Should a nurse be lying to a mentally ill patient in writing?

[l39]

My mother is a voluntary patient in a psychiatric hospital. She is depressed and suicidal. I know that the staff are all trying to do their best for her, and I do believe she will recover, because she always has before.

The consultant is thinking about sectioning her next week if the newest drugs don't work and she doesn't agree to ECT voluntarily. He told us so himself.

I have been to see my mother this morning and she is carrying around a sheet of paper which she says a nurse wrote and printed out for her. It is supposed to stop her worrying (ha! enough Diazepan to stun an elephant isn't stopping her worrying). Among other things (in really shocking grammar from an educated person) it says that she will 'never ever have to go to a locked ward, be sectioned or have a nasogastric tube'.

(The tube bit is because she wants to starve herself to death and doesn't want to be fed through a tube.)

Mum already distrusts the staff and thinks they are plotting against her. The promise on the paper is a load of rubbish as her consultant is thinking seriously about sectioning her and we hope he will - she's been sectioned before and treated with ECT without her consent and it WORKED. She was well and happy for years afterwards.

We have been trying so hard to reassure Mum for weeks now while being truthful with her. It's very hard work and now I find a nurse telling her a pack of lies IN WRITING. When they do section her this is only going to confirm her belief that she can't trust anyone! Is this really the proper way to treat an irrational and very distressed patient?

I think your mum should be on close observations given the events you describe. You should ask to speak to the consultant or ward manager if you feel you're not getting anywhere with the ward staff. Close observations is a way of ensuring your mum is not bothered by/bothering other patients because a nurse would be with her at all times and can intervene. However, the problem is that the ward staff may not have the same perception as you re. risk. They may think that your mum is imagining the threat from this other patient. I hope the ECT works. I have seen it work wonders where pharmacology fails. ECT needs to be authorised by an independent doctor (SOAD) so this may explain the hold up. Also, hospitals usually have specific days for ECT because specialist clinicians are required - such as anaesthetists.

I'm wondering if the psychologist was helping your mum to write down her own thoughts/hopes or fears. This may explain the muddled 'I' and 'you'. I don't know if your mum hears voices but could she have been writing down what the voices were saying? It does sound worrying and unprofessional if these were written as promises from the psychologist but it may be something completelly different- perhaps you could call him/her to find out?
I'm really sorry you're going through this- it sounds incredibly tough.

Ladylush - it's not the other patient hurting mum I'm worried about. She may well have said nothing at all threatening. I'm worried about mum carrying out violence, not being a victim, (despite her age and frailty) because how do you come back mentally once you have actually attacked someone?
I phoned the hospital to just make quite sure they knew what mum was saying.
The nurse who answered, as usual, was all wishy-washy and soothing.
She felt I needed to know that mum had been anxious this morning (she's always anxious!) and had been asking when she'd see her daughters again (I was in yesterday and my sister will be in tomorrow as I told mum repeatedly) - and didn't mention a word about mum's threats, but when I mentioned it, she clearly knew about it. I asked if they were sure it was all talk, hoping for a definite 'Of course! We'd be doing something if we thought your mother had any chance of becoming violent.'
and all I got was
'We think it's probably just talk, it usually is.'

How very reassuring.

Well, at least I'm not leaving them in the dark.

Wouldn't the ward manager be extremely irritated to be contacted by a patient's relative, and even more so the consultant? Presumably they trust their (stupid wishy-washy teenage) highly trained staff and want worried relatives to accept the (barely interested vague full of platitudes) professional opinions they offer.

l39 - I'm referring to the whole presentation, not just your mum feeling threatened by the other patient.

Forget about what the manager/consultant will think. That is their job. They have overall responsibility for care. The ward staff thus far have not been able to reassure you, so you need to see someone who can. Ime ward managers and consultants take it seriously when relatives highlight shortcomings in care delivery. They have to. In your shoes, I would find out when the next ward round is (the consultant ward round - not the SPR one)and book a slot to discuss the issue. Then, if the matter is still not taken seriously, you could put your concerns in writing to the hospital manager.

