhaps it's time to talk to the patient about end of life issues, hospice care etc....Pt's have a right to face death with dignity and maybe this patient just wants someone to talk to.

What you documented was correct. If that pt was sent home and killed herself and the family decided to sue which I doubt they would but you never know. You made a note that you were concerned about the patients welfare.

Don't argue the point with your sup but be comfortable in your heart that you did the right thing.

hppy

[Ricu]

Hi there,

You describe a difficult situation but I believe you handled it well. I wish I could say the same for your supervisor. She was out of line to chastize you for the action that you had taken and to state that she had to "cover your butt" was nonsense. She had to do her job which likely meant that she had to call for extra staffing to sit with the patient and ensure that she was safe. Thanks to your efforts, that became a reality. Whether or not the patient had a dry sense of humor was not for you to speculate on. You didn't know her and even if you did, to do as the supervisor infers would be her action and ignore the comment, takes unacceptable risk. What would happen if the next time the patient decided to get up to the commode and fall, she had the call bell wrapped around her neck? When you think about it, you covered your supervisor's butt by forcing her to take proper measures which she made clear that she wouldn't otherwise have done.

These situations are difficult to manage and drain resources but patient safety has got to be a priority. Any safety issue has got to be identified and specific plans must be instituted for how to address them. Your patient was at least a fall risk. Whether or not she is really a suicide risk is hard to evaluate due to elevated ammonia levels but that she verbalized suicidal ideation has got to be taken seriously and precautions must be taken. In all liklihood that meant that she needed a sitter and this would have been appropriate action for the fall and suicide risk issue regardless. Bed and chair check devices work only so well because by the time staff arrive the patient is usually already compromised and the legalities around restraints is prohibitive.

I would have done the same as you.

R

[Big Mama G]

I totally agree with the other's that said you did the right thing. Good for you!!! On the other hand your supp, I believe has acted unprofessional. I also believe that you saved her behind not the other way around as she has stated to you. Be proud that you are a good and conscientious nurse, you are the type of nurse that we need out there taking care of our loved ones.

[USMC2LPN]

Thank you all for the support. I really appreciate it.

I ended up leaving her a note telling her that I felt I did the right thing and asked her to please explain to me how I was in the wrong. I was professional in the way I did it so I wouldn't dig myself into a hole. I have a tendency to speak my mind, so I was very careful as to what I said and how I said it. I heard nothing back from her today.

The patient is doing well, admitted she was joking, but also understands now the seriousness of her statement.

Unfortunately the impression I got from some of my coworkers was that it was pretty silly of me to take it so serious. I wonder if I went to the corporate office or the State if they would feel the same way. I doubt it.

I come here often and read the forums. I spent 15 years in the Marine Corps taking people apart, and I think I have found my calling by putting them back together. I love being a nurse. I've only been one for a year and a half however and sometimes am unsure if I'm making the right decision, or doubt myself in times like this when I should just know I'm right. Your support has shown me a couple of things. One of the most important is that maybe I should look for a new place to work where the people around me can be more of a mentor to me than a discouragement.

I want to be great at what I do. My patients deserve that. I've been here for a year now and while I will miss the people I take care of, I also have to take care of myself.

Thank you again.

[SoldierNurse]

Thank you all for the support. I really appreciate it.

I ended up leaving her a note telling her that I felt I did the right thing and asked her to please explain to me how I was in the wrong. I was professional in the way I did it so I wouldn't dig myself into a hole. I have a tendency to speak my mind, so I was very careful as to what I said and how I said it. I heard nothing back from her today.

The patient is doing well, admitted she was joking, but also understands now the seriousness of her statement.

Unfortunately the impression I got from some of my coworkers was that it was pretty silly of me to take it so serious. I wonder if I went to the corporate office or the State if they would feel the same way. I doubt it.

I come here often and read the forums. I spent 15 years in the Marine Corps taking people apart, and I think I have found my calling by putting them back together. I love being a nurse. I've only been one for a year and a half however and sometimes am unsure if I'm making the right decision, or doubt myself in times like this when I should just know I'm right. Your support has shown me a couple of things. One of the most important is that maybe I should look for a new place to work where the people around me can be more of a mentor to me than a discouragement.

I want to be great at what I do. My patients deserve that. I've been here for a year now and while I will miss the people I take care of, I also have to take care of myself.

Thank you again.

Hello USMC2LPN,

I'd like to mention first that is an outstanding username... OORAH! I was active duty Marine from 1980-1988. I'm curious as to why you did not complete 20 years for retirement since you had only five years left. Probably non of my business. BTW, I sent you a PM.

Anyway, if I could play devil's advocate here. Did you post to whether you pursued the patient's suicidal comment with her? I realize hindsight is 20/20 but now you know this patient has a very dry sense of humor and her fall was not a futile attempt for a celestial transfer... if you get my drift. It is true that a nursing action is not done until it is documented. However, before charting an event make sure you have all the facts. I'm not saying you were wrong to chart the patient's comments. I'm just wondering if you told anyone about this patient's comments, or just documented the event.

Plus, you did not know this patient. I'd imagine after a couple more interactions you would have picked up on her dry sense of humor. I do realize people need to be mindful of what they say when it comes to suicidal ideations. A Soldier in my Unit [I'm presently deployed to Iraq] was frustrated about something and mumbled something to the effect he was going to kill him himself. Those were not the exact words and by the expression on his face you could tell he had no intention of carrying out his comment. Well, instead of his immediate chain-of-command talking to him privately his weapon was taken from him, he was to be with a battle-buddy at all times, and had to go through counseling. These were all short lived once it was realized his comments were spoken out of frustration and had no intent.

