Consultation–Liaison Psychiatry Basics
The psychiatric consultant should serve as an ally to patient care provided by the physician (or primary team), the associated health care disciplines, and the system of care. In this alliance, adaptability and diplomacy enhance the care provided by the psychiatric consultant.
Adaptability is necessitated by the challenge of working in a general hospital. The modern hospital is a busy and crowded environment that usually limits privacy and is often unfamiliar to both patients and mental health professionals. Many hospital floors do not have interview rooms. Medical treatment rooms are often not conducive to psychiatric interviewing. Evaluations may have to be performed in hospital rooms occupied by other patients. Thus, the consultant must be both practical and flexible. Speaking in a soft voice to allow confidentiality is sometimes the only option. Patients may be critically ill and attached to devices such as intravenous lines, catheters, and respirators. If a patient cannot speak due to a tracheotomy or attachment to a ventilator, a signing board or pad and pen may be necessary. The interview may be interrupted by medical or nursing staff, or by transport personnel for ad hoc procedures. Patients may be obtunded or unable to give a comprehensive history; use of other sources of information is often necessary but raises concern about the right to privacy. Such issues challenge the consultant but also establish the psychiatrist as a physician with unique skills necessary in modern healthcare teams.
Diplomacy in consultation is rarely discussed but inherently useful in practice. It is based upon the following qualities: awareness of the hierarchical and multidisciplinary nature of health care systems; respect for the roles and tasks a provider within a system assumes or is required to perform; regard for the boundaries or limitations of care, whether internal or external to the provider or system, affecting the patient's experience (e.g., economics determining hospital length of stay); and a collaborative or altruistic spirit that bolsters the care by the primary team through education and altered practice patterns. Examples of these qualities are the implementation of psychiatric care for organ transplantation patients and development of psychiatric screening in primary care settings. Consultation psychiatrists are ambassadors for the profession of psychiatry in large health care settings where communication between specialists can be limited.
Diagnostic Evaluation in the General Hospital
Consultations requests may have many origins and serve varied needs for the patient, team and system of care. Requests can be made by the patients, primary providers, multidisciplinary teams, and by the family members. Requests can arise when a physician ponders the clinical status of the patient in regard to mood or affect (e.g., depressed after surgery), cognition (e.g., ability to make medical decisions), or behavior (e.g., agitated or threatening). Requests may seek assistance anywhere along the continuum of diagnosis, evaluation, treatment and management. They may focus on a particular aspect of care, such as suicide risk assessment, or be more general in scope, such as the evaluation of a patient's reaction to medical illness.
Contacting the referring provider is important to understand the broader nature of the consultation request. The personal history of a psychiatric disorder may prompt a request for evaluation, although the consultant often is the first psychiatrist to evaluate the patient, even when the patient has a prior history of psychiatric symptoms. Some requests are urgent (e.g., “wants to leave against medical advice”) in which case contacting the referring clinician can provide important information to expedite the consultation. Often, a simple request such as asking for help in treating depression is really “the tip of the iceberg” heralding broader psychosocial difficulties within the patient and social system. Contacting the referring provider is the best way to elicit the “real story” behind the consultation request.
Collection of behavioral data from primary sources (nurses, medical students) is the next step. Prior to seeing the patient, consultants discuss the patient's status with nursing personnel who know the patient and are able to share observations regarding the patient's clinical status and interaction with family members. Nurses' notes are a trove of information about patient behavior (e.g., “lost returning from the bathroom”) that can guide the review. Medical students also can offer keen observations of patient behavior.
Review of medical records can be approached in the manner of detective work. A discerning review of medical notes provides clues to the patient's behavior, cognitive status, and physical function. Admission summaries and off-service summaries are concise records from which to obtain a time-line for the hospital course. Pertinent laboratory results and medication records reveal underlying medical conditions or areas that need further investigation. If the consultant is not clear about a medical illness, a review of the condition from available medical texts is done.
