1 Take the necessary time to assist patients in crisis, as they often present unexpectedly.
- Crises include
- a relapse of symptoms
- disruptive behaviour
- risk of harm to self or others
- Crisis offer a time-limited window of opportunity to encourage the patient to make positive steps towards Tx and ongoing recovery
- Provincial mental health crises intervention units are built on this principle
- The window for positive change is often limited to 24-48 hr
Potential crisis situations include:
- risk of suicide
- OD or self-harm such as cutting or burning (attempt to relieve distress and tension)
- Inability to perform regular tasks of daily living or self-care
- Refusal of Tx despite acute symptoms, significant interference, ongoing distress, or risk of self-harm
2 Identify your patient’s personal resources for support (e.g., family, friends) as part of your management of patients facing crisis.
Prior to onset of a crisis:
- Ensure families have access to info about how to ensure safety and provide support
- Work with pt and family to develop Tx plan:
- coping options
- lists of useful contact numbers
- when to seek professional help
3 Offer appropriate community resources (e.g., counselor) as part of your ongoing management of patients with a crisis.
- Problem-solve with pt and supportive family or friends
- Identify the trigger(s) & generate concerns from the pt
- Identify options / alt coping strategies
- Reassure that the crisis will pass
- Review supports and options should the crisis return
- Outreach resources (housing, social services) for community tx to help avoid hospitalization
4 Assess suicidality in patients facing crisis.
See suicide section
5 Use psychoactive medication rationally to assist patients in crisis.
Stock and use Lorazepam 1-2mg po, sl, im in the office.
- Alt: Diazepam 10-20mg po/im, olanzapine 5-10mg po Zydis, Seroquel 25-50mg po
6 Inquire about unhealthy coping methods (e.g., drugs, alcohol, eating, gambling, violence, sloth) in your patients facing crisis.
7 Ask your patient if there are others needing help as a consequence of the crisis.
8 Negotiate a follow-up plan with patients facing crisis.
9 Be careful not to cross boundaries when treating patients in crisis (e.g., lending money, appointments outside regular hours).
- Allow pt an opportunity for self-expression
- Acknowledge pt’s voiced concern w/o being apologetic
- Empathize with the situation to help defuse tension
- Explain why a particular demand cannot be met
- Negotiate a compromise if necessary
10. Prepare your practice environment for possible crisis or disaster and include colleagues and staff in the planning for both medical and non-medical crises.
- Ensure the physical safety of staff, other pt and the pt in crisis
- Provide panic alarms or energency signals & a means of exit that doesn’t involve crossing the pt’s path
- Provide de-escalation training to all staff
- Ensure the entire waiting area can be seen from the reception desk
- Call the police if situation seems likely to become violent
- Stock “Form 4”, and psychoactive meds
- Consistent rules posted in the lobby of the waiting area: “We don’t Rx BZD on intake interviews”
11 When dealing with an unanticipated medical crisis (e.g., seizure, shoulder dystocia),
- Assess the environment for needed resources (people, material).
- Be calm and methodical.
- Ask for the help you need.