Drunkicidal patient in the ED
Started by vanfanal
See twice (once drunk, once sober) and assess for interval improvement.
Depends.
If your facility has room for people to stay in the ER, a sober/eval is appropriate.
If your facility has tons of psych beds but limited ER space, then eval drunk and admitting the drunkicidal patient is fine.
If your facility has a drunk tank, definitely sober eval.
If patient has high risk for DT's, might see while drunk with plan for admit to medicine - then handoff to C/L team to re-eval when sober (to clear 1:1 if indicated).
I personally would not see twice in any case. ER psych I avoid a second look like the plague. One and done is the most efficient use of staff resources. A good relationship with the ER docs can save you a lot of your resources - if you can build a local culture to consult psych when folks are sobering up.
If your facility has room for people to stay in the ER, a sober/eval is appropriate.
If your facility has tons of psych beds but limited ER space, then eval drunk and admitting the drunkicidal patient is fine.
If your facility has a drunk tank, definitely sober eval.
If patient has high risk for DT's, might see while drunk with plan for admit to medicine - then handoff to C/L team to re-eval when sober (to clear 1:1 if indicated).
I personally would not see twice in any case. ER psych I avoid a second look like the plague. One and done is the most efficient use of staff resources. A good relationship with the ER docs can save you a lot of your resources - if you can build a local culture to consult psych when folks are sobering up.
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I have some strong feelings on this. First off, I don't use the term clinically sober and side-eye any ED provider who does. If they are still suicidal and you want psych to assess them, you can't know they are "clinically sober." Alcohol is, all by itself, a depressant and suicidality is associated with depression. Anecdotally, although I'm sure there is literature on this, 90%+ of patients who present suicidal while intoxicated (at any level) will have their suicidality fully resolve during the process of metabolizing the alcohol. Personally, some arbitrary cutoff for assessment is not critical for me, although we have negotiated 100 because EDs are concrete. I'm perfectly happy to assess someone at 200 or even higher if they have started denying being suicidal. The important thing is whether the suicidality has resolved. If it hasn't, they need to be sober. Full stop. I know there will be variations in state laws and resources, but a general inpatient psychiatric unit is not usually the right setting for someone with a primary alcohol use disorder. It typically doesn't offer the right resources and isn't likely to help someone along their recovery journey. There's a lot of literature that involuntary treatment of substance use disorders doesn't work and if they came voluntary while drunk, they will certainly want to discharge immediately when they sober up. It's a lot of paperwork for no benefit and lots of cost.
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For us in training it was made abundantly clear, no psych eval with BAL >80 period, no exceptions. Occasionally you would get some push back from the ED but they basically were always on board with that too. Often they wouldn't even call you until the pt was <80. It would take a lot of rewiring of my brain (even though I haven't done this work in >10 years) to change from this.
You have to be careful of this with depending on your state. In my state, this would be false imprisonment (likely felony, possibly only misdemeanor) unless you had clear and convincing evidence (or more exactly, have reasonable cause to believe that it could be shown clearly and convincingly) that dangerousness was a product of a primary psychiatric condition rather than a substance.
Similar here, although I was trained to evaluate when “clinically sober” in part due to pressure from the ED and would have difficulty adjusting from this.
100%. The state I’m in you can’t involuntarily admit someone for intoxication or where the primary diagnosis is a substance use disorder or substance induced disorder (albeit people violate this law all the time). I’m thankful that my residency program were sticklers about this law. Sometimes it met boarding in the ED for a day or two if someone came in on something like meth or hallucinogens.
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This is true assuming the patient has capacity to make decisions. If they’re intoxicated enough that a psych eval is inappropriate they’re almost certainly lacking capacity to make decisions regarding their medical care.
Hence the term “clinically sober” and assessing their capacity is baked into the eval. I always pushed back against ED attendings because they would request evals when pts were often too intoxicated at the time of the consult. At most I would do chart reviews and get collateral to appease them and then defer the interview to later.
In the case of state laws, this would still be illegal to admit to psych because you’d be admitting them for/while actute(ly) intoxication/intoxicated and not a primary psychiatric reason. Again, hence waiting until they are clinically sober to do the interview.
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State law will vary. There are definitely some states where active intoxication is definitively considered a mental health condition. It doesn't change a thing clinically, but it does legally. I STRONGLY doubt any DA would vaguely consider bringing false imprisonment charges in this situation anywhere in the country regardless of law, but I guess it can be used to shut down ED attendings. I mean you're detaining them in the ED... The patient is also actively commiting the crime of public intoxication, but that doesn't get charged either.
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Whether they have capacity or not it would be a crime, at least in my state. Infringements of liberty are only privileged in very specific situations, and mere incapacitation of medical decision making abilities isn't one of them (incompetency is a separate story).
Eh, you can be sued if you let them wander away and they get hit by a bus or just fall too. I actually think that is much more likely than getting sued (or even more bizarrely somehow prosecuted) for detaining them, regardless of the state. Of course your defense might be better (or worse depending on the state.) As always, you can be sued for anything at any time. It's ultimately about whatever you need to say to get the ED MD to calm down.
Really a weak case to win against a doctor. Someone is suicidal -> unspecified mood disorder. The amount of people who get drunk IN ORDER TO commit suicide is high. Or people who get high IN ORDER TO complete suicide. Ask real suicidal people, they get angry at themselves for being cowards and not completing. Would be hubris to think you have all the answers while people are drunk, "oh yeah, I one hundred percent believe this is purely due to alcohol."
Unwinnable case against a doc IMO
Edit: Imagine this - suicidal guy shows up drunk... sues and wins against doctor trying to save his life for false imprisonment? Who on earth wins this case? Of all the lawsuits possible in the ER, this is my lowest concern.