The review of medical records should search for medication that acts on the central nervous system (CNS), whether intended or as a side effect, and look for possible drug interactions (e.g., through cytochrome isoenzyme substrates and inducers). Substance-induced psychiatric disorders are common, not only for substances of abuse but also for prescribed medications (e.g., steroid-induced psychosis). In addition, a sedating (e.g., benzodiazepine) or activating (e.g., beta-agonist inhaler) medication administered prior to the evaluation can affect the assessment.
Review of pertinent laboratory investigations is informative. Metabolic derangements and end-organ disease can affect cognitive status. Awareness of the physiological status can focus the consultation examination and aid in the differential diagnosis. Radiological studies can hone the assessment.
Consent to interview the patient is obtained ideally by the primary team, prior to the consultant's interview, and this can be verified with the patient. The consultant should obtain permission from the patient to conduct the interview and to communicate findings with the treatment team. The consultant should adopt a neutral stance in order to increase patient participation. This way, the consultant is obtaining consent neither as a member of the medical team nor as a patient advocate. Patients with a prior psychiatric history may anticipate that individual psychiatric treatment is confidential; thus they should be alerted to the consultant's role, particularly the need to confer with the primary team on the patient's behalf.
Diagnostic interviews aim to gather sufficient information to develop an answer to the consultation request. Following the preliminary actions described, the consultant introduces himself or herself as a psychiatric physician. Firstly, ascertain whether the patient has been told that a psychiatric consultation has been requested. If the patient has not been informed, elicit his or her feelings about it and request permission to conduct the interview. Secondly, it is important that the patient be given privacy to speak openly to the psychiatrist. For this reason, it is better if a visitor or family member is excused from the interview. Even when assurances are offered by the patient to allow their involvement, privacy can be presented as a matter of policy for the initial interview. Patients are often in a vulnerable position and unable to ask openly for privacy; the psychiatrist should assume responsibility.
The approach to the interview must be guided by immediate safety concerns in emergent evaluations; this may require restricting the interview to a focus on acute intervention and behavioral management, as is discussed in more detail in II. F. Emergency Consultations (see also Chapter 48). Often, a consultation is requested to assess the patient's level of anxiety or depression. The underlying task may be to assess how the patient is adjusting to an illness. A range of inquiries can provide an understanding of the patient's capacity to cope:
- When and how was the disease diagnosed?
- Were there delays in coming to treatment? Was there patient denial? Were there limitations to access?
- How has the patient reacted to the treatment, medical or surgical, and to the primary team?
- Have any medications been particularly difficult to take? Have any helped?
- What knowledge does the patient have of others with similar disorders?
- What has been the psychosocial and financial burden of the disease?
- Has the illness forced changes in family roles and responsibilities? Is there a confidante?
- Is there a support system? Is there neighborhood/religious/cultural/community support?
- Does the patient have an accurate understanding of the prognosis? How does it affect the reaction to the illness?
- Are there end-of-life issues that the patient is unable fully to address? Do supports know about the situation?
Some consultations focus on cognitive capacity and whether an individual has dementia or delirium. This mandates careful attention to the nursing notes and understanding the effects of the underlying disease process or medication upon the CNS. A careful assessment of mental status is required for all patients, allowing for detection of psychopathological phenomena, affective symptoms, and cognitive integrity. Many patients fluctuate in their ability to attend; serial examinations can provide a more accurate assessment. Some patients are fearful that they will be judged “crazy” if they are experiencing hallucinations (e.g., due to medications such as opioids). Active inquiry about whether the patient has been confused or uncertain about their situation allows them to reveal their cognitive problems. Formal testing for cognitive status via the Folstein Mini-Mental Status Examination (MMSE) provides a baseline cognitive assessment for the initial evaluation; the score is easily recognized by other specialists, and can be followed serially.
General review of symptoms from the domains of mood, anxiety, psychosis and substance use should be elicited. Even when they are not the focus of the consultation request, they may inform differential diagnosis and treatment plans. A detailed discussion of the principles of interviewing is discussed elsewhere (see Chapter 4). Frequently, in medically ill patients, symptoms of prior concern to the patient are not reported to the primary team for a variety of reasons, whether omitted by the patient or missed by the team. The psychiatric consultant offers the patient a new opportunity to be heard, and can serve also as a medical translator. If possible, the patient should give verbal consent during the interview to contact other sources of information.
