Breaking Confidentiality with Confidence

While privacy and confidentiality issues are paramount parameters in all healthcare interactions, it is not uncommon for providers to feel constrained at critical moments by these concerns.

A recent consult received on our provider triage line [(858) 880-6405] involved a single, middle aged gentleman who had presented on his own steam to a clinic with a mix of mental health, substance use and medical problems— each presenting the provider with risk concerns of various dimensions.  Sorting through these issues with appropriate deference to confidentiality concerns was the focus of the consultation process.

The patient appeared marginally competent with prior behavioral health problems including a history of episodic substance abuse binges.  He also had underlying medical problems that had potential to spin out of control if his medication compliance and self-care were to falter, as seemed likely were he on his own.   He was depressed and angry, not well organized in his thinking, and made several veiled passing references to both potential self-harm and/or harm to others.   There was no clear indication of intoxication, but his past history of substance abuse was well documented. Though he might likely benefit from psychotropic medication intervention, he showed little insight or motivation to request or obtain care.

While not deemed to be acutely or intensively at-risk, the PCP called SmartCare wondering how to respond.  Would it be appropriate to contact law enforcement?  And if so, could he be safely maintained at the clinic until they responded?  If contacted, would the officers come in a timely manner and then be willing to bring him to the “not so” nearest psychiatric facility?   And, finally, if transferred would he ultimately be admitted for treatment or, as seemed more likely, would he simply be released angrier, more frustrated and perhaps a greater risk?

On the other hand, it was felt that the patient could not be released to his own recognizance given his clear deficits in judgement, insight and impulse control.  The patient’s visit to the clinic had been occasioned by a relatively minor medical concern.  He was clearly not seeking a behavioral health intervention, yet the clinic provider felt on the horns of a dilemma given the potential for harm.

After review of the presenting problems and past history, it was decided to ask the patient for his permission to contact his relatives, so that the safety concerns and a management plan could be discussed with them.   He agreed and details of monitoring, oversight, follow up care, and a safety plan were put into place with the family.

Bottom line:  Family, neighbors, friends and others in the community can be an important resource for patients and providers when additional information or community support is required as part of addressing a perceived safety concern—psychiatric or medical.  With patient consent, confidentiality requirements can be waived and provider confidence restored.

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