A Patient Who Says He Will "Finish It Properly" and Threatens to Leave

Treat this as a high acute risk statement, not as a passing remark.

1. Stay with him and do not leave him alone. Call for the assistant or another nurse to attend; a patient expressing intent with a stated plan and a timeframe ("next time") is at elevated acute risk.
2. Do not promise confidentiality. Say plainly: "I can't keep that to myself, because your safety matters more. I'm going to get the doctor who can help."
3. Ask directly and specifically - asking about suicide does not increase risk. Cover: current thoughts, intent, plan, means, previous attempts, access to means (does he have stockpiled tablets at home? a car? firearms?), protective factors (his daughter, any family support), and substance use. Record his words verbatim.
4. Escalate immediately to the on-call psychiatrist/mental health team and the nurse in charge. Request a same-night mental health assessment, not a morning referral.
5. Reduce access to means - remove belts, sharps, cords, and any medications from his bedside, check his belongings with him, and move him to a visible bed near the nurses' station with enhanced observation (1:1 or continuous observation within sight, per local policy).
6. Inform the medical team and request that discharge be placed on hold until the psychiatric assessment is complete.
7. Document the exact statement, the time, the risk assessment, actions taken and who was informed.

Why not wait: risk is dynamic and highest in the days after discharge and after a precipitant such as relationship breakdown and job loss. The overnight period is also a higher-risk time. A nursing handover alone would not be an adequate response.

Confidentiality is not absolute. It yields to the duty to protect life. The professional obligation is to share information on a need-to-know basis - the psychiatric team, the medical team, the nurse in charge - not to broadcast it. Telling his employer or neighbours would be a breach; telling the clinicians responsible for his safety is not.

Autonomy and capacity:

• A patient with capacity may refuse treatment, and physical restraint is not the answer to a verbal threat. But capacity must be assessed, not assumed: can he understand, retain, weigh and communicate the decision to leave? Severe depression, intoxication or acute distress can impair that.
• He is medically fit but psychiatrically unwell. "Medically fit for discharge" and "safe for discharge" are different judgements. A medical discharge does not require him to be released into an unsafe situation.
• If he insists on leaving, do not physically block him, and do not bluff with threats you cannot carry out. Instead: notify the psychiatrist and the nurse in charge immediately, consider whether the local mental health legislation permits an assessment or hold, ensure he is seen before he goes, offer every alternative (voluntary admission, crisis line, emergency contact), and document the capacity assessment, the advice given, and his decision.
• Protective engagement beats confrontation: "I'm not trying to lock you up. I'm trying to make sure tonight is safe. Will you talk to the psychiatrist with me before you decide anything?" Involving someone he trusts, with his consent, often de-escalates.

Safeguarding note: he has a five-year-old daughter in his care. If there is any indication that the child is at risk, that triggers a separate safeguarding duty to the child protection team, and this must be considered even though the child is not your patient.

A discharge is only safe if it is a planned discharge.

Before discharge:

• Completed psychiatric assessment and a documented risk formulation, with an agreed follow-up appointment - ideally within 24–72 hours, not "in a few weeks".
• A collaborative safety plan he helped write: his own warning signs, coping strategies that have worked before, people he can call, crisis numbers, and what to do if he feels worse at 3 am. A plan imposed on him will not be used.
• Means restriction: agree what happens to any remaining medication at home; supply only small quantities (e.g. weekly dispensing or supervised consumption), involve the pharmacist, and discuss safe storage. Paracetamol should not be bought in bulk or kept in the house.
• Treating the underlying problem: referral for talking therapy, consideration of medication, and assessment of alcohol/substance use.
• Social and practical factors: housing, finances after job loss, and childcare arrangements for his daughter - the practical precipitants are part of the clinical problem.
• Written information and confirmation of engagement using teach-back.

Involving family: ask his permission first - "Is there someone you'd like us to speak to?" With consent, involve a trusted relative in the safety plan and in monitoring, and give them the crisis numbers. Without consent, you may still share minimum necessary information where there is a serious risk to life, but you must explain to him what you are sharing and why. Never collude in a "don't tell anyone" pact that leaves the household unaware of an acute risk.

Handover and follow-up: send a discharge summary to the primary care physician and mental health team the same day, and consider a follow-up call within 24–48 hours. The highest-risk period is the week after discharge - plan for it explicitly.