Collateral information is important in situations in which the patient is unable to communicate accurately (e.g., altered consciousness, unreliable historian, cognitive impairments). The sources include spouse, family members, friends, case managers, or outpatient providers. The consultant must protect the patient's privacy; ideally patients can give consent to speak with others, but this is not always possible if the patient is impaired. In emergency situations, collateral information obtained from other sources can be vital, even if the consultant cannot provide information in return. Communication with family members can be essential. Reports from family members may differ from that of the patient and highlight problems. It is common to see elderly patients who consider that they can return to independent living arrangements while family members report numerous reasons to the contrary. Some patients deny substance abuse while family members contradict them. It is also useful to ascertain the patient's past adherence to treatment.
Consultation reports should summarize the data collected in a clear and legible manner; electronic charting is ideal for cogent communication. If consultations are dictated, put a brief note in the medical record immediately following the consultation with diagnostic or treatment suggestions that can be considered immediately. If time permits, a concise yet thorough summary of findings, expressed in an organized, standard format is indicated (see Fig. 49–1). Differential diagnoses, diagnostic workup, symptomatic treatment and, in most cases, cognitive capacity are documented. When the consultant seeks to narrow the differential diagnosis, it should be communicated to the treatment team that further investigations such as neuroimaging or specialized laboratory investigations are required (see Fig. 49–2).
Standard format for consultation note.
Common diagnostic laboratories/investigations.
Recommendations include further testing and medication advice. When psychopharmacologic recommendations are included it is essential to outline side effects that may occur, since the referring provider or treatment team may not be aware of them. The medically ill patient is particularly sensitive to drug side effects, and may tolerate only a reduced dose. Over-sedation may lead to aspiration while eating, and drug–drug interactions can cause toxic side effects. The consultant should warn about possible problems in the consultation report and in person with the consulting provider. Working with nurses and allied health professionals to ascertain the behavioral effects of medications is within the scope of consultation practice. Recommendations to assist with psychiatric disposition and capacity to live independently may rely on collaboration with social work services and liaison with outpatient mental health providers. Recommendations regarding cognitive status may include referral to or liaison with social workers or legal counsel, in accordance with hospital policies and local statutes. Consultation psychiatrists should be informed about the policies and laws that protect patient rights in every setting (see Chapter 50).
Discussions about end-of-life issues commonly arise in the medical setting, often when discussing the patient's coping strategies. Hospitalization itself can evoke fear in a seriously ill patient who is unprepared for death. Others may seek relief from suffering and express a passive wish to die interpreted by staff as suicidality, prompting a psychiatric consultation request. Family histories may reveal an early demise from a condition similar to that of the patient, causing the patient to be concerned about the current situation. This psychological connection may not be readily identified by the patient but expressed behaviorally, for example by a refusal of procedures reminiscent of the deceased's medical course. A review of the patient's expectations for the future should be included in the initial diagnostic interview, although rapport should be developed sufficiently for the patient to explore his or her own mortality; premature introduction of a discussion of death may be unnecessarily alarming and better deferred to a follow-up session.
Follow-up of the patient is provided in collaboration with the treatment team, and the frequency of contact determined by the patient's clinical status. For example, a patient experiencing delirium while the team conducts a search for the underlying causes may require daily mental status examinations by the psychiatric consultant to monitor progress. Alternatively, a patient unable to make decisions regarding a procedure may require little or no follow-up once a surrogate decision-maker has been identified. Follow-up after the initial consultation may allow the consulting psychiatrist to determine whether there should be changes in the initial recommendations. Each contact should be documented.
Screening Techniques to Identify Psychiatric Patients
In comprehensive medical and surgical care, often in outpatient settings, screening for comorbid psychiatric disorders can be time-efficient and cost-effective. Screening tests help nonpsychiatrists to uncover a symptom profile that heralds the need for evaluation by a psychiatrist. Screening tests are not a substitute for a psychiatric interview, but serve as a technique for early detection.
