England Northern Ireland Scotland Wales

Last updated:

An admission of guilt

writing competition no. 8

Turning a patient away racked highly commended BMA writing competition entrant Jennie Higgs with guilt

He looked so crestfallen that I almost wavered.

I almost said the words that would make his life, in that moment, a good deal easier. I almost said: 'OK, we will admit you.' But I didn’t.

At 10pm on a Saturday my night shift was only just starting. Like many nights we were starting with a woefully small number of available beds. Earlier my colleague had admitted someone acutely psychotic into one of the few remaining and I knew that despite their supreme effort the charge nurses couldn’t magically create one should we run out before morning.

As a result, I said: 'No we can’t admit you.' I glanced at my nursing colleague who indicated his agreement. We had discussed it of course. We had taken some time out after our assessment to confer in a corner of the busy emergency department. Weighed up the right and wrong thing to do, considered our options.

I will admit that a tiny part of me hoped my colleague would disagree with me, give me an out. But actually, the bigger part of me knew that having someone to share the burden makes me lucky.

The patient’s eyes darkened and what he said next didn’t surprise me. The rude words about me and my profession weren’t unexpected. They still stung though. Then again, I had essentially just told him to go and sleep on the street. Had told him to wait another cold and lonely 36 hours for services to reopen after the weekend. Services which might possibly be able to help him but possibly not.

The question of why I didn’t just admit him looms large. I didn’t because I knew from my assessment and clinical judgement that admission to psychiatry wasn’t going to be helpful. His problems were real of course but poverty and long-standing addiction aren’t something a brief mental health admission can solve.

But I also didn’t because I couldn’t. Not really. I wasn’t worried about being told off by my seniors. Happily, that doesn’t tend to happen where I work. I reckoned some eyebrows would be raised at the 'soft' admission if I did go ahead but time was I probably would have done that – prioritised the short-term plan and let a consultant sort it out later.

Of course, it wasn’t the patient’s job to know about any of that. Wasn’t for him to think about the fact that we already had another five patients waiting and that I reckoned at least two were going to need admission. Possibly I was wrong, hopefully I was. Hopefully the patient with schizophrenia who had stopped his medication would be able to have support from the home treatment team. Hopefully I would be able to convince the patient with emotionally unstable personality disorder to make a safety plan and go home to sleep before calling her community psychiatric nurse in the morning. Chances are though I was going to have to persuade one person to come in while telling yet another that 'no, admission isn’t really an option'.

Each case is different of course. Telling someone that admission isn’t going to be helpful isn’t so bad if you know they have a safe and sensible management plan already in place in the community. You can remind them of that and work together to make sure that they are OK to go home. If on the other hand the need for admission it is clear cut, perhaps because it is necessary for the patient’s safety, then that is also good. Sometimes of course we need to persuade, cajole, even enforce admission. But if I can honestly say that if it is in the patient’s best interests then I am OK with that.

In this case it didn’t feel good. It felt sad and unfair. The patient’s issues weren’t psychiatric, they were social, but that didn’t help. The patient had no money for a B&B. Night shelters, I was told to my sadness but not huge surprise, are charity run and only operate during the winter. Technically he had a place to stay in a nearby city so social work couldn’t help. Despite all of that I stood firm and said no.

The emergency department nurses let him stay until morning. Presumably they had to ignore the waiting time targets and field questions from the hospital managers. They certainly didn’t call security and send him away. I’m pretty sure I saw one of them take him a cup of tea. I think they were probably more in the right than me and I won’t deny I felt a little bit envious.

Jennie Higgs is a clinical teaching fellow in psychiatry in Edinburgh