A Safety Plan or Patient Abandonment?

Why ‘Go to the ER’ or ‘Call 911’ voicemail reflects a deeper failure in outpatient care.

Recently, when supervising a psychiatric resident, I heard something very disturbing.

He described his coverage plan as ending with:

“If this an emergency, hang up and go to the emergency room or call 911.”

This is all too common. To be frank, it’s also patient abandonment.

On the surface this message may seem reasonable. It isn’t.

If you are using “Go to the ER or call 911” messages — or something like it — as too many clinician do, ask yourself honestly: Have you thought this the through? Have you discussed and planned for management of emergencies? Is this advice, something you have heard, copied, and accepted as a safe practice without examination?

On the surface this message may seem reasonable. It isn’t.

Common rationales shared among outpatient clinicians are that this message prevents disruptions while seeing patients, protects clinicians from demanding patients, limits access for manipulative or suicidal patient crying wolf or asking for urgent medication refills when there is no “real” emergency.

What the “Call 911” Message Actually Communicates

What this message says to all our patients—“When you are annoying, distressed or in crisis, it’s not my problem!”

What all patients have a right feel is “We have got them” —that as their therapist, we are available, have made arrangements to help our patient manage whatever comes up.

Police and emergency rooms are not the first answer. They have little or no skill to manage this.

The Four Failures Underneath It

The voicemail problem is a symptom. The actual disease has four parts.

1. We don’t discuss management of emergencies at the beginning of treatment.

Intakes mainly gather data about problems and histories, neglecting emergency planning. What is often forgotten is to have a direct conversation about what emergencies are; what they are not; what a patient can expect as a response; what the patient can do if an emergency occurs; and what happens when the patient can’t reach the practitioner.

2. Many clinicians fail to collect important information at intake.

Obtain two emergency contacts. Not one — two. One should be someone close to the patient, and the other a local support person living nearby. If your patient can’t identify two people, you have learned that they are isolated or have dysfunctional relationships and are at a heightened risk for emergencies. No names means you will have to help the patient construct a safety ecosystem.

3. Clinician are imperfectly setting limits.

Setting firm limits with compassion isn’t always easy. Practice saying something like “Calling me on Christmas Eve for a medication refill or about an argument with your wife is not a psychiatric emergency. We need to discuss better ways to help you manage these issues. We should talk about options for managing you distress and immediate needs, so when you really need me, I can, and will be available.”

Question: Is your patient in crisis, struggling or overwhelmed, or is the patient abusing you or misusing the system to gain access?

Setting a boundary during routine sessions requires a clinician discernment: Is your patient in crisis, struggling or overwhelmed, or is the patient abusing you or misusing the system to gain access? We should be able to address or confront these differences directly, with compassion rather than avoidance. We all need to become experts at managing the countertransference elicited by annoying, disruptive, manipulative patients. They need firm compassionate limits and mostly our help to understand how these repeated behaviors are damaging their relationship with us and others in their own lives.

4. Many clinician lack experience in managing emergencies

Emergencies will disrupt both your work and personal time. Clinicians need to accept this as part of the job and prepare for these situations in advance. If your patients are having frequent emergencies that you are expected to manage, or if it takes more than one to two hours to manage most emergencies, it means that you haven’t proactively prepared for these situations. Revisit the basics.

Sit with this

Good emergency preparedness means caring for patients when they need us the most; it requires intentional planning.

When this intentional planning is absent, the alliance with patients is threatened. Remember calls to emergency services send patients to systems that can’t necessarily manage the care they need.

We all need to do this better. Our patients deserve more… And frankly, so does our profession.

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Coming Next Week:

• Part Two: What good emergency management actually looks like

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About the Author:

Robert E. Feinstein, MD

Professor of Clinical Psychiatry, Zucker School of Medicine at Hofstra/Northwell

Psychiatrist, Psychoanalyst, Educator, and Supervisor Contact: Feinster@RobFeinsteinMD.com

Owner & Founder Empathian LLC ( An Online Mental Health Education Company) Empathian.com

https://www.linkedin.com/in/robert-e-feinstein-md-a71566178/Add me on LinkedIn