Endorsement of psychiatric symptoms may be elicited by self-administered patient questionnaires or by clinician-administered, structured interviews. Although myriad questionnaires are available, the self-administered questionnaire that is well standardized to detect depression, anxiety, and alcohol use in the primary care setting is the PRIME-MD Patient Health Questionnaire (PHQ). The PHQ-9 screens for depression and is available through its initial publication. The PHQ-2 is an abbreviated, standardized subset of the PHQ-9 that screens for depression in a general population, with high sensitivity (0.83) and specificity (0.92). The PHQ-2 is often added to a battery of health care questions completed in the outpatient waiting room. The Folstein Mini-mental State Examination (MMSE), a structured, clinician-administered screen for dementia, is available through its initial publication. The MMSE is used in screening for cognitive disorders such as delirium, but is standardized only for dementia. The Mini-Cog is an abbreviated, standardized test that utilizes the 3-object recall item of the MMSE combined with the Clock Drawing Test; it has comparable sensitivity and specificity to the MMSE but taps additional regions in the brain. The CAGE questionnaire, a simple screen for detecting alcohol use is utilized by psychiatric and nonpsychiatric clinicians, and can prompt referral to substance treatment programs (see Chapter 15).
If the patient requires further evaluation after a positive screening questionnaire, referral to the psychiatric consultant is the next step. Patients reluctant to seek care in a psychiatric clinic may agree to evaluation by the consulting psychiatrist who, as a member of the primary care team, avoids the stigma of psychiatric referral. Consultation psychiatrists assist primary physicians who manage general psychiatric disorders directly and reserve referrals to psychiatric care for patients who are acutely ill or require a complicated medication regimen. There are good reasons for these strategies. Even though medical conditions, especially chronic conditions, increase the likelihood of a psychiatric condition, a minority of patients with a psychiatric disorder will be evaluated by mental health specialists. Moreover, half of all visits to physicians by patients with diagnosable psychiatric disorders occur in primary care clinics, and primary care physicians write most of the prescriptions for antidepressants and anxiolytics.
Psychiatric care provided in the medical setting in situ searches for untreated psychiatric patients. Psychiatric care within the setting of primary care closely resembles diagnostic evaluations in the general hospital in that it involves the direct collaboration with the primary provider in the treatment of comorbid medical and psychiatric conditions. However, in response to early detection, whether through screening or by the astute primary provider, psychiatric consultation in primary care settings serves a greater number of psychiatric patients than in general psychiatric settings.
Treatments in Consultation Psychiatry
Special considerations are necessary in the treatment of medically ill patients with psychopharmacologic agents. The pharmacokinetic and pharmacodynamic properties of medications and the underlying clinical status of the patient are germane to the consultant's practice. A search for the cause of psychiatric symptoms is essential, but it also raises concern for the complex variables that affect the medicated, medically ill patient.
Pharmacokinetic changes in absorption, distribution, metabolism, and excretion often modify choice of agent and dosing regimens. Absorption of agents in patients who cannot take oral agents may be possible only via intramuscular, intravenous or rectal routes. Novel routes of administration such as buccal wafer and topical patch offer options for the treatment of patients who cannot swallow. Distribution of drugs is altered in patients who are hypovolemic. Antacids, commonly prescribed for hospitalized patients, may slow the distribution and limit the onset of action of oral benzodiazepines. In patients who are chronically ill there is often reduced protein-binding available which can create toxic levels of free agent. Metabolism by the liver transforms many psychotropic agents; thus the presence of liver disease mandates reduced dosing. Drug–drug interactions can raise or lower drug level via inhibition or induction of metabolism by cytochrome P450 isoenzymes. Many psychiatric medications have narrow therapeutic indices in which the agent (substrate) has a narrow path for metabolism via a specific isoenzyme; altered function of the isoenzyme, either through its inhibition (immediate) or its induction (delayed) can markedly affect the blood level of the agent. Medical literature and online resources such as micromedex.com can provide this information. Excretion via the kidneys is limited in acute and chronic renal failure; patients receiving medication dependent on renal function, such as lithium or bupropion, may require lower dosing. For patients on renal dialysis, lithium must be dosed very carefully. Only a single dose may be required following dialysis since it will not be excreted until the next dialysis.