Unwinnable case against a doc IMO
Edit: Imagine this - suicidal guy shows up drunk... sues and wins against doctor trying to save his life for false imprisonment? Who on earth wins this case? Of all the lawsuits possible in the ER, this is my lowest concern.
It’s happened in my state and patients have successfully used it to fight commitments.
Sadly I believe you - and glad I practice where I practice.
How exactly would a court have time to hear a case while the patient is drunk to "fight the commitment"? Of course the patient would win it once sober, that is why we don't assess them until then and if they snuck in, you discharge when they sober up, certainly well before a court has time to get involved. I would love to read about a false imprisonment case based on patient alcohol intoxication.
Patient was admitted while acutely intoxicated and declined to sign-in voluntarily so was placed on a 72hr hold. Attending went to court for a commitment and patient and his attorney made the case that SUDs and substance induced disorders are not qualifying reasons or diagnoses for involuntary admission - case lost on the part of the attending psychiatrist. Regarding the false imprisonment case, I’ll do some digging to see if I can find it. We discussed it in detail in residency specifically because of this issue and pushback from the ED as to what they deemed clinically sober v. what the psych department deemed clinically sober.
If they were admitted while intoxicated and when they sober up they were still suicidal, they could prevail in court because their due process protections were grossly violated. So yes, not just illegal but sabotaging treatment if they need it. Good luck if they do commit suicide afterwards if the judge sides with them, while ordinarily you are absolved of responsibility if the release is court ordered, an argument could be made that the death was ultimately a product of your malpractice in admitting them illegally rather than waiting until it was privileged ("in my expert opinion, the standard of care is to adhere to the law").
Also, even if they are released before a court hearing they still have a tort against you. Just the loss of liberty will be about $15-20k per day, plus whatever damages they can convince a judge or jury of.
Not to mention, every subsequent psychiatrist that sees them has to release them or be party to the crime as well.
In sum, don't do crime.
(Note: In my original post I stated in certain states death during no privileged retention might meet criteria for felony murder. I realize I misremembered and this was more dependent on an unadjudicated legal definition than I recalled in the state I was thinking of; while it still might be the case in that state or a different state, I don't have sufficient confidence in the statement anymore).
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Can you cite case law to prove this? Because frankly I don’t believe you. I also don’t believe your point on felony murder unless the argument is they required medical admission due to the substance use which is a completely different argument.
Ongoing SI is valid grounds for involuntary admission in almost any state I’ve talked to people in. Even if they could sue you for an initially inappropriate admission, I’d bet you’re far, far, far more likely to get destroyed in court if you discharged that patient and they killed themselves than if you kept held them when they continued to express SI.
Regarding the possibility of feeling murder, I realized I had misremembered a nuance, so I edited my post.
I'll have to dig through things to find case references but I don't have access to my computer right now (will update post when I do), but in the meantime I'll do you one better and cite law law (applicable to folks in NYS):
NYS Open Legislation | NYSenate.gov
Also, in cases where clinically someone needs hospitalization but it is not legally privileged, you are never discharging (medical decision), you are releasing (not preventing them from leaving) and that can never be malpractice in those cases because "there can be no duty to do that which the law forbids."
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Yea, I just read that page and you’re leaving out A LOT.Regarding the possibility of feeling murder, I realized I had misremembered a nuance, so I edited my post.
I'll have to dig through things to find case references but I don't have access to my computer right now (will update post when I do), but in the meantime I'll do you one better and cite law law (applicable to folks in NYS):
If the examining physician determines at any time that such person is not incapacitated by alcohol and/or substances to the degree that there is a likelihood to result in harm to the person or others, he or she must be released. Notwithstanding any other law, in no event may such person be retained against his or her objection beyond whichever is the shorter of the following: (i) the time that he or she is no longer incapacitated by alcohol and/or substances to the degree that there is a likelihood to result in harm to the person or others or (ii) a period longer than seventy-two hours.NYS Open Legislation | NYSenate.gov
www.nysenate.gov
Also, in cases where clinically someone needs hospitalization but it is not legally privileged, you are never discharging (medical decision), you are releasing (not preventing them from leaving) and that can never be malpractice in those cases because "there can be no duty to do that which the law forbids."
It also says that you may continue to hold until they are no longer a threat to themselves or others and that you can only hold them specifically in the ER for up to 72 hours and if they are held longer they MUST be transferred to a treatment center or discharged (which what happens if no one will accept? Seems like NY missed a big situation there…). Kind of the opposite of what you’re saying where they must be released, period, end of story once no longer incapacitated.
I would guess that if they are evaluated and determined to no longer be “incapacitated” per the legal definition and continue to express SI that legal argument would shift to whatever NY’s MH hold laws are and you would follow those, not that you just let them go once they’re sober enough to no longer be impaired.
If they sober up and they’re no longer suicidal, then it sounds like you let them go, but I don’t think anyone was arguing against that specifically and I’m sure plenty of states (mine included) have similar laws.
The actual description of the NY law seems to say you can hold/admit suicidal people while drunk? I know this board obsesses over liability, but you aren't being (successfully or really at all as no attorney would take it) sued for detaining a drunk suicidal patient and you aren't going to be charged with kidnapping or illegal imprisonment either. My bet is anywhere in the country because no judge or grand jury is going to view the harms outweighing the benefits even with weird state specific legal technicalities. Now of course the court is going to release them when they sober up if you kept them after that for some reason, that's standard, expected and the whole point of having judicial involvement. All that said, some of the stuff above might be the kind of stuff I would say if the ED got super annoying about having to board the patient. 🙂