Is your mum informal or detained under the MHA? If the latter applies, the staff should imo consider giving your mother some medication to reduce her level of anxiety. If on a section, they can do this without her permission. Obviously that is not pleasant for her and will seem violating, but equally it is not humane to leave someone in such a heightened state of anxiety that they feel homicidal!

To be honest I'm scared to death of attempting to question the consultant! The time we saw him I had to screw up all my courage to ask if they'd changed their minds at any point (so many people had said 'Are you sure it's depression and not bipolar?')
and then he asked me first WHO these people had been (as if I had been dragging mum around to get a second opinion! They were just ordinary people with relatives who suffer like mum, and I thought I had been quite clear I was just checking there hadn't been a change in the official diagnosis, not questioning his judgement) before answering that the diagnosis is the same as it has been for 30 years, depression.

Um, I hope you can follow that confusing sentence! Sorry.

Anyway - isn't he going to answer with 'I'm the doctor here, not you!'?
However, I will try, if the situation is still the same. We were told the consultant would see mum and us on Thursday.

I think my mum is still a voluntary patient as while they told me on Wednesday they were about to section her (and asked if I had any objection, which I definitely haven't) they were waiting until after the weekend for the second opinion doctor. Is there anything better than Diazepam they could be giving her for the anxiety? She was only taking one a day before she went in, she's now taking 9 (3 at a time 3 times a day) and the consultant did say that was a high dose, though I'm afraid I can't remember how many mg it was.

Thank you, ladylush, for the advice.

Thanks also ra29 for the good wishes. Mum does not hear voices - or at least she's never suggested that she does and she's been very vocal about a lot of very odd ideas indeed.
If the psycologist was writing to mum's dictation - first I really think there'd be a lot more about death, bowel movements (sorry) and people moving her stuff (these have preoccupied her since she got there and none is mentioned in the list) -
second she would never have said 'ECT is not important' as it was her major preoccupation (and terror) a few days ago though now it is secondary to her fear of this other patient -
and third despite her very odd state of mind she has never referred to herself in the second or third person. The list does both. It's not handwritten but typed on a computer and printed (2 copies) which would surely have given someone the opportunity to make it less confusing if it was actually a part of her treatment?

My sister is visiting without me today so maybe there'll be some good or at least not worse news!

Very brief reply l39 - imo Clonazepam is a better benzodiazepine than Diazepam. It's from the same drug group but has a longer half-life so doesn't wear off as quickly. Another option might be to try something like Olanzapine which is an anti-psychotic medication which has a sedative action as well. So if she has paranoid ideas or is hearing voices/command hallucinations etc which are then making her very anxious, the drug would work on 2 levels. HTH. The consultant should not intimidate you. He might be the doctor but you are also an expert as you are the daughter of his patient and know her better than anyone.

The other 2 medications she is on are Olanzapine and - I think - fluoxetine. I'm sure about the Olanzapine, not quite certain about the other.

No voices but she certainly seems paranoid.

I'm not terrified of consultants in general - I managed to talk to my own at the hospital as if she were a normal person - (planning a VBAC) - but there were 7 of them arrayed in a semicircle and we were trying to keep mum from backing her chair away from them to the door - I felt at rather a disadvantage. Plus feeling guilty about mum wasting their time with her rambling every time they asked her something (I'm sure they totally expected it, in her condition, but still).

l39 - don't worry about your mum's behaviour in the ward round as they will be well used to it. The nurses should really be looking after your mum and you shouldn't feel responsible for caring for her in that setting (easier said than done I'm sure). However, if your mum's behaviour is that distracting I would suggest that you ask to be seen in the ward round before your mother is brought in - so that you get time to talk through your concerns/worries.

Do you know what dose of Olanzapine your mother is taking? Depending on the dose, she can be given extra by the nurses provided it is written as PRN on her medication chart. It seems from what you say that your mother is very aroused/agitated and may need higher doses of medication. Though of course it is impossible for me to say without knowing your mother, the dose of medication she's taking and what effect medication has on her.

Now, that said, there is something else I need to say. High doses of benzodiazepines can make some patients disinhibited (more aroused/agitated). It is not that common but nevertheless can happen. The consultant will know what to look for.