All I'm saying is your supervisor probably would have liked for you to pursue the matter futher before documenting the patient's suicidal comment. Devil Dog, IMHO please don't take all this to Corporate, or State. Your intentions were good & compassionate, and maybe the next time an elderly patient falls and makes a serious comment you will be better prepared to handle the situation.

Semper Fi!

[Ricu]

Thank you all for the support. I really appreciate it.

I ended up leaving her a note telling her that I felt I did the right thing and asked her to please explain to me how I was in the wrong. I was professional in the way I did it so I wouldn't dig myself into a hole. I have a tendency to speak my mind, so I was very careful as to what I said and how I said it. I heard nothing back from her today.

The patient is doing well, admitted she was joking, but also understands now the seriousness of her statement.

Unfortunately the impression I got from some of my coworkers was that it was pretty silly of me to take it so serious. I wonder if I went to the corporate office or the State if they would feel the same way. I doubt it.

I come here often and read the forums. I spent 15 years in the Marine Corps taking people apart, and I think I have found my calling by putting them back together. I love being a nurse. I've only been one for a year and a half however and sometimes am unsure if I'm making the right decision, or doubt myself in times like this when I should just know I'm right. Your support has shown me a couple of things. One of the most important is that maybe I should look for a new place to work where the people around me can be more of a mentor to me than a discouragement.

I want to be great at what I do. My patients deserve that. I've been here for a year now and while I will miss the people I take care of, I also have to take care of myself.

Thank you again.

Hi again,

I get volumes out of your last two paragraphs. You carried a lot of wisdom into your new career and the assessment of your current situation reflects that. Being relatively new to the profession, you do need good mentors and a lot of support otherwise how would you expand and refine your skills? From what you write, it sounds as though another facility would likely fit those needs much better. Taking care of yourself not only means career safety in terms of best practice but it also means avoiding burnout. Moving around the career path helps prevent that as does avoiding negative people and situations. By taking care of yourself this way means that you will be the best possible nurse that your patients rightly deserve. Finally, I sense that you will be an excellent mentor yourself.

Keep at it,

R

[Grandma-RN]

I, too, agree an incident report and documentations were the reight thing to do. Moreover, if you only doucument and not take actions regarding your doucumentation, what is the point of documenting? This question is food for thought not to make you feel bad.

Although not tactful on the part of your supervisor, she/he may mean covering you by following up on your documentation of the possible sucidial comment.

[USMC2LPN]

Hello USMC2LPN,

I'd like to mention first that is an outstanding username... OORAH! I was active duty Marine from 1980-1988. I'm curious as to why you did not complete 20 years for retirement since you had only five years left. Probably non of my business. BTW, I sent you a PM.

Anyway, if I could play devil's advocate here. Did you post to whether you pursued the patient's suicidal comment with her? I realize hindsight is 20/20 but now you know this patient has a very dry sense of humor and her fall was not a futile attempt for a celestial transfer... if you get my drift. It is true that a nursing action is not done until it is documented. However, before charting an event make sure you have all the facts. I'm not saying you were wrong to chart the patient's comments. I'm just wondering if you told anyone about this patient's comments, or just documented the event.

I did. I spoke with the attending (who happened to be oncall that night). He felt the same way that I did. I don't think she was ever serious about making the comment. There were just too many things I couldn't determine to rule it out at the time. The woman was extremely confused, I didn't have any type of relationship with her to know her personality, etc. I also spoke directly with her husband who ended up coming in. I explained to him that while I didn't feel she was serious, it wasn't something I felt comfortable ignoring at the time either.

Plus, you did not know this patient. I'd imagine after a couple more interactions you would have picked up on her dry sense of humor. I do realize people need to be mindful of what they say when it comes to suicidal ideations. A Soldier in my Unit [I'm presently deployed to Iraq] was frustrated about something and mumbled something to the effect he was going to kill him himself. Those were not the exact words and by the expression on his face you could tell he had no intention of carrying out his comment. Well, instead of his immediate chain-of-command talking to him privately his weapon was taken from him, he was to be with a battle-buddy at all times, and had to go through counseling. These were all short lived once it was realized his comments were spoken out of frustration and had no intent.

All I'm saying is your supervisor probably would have liked for you to pursue the matter futher before documenting the patient's suicidal comment. Devil Dog, IMHO please don't take all this to Corporate, or State. Your intentions were good & compassionate, and maybe the next time an elderly patient falls and makes a serious comment you will be better prepared to handle the situation.

Semper Fi!

I would never go to State or Corporate. I'm too darn loyal to the people I work for (not necessarily the company, just the people) to do that. I always try to look back at things when I get upset and see the whole picture. I'm a type A personality and a Leo... but I know it and that helps when I get angry or feel threatened. I force myself to step back and look at things rather than just react.

My supervisor actually made it a point to come in early a few days later and we spoke about this for some time. I explained my side to her and she admitted that, after reading my letter, she hadn't seen it from a "new nurse" perspective. We came up with several plans of attack and options if it ever happened again. I told her that at times I don't feel comfortable being a fairly new nurse all alone on 3rd shift, but ironically, I wouldn't have it any other way. I thrive on challenge. I enjoy it. I feel I'm at my best under pressure. It must be the Marine in me. Makes us all crazy.

I apologize for taking so long to respond to both your PM and this post, but I've been very busy lately. Thanks again to everyone for your insight and comments.