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.

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

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Posted in 19 Crisis, 99 Priority Topics, FM 99 priority topics, Psych

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