Crisis – BC Family Physician Guide 2008

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).

De-escalation

1. Allow pt an opportunity for self-expression
2. Acknowledge pt’s voiced concern w/o being apologetic
3. Empathize with the situation to help defuse tension
4. Explain why a particular demand cannot be met
5. 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.

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Reference: http://www.health.gov.bc.ca/library/publications/year/2008/fpg_full.pdf