Prior to working as a nurse practitioner, I worked as a psychiatric registered nurse in an inpatient behavioral health setting, caring for individuals with severe mental illness (SMI). Individuals with SMI die ten to twenty years earlier than the general population due to comorbid medical conditions. I had been aware of this statistic for some time but only understood the devastation after I had an encounter with a patient in my role as an inpatient nurse. I will refer to this patient as “John.”
John was a newly admitted middle-aged patient to our psychiatric facility. He presented similarly to other patients experiencing psychosis. John had been hearing voices telling him to harm himself and others and was brought into the emergency room. He was then voluntarily admitted to our behavioral health unit. I had the opportunity to care for John as his nurse that day.
John came with a significant medical history—he had multiple prior surgeries, all relating to his heart, and had several aortic aneurysms as well. Later that day, after John had been admitted to the unit, he complained of having a “soreness and tightness” in his throat as he pointed to his larynx and chest area. He later began complaining of “chest tightness.” I called John’s psychiatrist (who happened to be the attending physician on call) and notified her of the patient’s complaint, and asked if I should conduct an EKG to rule out cardiac abnormalities. She agreed to the order, and with the assistance of my co-worker, we did an EKG on John.
The EKG reading indicated a possible anteroseptal myocardial infarction. After notifying the on-call physician, I was directed to send John immediately by ambulance to the local medical hospital for evaluation. John’s attending psychiatrist was notified as well, and my shift supervisor was made aware of the send-out. I mentioned to the night shift nurses that John would most likely be admitted to the hospital and not return on their shift. After all, with complaints of chest pain, the standard patient coming 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.
When I returned to work the following week, I learned I was very wrong. John had died early that morning.
I learned John was not admitted but was medically cleared with a diagnosis of pneumonia and returned to our psychiatric facility. It was not until that morning, when the medical assistants at our facility were conducting routine vitals that John was found unresponsive. I was later told he had woken up several times during the night, complaining of difficulty sleeping. He was given medications to help with sleep and sent back to his room.
Most saddening to me is the possible lack of diligence in preventing John’s death. It is a complex issue, but it seems what John needed were providers who appreciated the complexity of his condition enough to demand he stay medically admitted. He needed doctors at our facility to fiercely refuse to accept this patient back to our facility, knowing his prior cardiac history, and to question the diagnosis of pneumonia. John needed nurses at both the emergency room and our facility to argue that his complaints were valid and warranted 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.
I remember John so clearly as I reflect on my experience with him. He was gentle, kind, cooperative, and trusting of his providers and the health care system to care for him. John was an individual with severe mental illness, and he is part of a larger vulnerable population that, too frequently, does not receive the care they need.
The circumstances of John’s death deeply affected my outlook on health care and reinvigorated my passion for advocating for this vulnerable population. I remember John each time I cared for a patient with SMI and let it guide my work to be diligent, compassionate, and potentially lifesaving.
While I no longer work in the inpatient setting, I believe steps can be taken—particularly in community mental health—that can work towards improving comorbidity in individuals with SMI. My passion lies in closing the gap in early mortality of individuals with SMI through integrated care measures.
I believe this begins with better preventative screening measures, specifically monitoring metabolic functioning (for example, hemoglobin A1C levels, lipid panels, BMI), and then managing metabolic abnormalities using consultation with primary care providers and equipping mental health providers with decision support tools and specific protocols to follow for initial management of metabolic abnormalities.
Addressing metabolic How one patient’s death transformed my approach to mental health care through an integrated care approach, in which close collaboration occurs with a primary care provider in a community mental health setting, allows for more effective patient treatment and helps avoid gaps between screening and treatment. Using case managers who assist with appointment follow-through for patients is important as well. Ideally, this intervention of early identification of metabolic issues will improve metabolic outcomes of individuals with SMI and ultimately improve overall physical and mental health regarding longevity and quality of life.
To close this gap significantly, changes need to be made at both the system and policy levels, but I believe the work begins with changes in my own clinical practice environment.
On a patient level, I aim to provide evidence-based treatment to create a foundation for long-term healing and recovery. On a systems level, I’m a strong advocate for more integrative health care and working to reduce the stigma of mental illness, which can often be as debilitating as the illness itself.
My vision for the future of mental health care is that parity of mental and physical health is the norm as individuals, communities, and our nation strive for improvements in both physical and mental wellness. I strive towards this ideal every day in practice, with the memory of John’s story in mind.
Claire Ellerbrock is a nurse practitioner.