Pharmacodynamic issues involve the alteration of a drug's intended pharmacologic effect by another drug or mechanism at the site of action. The serotonin syndrome exemplifies this phenomenon. Drugs such as meperidine or dextromethorphan interact with selective serotonin reuptake inhibitors (SSRI) to provoke a potentially fatal syndrome characterized by confusion, ataxia, hyperreflexia, clonus, nausea and hypertension. The putative effects of SSRIs in prolonging bleeding may have clinical consequences. The association of gastrointestinal bleeding in the elderly who are taking serotonin reuptake inhibitors should alert the clinician to minimize such agents in medical settings. Cumulative and excess anticholinergic effects from drugs can cause confusion and decrease bowel and bladder motility in vulnerable patients. Excess sedation in elderly patients can be due to the additive effects of sedatives such as benzodiazepines and hypnotics given together. Independent of sedation, benzodiazepines can increase the risk of falls in the elderly.
The use of medication in the medically ill requires careful attention to all the medications a patient is currently taking, the contribution of underlying medical conditions, possible drug interactions, and possible dosage adjustments. Other variables include nonadherence to prescribed medication, and polypharmacy in patients treated by several providers. Efforts to simplify medication regimens start with a polite inquiry into the indications for the prescribed agents, especially those suspected of CNS activity. Patients may be overwhelmed by the complexity of pill-taking, which may prompt recommendations that the regimen be streamlined while the patient is hospitalized and thus directly observed. Some hospital units provide “self-medication” programs, allowing the patient to retain some autonomy in self-care. This can serve as an opportunity to further monitor illness behavior.
Psychotherapy in the Medically Ill
Psychotherapy for the hospitalized patient is usually brief and supportive. The type of intervention will depend upon the patient's cognitive status, disease state, and treatments. If a patient has had delirium, often there are gaps in memory that can foster fears of embarrassment and distortion of what happened. The psychiatric consultant should inquire about such issues and fill in the periods of time the patient does not recall, replacing misperceptions with accurate information. The patient who has had frightening hallucinations due to opiates or steroids requires reassurance that these were drug effects.
Even when cognitively intact, patients may be depressed and express feelings of helplessness and hopelessness. Patients who have witnessed the unsuccessful resuscitation of a roommate can benefit from gentle inquiry into the emotional sequelae of such an event. Supportive psychotherapy includes not only eliciting fears and emotions but also initiating helpful measures. For example, when patients are distressed by the conditions of hospitalization, they may respond to dietary supplementation from home if allowed or from room change when a noisy roommate disturbs sleep. Simple measures like making a wall calendar available or locating eyeglasses can aid adaptation.
Common themes in brief psychotherapy are found in the exploration of the patient's ideas about the etiology of the illness, as well as the toll it has taken, and the exposure they have had to others with similar illnesses. Many patients fear discussing these issues with their primary physician. Distortions of causal factors, prognosis and treatment effects should be corrected. This can alleviate anxiety if the patient is overly pessimistic. A contrasting situation occurs when the patient minimizes serious disease or the need for intervention. The diagnosis of denial requires that the patient be told the nature of both disease and treatment. Denial wards off the terror of diagnosis and must be managed slowly and carefully. If denial wards off the implications of disease such that refusal of care is at stake, it is essential to utilize available family supports to understand the factors that promote denial and decide how to intervene.
Long-term psychotherapy is usually conducted in ambulatory or rehabilitation settings. Limited data confirm that this treatment has efficacy for somatic syndromes such as irritable bowel disorder or chronic fatigue syndrome. Cognitive behavioral therapy has been reported as effective for fibromyalgia. Graded exercise can help patients with chronic fatigue syndrome or fibromyalgia, whereas psycho-education is important for patients undergoing treatment for a variety of disorders. Evidence is growing that psychotherapy and psychopharmacological treatment are synergistic in the treatment of depressive disorders, better than either treatment alone. In the context of genetic testing for some diseases such as breast cancer or Huntington disease, the patient needs full knowledge of the risks and benefits of such knowledge. This may generate a role for psychotherapeutic consultation.
