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Dr O’Mahony illustrates in his literary and graphic way the difficulties associated with dealing with this condition (from which his patient was almost certainly suffering).1 It is good to know that his hospital is taking seriously the issue of actual or threatened violence to staff. Having had several similar cases over the past couple of years, including one who eventually committed suicide, I have been able to make appropriate arrangements with a psychiatrist who was unequivocal in his advice that he should be in on a subsequent consultation right from the start and be introduced to the patient as a double consultation. The ethics of this include the fact that such delusional patients are, of course, psychotic and unable to bring rational decision making processes to the problem.
Since then, I have discovered a very helpful paper on the subject, which discusses the psychodynamics of the situation with particular emphasis on prevention.2
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