Home Health Big Book of Emergency Department Psychiatry
Assessing Homicide Risk
A similar line of questioning can be utilized to explore homicidal thoughts.
Access to firearms or other deadly weapons needs to be addressed in cases of both suicidal and homicidal ideation. If the patient admits to having access to firearms or other weapons, your local law enforcement agency or family or friends of the patient can be contacted to help locate and remove the weapons thus decreasing the patient’s ease of access to self-harm or harm to others (Barber and Miller 2014). Please see Chapter 9 on ethical issues for more information.
Assessing for Grave Disability
Grave disability, or the inability to plan for or care for one’s basic needs due to a mental illness, is another area that requires a risk assessment. The basic idea is to elucidate the patient’s current plan of care, essentially how do they plan to provide themselves with food, shelter, and clothing upon discharge from the ED?
Even in the legal system, a judge may make a decision to involuntarily commit a patient to a hospital for psychiatric treatment based on their perception of the patient’s ability to provide for their basic needs (Holstein 1984). Simply asking the patient, “When you are discharged from the ED, how do you plan to provide yourself with food, clothing, and shelter?” is a simple way to determine the patient’s self-care plan.
It is important to note that homelessness in and of itself does not constitute grave disability. Many patients may prefer to be homeless or may be in transition between housing. If a patient reports that they plan to live under the bridge overlooking the river, this can qualify as a plan for shelter.
The label “gravely disabled” can only be placed on a patient by a mental health or legal professional (e.g., judge). The patient must have a known prior or current primary psychiatric disorder, such as schizophrenia or major depression.
Risk Level Scaling
Each of the topics in the risk assessment section should be rated using a scale. We have found that the use of the labels “low, medium, and high” work well. So, a given patient can be given a risk rating of “low” for danger to self, “low” for danger to others and “high” for grave disability based on the assessing provider’s clinical opinion. The label “none” should not be used as a rating in the risk assessment as it does not leave any room for clinical error in the assessment. It is important to note that any person one comes in contact with has some potential level of risk present. The scale we are talking about utilizes “low” as the base score in order to prevent the use of the label “none.”
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