Electroconvulsive therapy (ECT) is a first-line treatment in medically ill patients with suicidal depression, psychotic depression, depression during pregnancy, and in medical conditions that cause inanition or risk for cardiovascular collapse. Although generally reserved for refractory disorders and special circumstances, it is the most effective treatment for depressive disorders. The consulting psychiatrist may be in a position to initiate education of patient, family, and the patient's provider regarding the indications, potential side effects (retrograde amnesia, elevated blood pressure), and treatment outcomes of ECT. Many patients with a remote history of “shock treatment” require education about recent advances in ECT in order to inform them about the procedure.
Legal Issues in Consultation Psychiatry
The legal issues that arise in consultation psychiatry are most commonly those of confidentiality, competency (decision-making capacity) and whether a patient has a right to die despite attempts to treat. Documentation of the patient's wishes in advance of the need to know often obviates many legal issues. Requests to leave against medical advice are a subset of competency assessments.
Confidentiality is mandated comprehensively by the Health Insurance Portability and Accountability Act. The consultation psychiatrist has a relative exemption from strict confidentiality when sharing information with the health providers who are treating the patient. The consultation note, as well, is exempt from the Health Insurance Portability and Accountability Act confidentiality. When obtaining corollary information from family members, the clinician should attempt to get verbal consent if the patient retains decision-making capacity. In some situations, information the patient divulges should remain confidential. Intimate details of a personal nature with no bearing on the issues that led to the consultation request are confidential and should not be revealed to other medical professionals or in the treatment record. Psychotherapy notes are considered private under the Health Insurance Portability and Accountability Act regulations and separate from the medical record. This does not mean that data from consultation follow up visits that document diagnosis or response to treatment cannot be noted in the progress notes.
Competency is a broad concept that applies to a variety of acts and behavior. It is a legal issue, bestowed at birth. If the patient is impaired, a physician must provide evidence of erosion of competency to the legal system (in probate or “family” courts). Informed consent to a particular procedure or health care intervention, however, focuses upon the individual's ability to make a decision based upon the capacity to understand the information that must be provided in a clear and understandable manner; to recognize the options available (including the risks and benefits of each option); to use reason with regard to the information provided by the team; and finally to make a rational decision that is sustained over time. Decisional incapacity, which is determined ultimately by a probate judge or other legal representative, does not automatically indicate incompetence in other activities of living.
Discharges Against Medical Advice (AMA) evoke legal fears and risk management concerns. In order to oppose the patient's free will to leave, the consulting psychiatrist must diagnose a condition that impairs judgment, such as delirium, dementia or depression, of such severity that the patient's safety or the safety of others is threatened, either by direct threats to self or others, or by grave disability (unable to obtain food, shelter or clothing). Issues of competency assessment described previously may apply. The challenge is to discriminate subtly impaired decisions (due to mental conditions, with or without physical conditions) from bad decisions (e.g., marginal capacity to provide for self, homeless, refusing treatment). A rapid assessment of level of risk is required. Often efforts to address the pressing need for discharge reveal the origins of the AMA discharge request. Some patients require social worker assistance with responsibilities such as childcare, housing or work mandates that are valid but impracticable in the face of serious illness. Finally, patients who abuse substances sometimes request abrupt discharge. If no withdrawal state is observed, the consultant can enlist the help of family members to convince the patient to remain in the hospital; however, this is often impossible. In the circumstance where the patient demonstrates capacity to make a decision, albeit inconsistent with what is recommended, the patient retains the right to leave. Clinical status and attempts to contact support systems should be documented.
