Suicide Risk and Request to Leave Against Medical Advice
Ms. T is a 34-year-old woman admitted to the medical unit after an acetaminophen overdose. She was medically cleared 6 hours ago; vital signs are stable, the acetaminophen level is below the treatment line, and liver enzymes are normal. She has a history of major depression and one prior suicide attempt at age 19. She lives alone, lost her job 2 weeks ago, and says, 'I'm fine now. I just want to go home.' She has a flat affect, avoids eye contact, and gives inconsistent answers about whether she has a plan. The psychiatric consult is scheduled for tomorrow morning. She is asking for her belongings and street clothes. The unit has a 1:1 sitter available for one patient; the charge nurse asks you to assess her and decide whether she can leave against medical advice.
1. How do you assess suicide risk and capacity, and can she leave against medical advice?
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Assess directly and privately: current suicidal ideation, plan, intent, access to means, rehearsal, hopelessness, prior attempts, recent losses, substance use, and protective factors. Her recent overdose, prior attempt, social isolation, job loss, flat affect, and inconsistent answers place her at high risk. 'I'm fine' is not reassuring when it conflicts with behavior and history. Capacity requires understanding the risks, appreciating consequences, and reasoning; depression and active suicidality may impair this. The nurse does not make the final legal determination alone. If she insists on leaving, call the provider and psychiatric team immediately; many jurisdictions allow an emergency hold when the patient poses a danger to self. She may not be physically restrained without an order and immediate danger. Document verbatim statements, the assessment, consultations, and the patient's response.
2. What immediate nursing actions reduce risk while awaiting psychiatric evaluation?
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Place her on 1:1 observation, search belongings according to hospital policy, and remove ligatures, sharps, medications, and cords; use a safe room near the nurses' station. Ask directly about suicide and do not promise secrecy. Maintain a calm, nonjudgmental presence and avoid arguing about discharge. Notify the provider and psychiatric consult, request an expedited evaluation, and involve social work. Provide comfort and orientation; allow supervised phone calls only per policy. Document mood, affect, statements, and safety interventions. The least restrictive intervention that maintains safety is preferred: 1:1 observation and environmental safety, not restraint or seclusion. If she attempts to leave, follow the emergency hold policy, call security, and do not physically block her unless policy and law permit.
3. What should the handoff to the psychiatric team and discharge planning include?
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Use SBAR: '34-year-old with recent acetaminophen overdose, prior attempt, job loss, lives alone; flat affect, inconsistent plan; currently on 1:1; medical clearance complete.' Clarify the observation level and who can reduce it. Before discharge, a formal risk assessment, safety plan, means restriction, crisis numbers, follow-up appointment within 24–72 hours, and involvement of family or social work are needed. Do not discharge solely because the medical team has cleared her; psychiatric clearance is separate. Document the handoff, the patient's understanding, and any refusal. If she remains at risk and refuses voluntary treatment, the provider must evaluate for involuntary commitment.