This must be very hard for you but it is great that you are advocating for her. A lot of psychiatric patients have no family on board

Funnily enough I feel more intimidated by obstetricians than psychiatrists

Things are a bit better with mum. We are told her new drug (chlorpromazine?) is working, which is odd but good (usually drugs are pretty useless). She's not threatening to kill anyone else any more and she didn't carry out any violence. Still sure the staff hate her and will start beating her, but not as distressed as she was.
I couldn't go to the last ward round (had to see a mortgage advisor and it was the only time the advisor and my dh could possibly meet), my sister was supposed to go but didn't as she overslept.

However I will be at the next on Tuesday. No ECT yet as the second opinion doctor couldn't come, but hopefully soon.

I'm not as worried as I was, and thank you again, ladylush, for the replies.

l39, sorry you are dealing with all this stress while pregnant especially.
I don't have anything much to add, except that letter, if it was really written by anyone professional, is shocking! I hope you can get to the bottom of it.

l39 - glad things are a bit better for your mum. Chlorpromazine (also known at Largactyl) is a very old drug. In fact it was the first licensed anti-psychotic medication in the late 50's. A lot of doctors won't prescribe it because NICE say atypicals (newer drugs like Olanzapine) should be tried before typicals like Chlorpromazine because the newer ones have less side effects. However, NICE also says that patients who tolerate the older drugs well should be given them if effective. The side effects to watch out for are called EPSEs (extra pyramidal side effects)- the nurses will know what to watch for. There is another drug (Procyclidine) that can be given if she does experience any EPSEs.

I finally have an answer as to who wrote the paper! Yesterday while visiting a young male nurse came over and said he wanted to apologise. He had written the list with the intent to calm Mum down, but been told later he should not have been making promises he had no way to keep. So I am glad they did at least sort it out. When Mum got worse soon after she lost interest in the promises on the paper anyway.

I'm glad to say she is doing better. She's had 2 ECT treatments and they've been able to cut her Diazepam down as it started to make her woozy - until recently she was still very agitated despite taking loads of it. She's very weepy but has started talking about the future and how long before she'll be able to leave hospital, whereas until now she was insisting she'd be dead within days. The ECT has worked well for her years ago, and seems to be doing the same again. She'll be having more ECT, though they don't know how many sessions yet.

Thanks for the comments, they've helped in a difficult time! At least she only had to be in hospital for a month this time before they started the ECT, which will hopefully mean she'll be home sooner.

Great news l39 I'm shocked that the nurse was stupid and unprofessional enough to write those things in the first place but glad that he at least apologised and acknowledged his error. Glad ECT is working. A lot of people think it's a barbaric treatment but they don't get to see the success stories. Spelt Largactil incorrectly Will they continue treating her with chlorpromazine?

The hospital have decided Mum is well enough to come home - in fact, later today! The plan at the beginning of this week was for her to come home over the weekend and probably spend another week in hospital, but yesterday they changed their minds and decided she could leave altogether.
She has had 4 ECT treatments which had a dramatic effect. The diazepam has been cut down from 9 x 5mg to 5 x 5mg and the anxiety hasn't come back. She's still on the chlorpromazine as well and 2 other drugs. The crisis team are going to be coming out daily to see her.
I do hope this goes well. Mum almost seems to have snapped back to the time a few weeks before she went into hospital - she does remember what's happened, but she just dismisses it as irrelevant. Like she's complaining about other patients being disruptive! If you say 'Well, they're ill - two weeks ago it was you upsetting everyone else,' she just changes the subject. Better than dwelling on it I suppose. Oh, and she's been to an 'Assertiveness' class. I read the sheet they gave her (it is at least written in good English) and their suggestions for being assertive look like plain rudeness to me. She has this image of herself as being a martyr to all around her which just doesn't match with reality - she was so much happier and nicer when she recovered from her 2005 hospitalisation and now we are all worried the 1980s - 2005 version is back, sane but always stressed and badtempered (with the exception of the times she lost it totally). However I'm just rambling now! The worst is over. Thank you for the posts!