Right-to-die decisions require that the patient be judged competent and fully understand the nature of the disease state. Impairments in cognition or thought process (e.g., dementia or paranoia) may necessitate transferal of the decision to surrogates. Another complicated issue is of depression that causes a subtle erosion of decisional capacity. The seriously ill patient is often clinically depressed. If depression is aggressively treated, the wish to die may change. Family meetings in concert with the treatment team, and consultation with hospital ethics committees and legal counsel, maximize the opportunity for a fair appraisal of the request to withhold treatment.
Advanced Directives should be reviewed in the patient who has become cognitively compromised. Optimally, a surrogate decision-maker has been identified for a future period of incapacity, and the consulting psychiatrist renders a second opinion to the team declaring that the time has come to utilize or invoke it. Advance preparation pays off for these patients as they avoid the legal proceedings of competency. Social workers can assist with documentation of advanced directives; these should be recommended for every patient found to retain the capacity to make such decisions.
A few situations need immediate attention, requiring a rapid assessment of a range of factors, including a scan of the physical situation (e.g., the patient might use medical equipment as a weapon) and the environment (e.g., multiple patient room or intensive care setting). Policies regarding clearing the room of sharp objects and having restraints available on medical and surgical floors, should be in place. However, it may not be routine for staff in the usual medical setting to follow such policies, increasing the need for psychiatric consultant assistance.
Violent patients may be suffering from delirium or substance withdrawal. Such information can be obtained from a review of the medical record, focusing upon the disease status (e.g., presence of a mass lesion in the CNS) or prescribed medication fostering an encephalopathy. In such situations it is imperative that staff and other patients be protected. The concurrent presence of security guards allows safe assessment. The emergency use of psychotropic medication can diffuse these dramatic situations. Involving a family member can be helpful but there may not be sufficient time to allow this.
Suicidal patients become emergencies if there is an attempt at self-harm or if drugs, knives, or weapons are detected that the patient is secretly storing to use for self-harm. Is the behavior a means of attention seeking, is it due to a mood or psychotic disorder, or is it an attempt to assume control when the situation has become so ominous that ending life is preferable to enduring a fantasized medical scenario? Following initial assessment, it is necessary to observe closely the patient who is acutely suicidal but too medically ill to be transferred to a psychiatric unit. Nursing personnel are trained in the monitoring of suicidal patients, but the psychiatric consultant may be sought for management advice. The care of high-risk individuals in such settings is eased by family supports, if available.
The liaison psychiatrist is a regular member of a treatment team in transplant programs, cancer centers, or dialysis units. A subspecialized focus of liaison psychiatrists on diseases states (e.g., HIV psychiatry) or medical specialty (e.g., gynecology or pediatrics) has developed in recent years.
Transplantation psychiatry is important due to the psychological stress upon patients and families who undergo life saving procedures or wait on a list for a limited number of available organs. The organ to be transplanted dictates the common psychiatric issues within each procedure. For related-donor kidney transplants, the psychiatric consultant may evaluate both overt and covert family pressures that the putative donor experiences and how the potential recipient feels in response. Treatment adherence is important, especially in patients with diabetes who have not followed diabetic regimens. The essential issue in liver-transplantation recipients who have been substance abusers is their history of abstinence. If potential recipients are still using alcohol or other substances of abuse they need rehabilitation and abstinence before receiving a liver transplant, although candidacy is individualized and may vary according to the scarcity of the organ to be transplanted. Liaison psychiatrists may be called upon to assist with screening to identify latent psychiatric disorders, and to assist with the psychological stressors as discussed. For heart transplantation patients, ongoing support is necessary during the waiting period before an available organ is found. Such patients commonly experience anxiety and depression, and wrestle with mortality.
In oncology settings, central issues are depression in the terminally ill, delirious states due to diseases and treatments, and family reactions. In nephrology centers, patients who request termination of hemodialysis must be evaluated for delirium and dementia. The treatment of underlying depression may alter the request for cessation of hemodialysis. The role of the psychiatrist in nephrology also focuses upon patients who resist dietary and fluid limitations, often in the context of depression and dementia. The psychiatrist will have many opportunities to teach health professionals to recognize and manage psychiatric disorders in chronic illness and end-of-life care.