What if I told you that you would die up to 25 years earlier than you were expected to? 25 years sooner.
Many individuals with severe mental illness (SMI) experience this loss of life. Individuals with SMI die on average 10-25 years earlier than the general population due to co-morbid medical conditions. I had known of this statistic for a long time but had never truly known the devastation until I came face to face with it.
The First Day
One Christmas eve, I did the intake for a patient—John, a 54-year-old Caucasian male— who had been admitted to the inpatient psychiatric unit. John presented similarly to any patient experiencing psychosis on the unit. He heard voices telling him to harm himself and others and was brought into the emergency room. He was then voluntarily admitted to our behavioral health hospital.
I had the opportunity to care for John as his registered nurse that day. He was calm, pleasant, well-groomed, and easy to assess. John answered questions openly and truthfully. He endorsed having auditory hallucinations and that he had been struggling and wanting help with the voices. John did come with a significant medical history—he had had 17 prior surgeries in his life relating to his heart! He had had several aortic aneurysms as well. I made sure to document these facts told to me during my assessment with John.
Later that day, John complained of having a “soreness, tightness” in his throat as he pointed to his larynx and chest area. I suspected he might have had some indigestion or heartburn and gave him Mylanta (an as-needed medication). This medication was not effective, so I gave him Motrin to help with pain and Neurontin, suspecting he could be experiencing anxiety possibly.
None of the medications helped.
The Progression
It was about 3 pm at this time that John began complaining of “chest tightness.” John never demanded assistance with each of his symptomatic complaints. Each time, he quietly came to the nursing station asking for help/medications with his chest and throat. This time that John complained of chest tightness, I obtained a set of vitals that were within normal limits. I was concerned about John’s chest tightness complaint due to his prior history of aortic aneurysms. John suggested that he go to the hospital, stating that he has felt this way before when he experiences heart issues.
I initially called the medical doctor leaving a message asking to be called back regarding a patient’s complaint of chest tightness. I then called John’s psychiatrist (who happened to be the attending physician on call) and notified her of the patient’s complaint as I asked her if I could conduct an EKG to rule out cardiac abnormalities. She agreed to the order. With the assistance of my co-worker, we did an EKG on John.
The EKG reading showed: anteroseptal myocardial infarction.
I immediately called back the on-call psychiatrist to notify her of the results. She let me know that EKGs are notorious for providing inaccurate readings. She told me to call the medical doctor on-call about how to proceed. I was able to get in touch with the physician at this time, and I notified him of the EKG findings. He directed me to send this patient out via ambulance to the local medical hospital for an evaluation immediately. He, too, was suspicious of the EKG findings, but because of the patient’s past medical history, he felt that sending the patient to the emergency room was the best thing to do.
I called the 911 extension number for transport, and John was quickly picked up. I gathered all the necessary documents, called the medical hospital to provide a nurse-to-nurse report about the patient they would be receiving. The patient’s attending psychiatrist was notified, and my shift supervisor was made aware of the send-out. I completed a standard incident report (done each time a patient is sent to the ER), and I wrote a clinical event note documenting all of my actions.
It was towards the end of my shift by this time. I gave a hand-off report to the oncoming nightshift nurses describing the events. At the end of my report, I mentioned to the nightshift nurses that John would most likely be admitted to the hospital and not returning on their shift. That he would be kept at the medical hospital where numerous tests would be run, and he would be stabilized and medically cleared before returning to our psychiatric facility. After all, with complaints of chest pain, the standard patient walking into the emergency room is rapidly put onto a specific protocol because time is of the essence in these situations where cardiac tissue can become quickly damaged.
The Last Day
After returning from holiday, I learned that I was very wrong. John died on Christmas day, during the early morning.
I learned during my first shift back after the holidays that John was not admitted to the medical hospital but medically cleared with a diagnosis of pneumonia and returned to our facility. No nurse-to-nurse report was provided in which the nurses in the emergency room called to give a report to the accepting nightshift nurse at our facility. John was returned to our facility. It was not until that morning, when the techs at our facility were conducting routine vitals, that John was unresponsive. I was later told that during that night, John had woken up several times, complaining that he had difficulty sleeping. He was given medications to help with sleep and sent back to his room.
A failure of systems
Most saddening to me about this outcome is the potential lack of diligence in preventing this death. John did not necessarily have to die that night. It is a complex issue, but it seems that what John needed were providers who appreciated the complexity of his condition to demand that he stay at the medical hospital.
John needed doctors at our facility to fiercely refuse to accept this patient, knowing his prior cardiac history, and to question the diagnosis of pneumonia. John needed nurses at the emergency room and our facility to advocate that his complaints were valid and warrant further attention. John needed an entire team fighting to ensure he stayed alive and well. There is no single person to blame for this outcome but rather a failure of systems to respond effectively.
Advocacy
I remember this patient so clearly as I reflect on my experience with him now. He was gentle, kind, cooperative, and trusting of his providers and environment to care for him. John was an individual with severe mental illness who makes up a largervulnerable population of individuals who too frequently do not receive the care they need. I am frustrated by the outcome of this situation. I wonder what I could have done differently as a nurse that day he was my patient and what I can do going forward to prevent this kind of unnecessary death.
My career goal is to close the horrific gap of individuals with SMI dying 10 to 25 years younger than they should. John and the surrounding circumstances have deeply affected my outlook on healthcare and reinvigorated my passion for advocating for this vulnerable population. I will remember John each time I care for a patient with SMI to guide my work as a nurse practitioner to be diligent, compassionate, and potentially lifesaving.
