Category Status Conversations in the Psychiatric Context

• Main Author: Provencal Levesque, Olivia
• Other Authors: Vandyk, Amanda
• Format: Others
• Language: en
• Published: Université d'Ottawa / University of Ottawa 2020
• Subjects: psychiatry; mental illness; category status discussions; qualitative
• Online Access: http://hdl.handle.net/10393/41505; http://dx.doi.org/10.20381/ruor-25729

Background: Patients with mental illness often experience stigma and marginalization, which affects the quality of their healthcare. In most settings, end of life decisions, including goals of care, must be discussed with all patients upon hospital admission. This includes determining cardiopulmonary resuscitation preferences, in the event of a medical emergency. Despite this requirement, category status conversations do not routinely occur in psychiatry. It is common for psychiatric inpatients, including those at high risk for cardiac or respiratory arrest, to be admitted, cared for, and discharged without their category status known or documented. By default, patients become a ‘full code status’, which mandates life-sustaining interventions, including CPR. Unwanted interventions are often unsuccessful and inappropriate. They might also cause harm through increased pain and suffering or have no medical benefit. Aim: To explore how and why category status conversations occur, or do not occur, for patients admitted to psychiatry. Methods: This was a descriptive qualitative study, with data collected through two semi-structured focus groups. Nine nurses working in psychiatry, representing two campuses of a larger tertiary care academic hospital in Ottawa, Ontario participated. Elo and Kyngäs’s approach to inductive content analysis was used to analyze the verbatim transcripts of the focus group discussions. Findings: Findings reveal the shared experiences of nurses initiating and engaging in category status conversations with patients admitted to psychiatry. Four overarching categories were identified: ‘The Psychiatric Culture’, ‘Being a Psychiatric Patient’, ‘Physical Health Status’, and ‘Suggestions and Recommendations’. Participants spoke about important considerations for the advancement of knowledge regarding category status conversations in psychiatry, including the nurse’s role in category status determination, the challenges of implementing a ‘one-size fits all’ approach to category status policies, and the ways in which HCPs perceptions of patients who are receiving care for depression or suicidal ideation influence these conversations in psychiatry. Conclusion: Nurses working in psychiatry care for patients with complex medical and psychiatric comorbidities, who are also sometimes older and frail. Category status determination for these patients is complicated and often the documented status is based on clinician presumption rather than consultation with the patient. Although the importance of completing category status conversations with patients admitted to psychiatry is known, they seldomly occur, and there is ambiguity about the nursing role within the psychiatric context. Efforts are needed to improve nurses’ contributions to category status determination for patients admitted to psychiatry, to ensure that patients’ preferences are known and upheld. Further, there are illness-related factors that complicate typical processes used to discuss and identify patient preferences, such as suicidal ideation and minimal family support. These considerations must be accounted for in hospital policy if meaningful practice change is expected.