Crosspost from /r/Psychiatry. Some patients with BPD make conditional threats that they will commit suicide if you do not admit them (or extend their admission). I send a lot of these people home. Some of them do try to commit suicide and end up on a medical or surgical ward. The direction I tend to give is that they should be stabilised and sent home rather than to the psych ward, especially if the act was because a previous admission wasn't extended. IMO this makes it abundantly clear admission is not benefiting them if they are continuing to present like this despite a recent stay, my feeling is there is probably some iatrogenic harm there as there would not have been an extinction burst at the point of discharge if there had never been an admission, and I certainly do not want to reinforce behaviour that high-lethality suicide attempts are tickets to previously-declined admissions. However, what do we do if a patient attempts to leave while being medically stabilised, and demonstrates capacity to do this? They are aware they are being stabilised, that they are unwell, and that the risks of leaving include death. I've seen two schools of thought from attendings. One is that we should not allow people to commit suicide, and that having BPD impacts capacity. However, I would argue that many people are allowed to deny lifesaving treatment in ways which essentially amount to suicide, and that there are clearly disordered personality-driven processes contributing to these in some people, e.g. I am going to leave before being treated for my MI because I am annoyed that someone else was seen before me. We still allow them to leave. I find myself aligning more with the second school of thought which is that leaving is a stupid decision, but it is their stupid decision and they are free to make it - thus this should be handled along the DAMA pathway, they should not be detained, and they should be allowed to leave with thorough safety netting and return instructions (and a signature on the DAMA paperwork). If we detain them, often I see that they are detained until stabilisation, are sent home, and then promptly end up in hospital again with another suicide attempt. Conversely when it becomes clear you will not detain them they tend to stop threatening to leave (or come back if they have already left). What are your thoughts on this? Keen for some discussion.   submitted by   /u/formulation_pending [link]   [comments]