Bedside manner with involuntary patients and patient's in denial

[pre med 2014]

Fair, not all places have the same rules, but "no internet" definitely happens. When it does, I'm curious how the patients are expected to find out the details of the legal proceedings prior to making their decision.

Maybe the Internet is too dangerous for the 'mentally ill'

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[notdeadyet]

First of all, that's partially my point...what do you expect people to know of the system coming in? How it ACTUALLY works isn't really the issue as much as what the impression is on the wards, during the conversation in which the judge is brought up.

This is why I was asking if your impression is coming from TV or the movies.

When the patient is on a hold (the type varies by state; in California, it's the 5250), they have the right to appeal. When the time comes for their appeal, they are visited by counsel representing the patients who explains the legal process and their rights.

This is why what you're envisioning is less of an issue than you think it is. If doctors could somehow get patients to sign away their rights, that would be something, but it doesn't work that way. Even if a doctor completely fooled a patient into not appealing because bad things would happen, the patient's counsel visits and explains how it actually works. That safeguard is intentional.

Even if the patient's opinion is shaped by television or by evil doctors, they have a 1:1 visit from a public defender to explain the process and their rights. It doesn't get any more clear than that. Patients then have the right to appeal or not appeal that day.

And what access to legal information do they have prior to actually starting the dispute and getting counsel? Deciding to go to a judge in the first place is a big decision on its own, especially if they haven't been in the hospital before, are young, have no family they can contact to look things up for them, or have watched too much freaking TV! It's unreasonable to expect that they know how the system works coming in, and if they're sitting there in a closed ward with no internet and limited phone access, I don't see how they're expected to gain that information BEFORE making their decision.

See the above. They have legal counsel that can/will represent them that comes to them, whether they want it or not, and explains their rights. The patient then determines if they want to go before the judge and appeal or not.

You're placing a lot of emphasis on what the doctor tells the patient, but this is a phantom argument. It's too potentially biased. That is why the patient has legal representation.

 

[mehc012]

This is why I was asking if your impression is coming from TV or the movies.

When the patient is on a hold (the type varies by state; in California, it's the 5250), they have the right to appeal. When the time comes for their appeal, they are visited by counsel representing the patients who explains the legal process and their rights.

This is why what you're envisioning is less of an issue than you think it is. If doctors could somehow get patients to sign away their rights, that would be something, but it doesn't work that way. Even if a doctor completely fooled a patient into not appealing because bad things would happen, the patient's counsel visits and explains how it actually works. That safeguard is intentional.

Even if the patient's opinion is shaped by television or by evil doctors, they have a 1:1 visit from a public defender to explain the process and their rights. It doesn't get any more clear than that. Patients then have the right to appeal or not appeal that day.

See the above. They have legal counsel that can/will represent them that comes to them, whether they want it or not, and explains their rights. The patient then determines if they want to go before the judge and appeal or not.

You're placing a lot of emphasis on what the doctor tells the patient, but this is a phantom argument. It's too potentially biased. That is why the patient has legal representation.

You're still ignoring the entire part UP TO the point where the patient decides to appeal. How is the patient supposed to make an informed decision about whether or not to appeal or go before the judge, a decision which is made, even in your description, BEFORE they see counsel.

This is NOT a phantom argument. The entire discussion is about patients seeing "if you disagree with me, let's see what the judge says" as an attempt to strongarm them rather than the conciliatory/compromising gesture it is apparently meant to be. What is said to the patient about the judge, what information is available to them PRIOR to setting in motion any actual legal proceedings, and their initial impression of the system are all very germane to that discussion.

Quite frankly, the fact that IF they decide to go to court, THEN they will receive legal counsel is irrelevant to whether or not they'll decide to go, especially if they aren't aware that they will be given legal counsel when they make that decision.

And again, my impression is not coming from TV or movies. The judge can be used as a threat, and is sometimes...I'll admit that I've only seen one admittedly cruddy hospital in action, but it was most definitely reality, not TV. It's nice that the system is in place so that, once the appeal is started, this is "less of an issue than I think it is", but that's not even the issue I am concerned about. I think it is idealistic to pretend that patients' decisions aren't partially shaped by trying to AVOID court...and if they avoid appealing, they're not going to even see that legal counsel you keep mentioning.
You say the doctor can't get the patient to sign away their rights...I consider having them sign voluntary commitment papers, extending their stay, to be included in that...maybe it's a good decision for the patient, but it's still one the patient should be able to make an informed decision on, and they are NOT always given legal counsel when that option is presented to them.

 

[notdeadyet]

How is the patient supposed to make an informed decision about whether or not to appeal or go before the judge, a decision which is made, even in your description, BEFORE they see counsel.

Read my post again. I don't know how to make it more clear. The patient does NOT make the decision until after he sees counsel.

Quite frankly, the fact that IF they decide to go to court, THEN they will receive legal counsel is irrelevant to whether or not they'll decide to go, especially if they aren't aware that they will be given legal counsel when they make that decision.

Again, read my post. The doctor does not have the option of denying the patient right to counsel. This is provided and the patient speaks to counsel BEFORE they are able to accept/refuse their right to a hearing.

I'm all about compassionate care. My point is that there are safeguards for patient rights so that doctors, nursing, and family do not have the ability to stop a patient from exercising their rights. Just reality checking here...

 

[Trismegistus4]

Am I the only one in this thread wondering what the heck a "proctor" is in this context? Why does the OP, who says he's in private practice, have someone looking over his shoulder?

 

[mehc012]

Read my post again. I don't know how to make it more clear. The patient does NOT make the decision until after he sees counsel.

Again, read my post. The doctor does not have the option of denying the patient right to counsel. This is provided and the patient speaks to counsel BEFORE they are able to accept/refuse their right to a hearing.

I'm all about compassionate care. My point is that there are safeguards for patient rights so that doctors, nursing, and family do not have the ability to stop a patient from exercising their rights. Just reality checking here...

So every involuntary meets with legal counsel once they get there? Or are at least very clearly informed of their ability to meet with them?

Either CA is the magic kingdom (and good for them if that actually happens) or that's an idealistic description of it.

I never said the doctor could deny the patient the right to counsel...you are missing the point entirely. It's not about what options are technically there if you know to ask for them or blindly take the plunge and find out that the system is safeguarded after all. It's about how the options are PRESENTED to the patients, what they KNOW is available, and HOW the staff tries to persuade them to cooperate. These are the things that are going to influence their decisions on the spot.

It's fine to sit back and go "look, if you know how it all works there are safeguards in place, see? It's a good system!" but that doesn't necessarily help the person sitting in the ward going "if I do xyz, that may mean court...what are my chances? Will that go on my non-medical record? Can they keep me past 72hrs while we're waiting for the court date?" whose only sources of information, before they meet with counsel, are other psych patients, friends/family IF they have someone to call, and the very people they may end up in court arguing against.

And for the 8 BILLIONTH time, my point in all of this is not that we ought to change the court setup or that it's bad, but that a difficult patient or one in denial, who wants to leave, could VERY EASILY and UNDERSTANDABLY take "if you continue to disagree we'll get a judge to settle it" as a threat and not an offer of a viable alternate route...which is very relevant to the discussion of "handling conversations ON the ward, WITH the patient".

 

[notdeadyet]

So every involuntary meets with legal counsel once they get there? Or are at least very clearly informed of their ability to meet with them?

Every patient on a 5250 (the involuntary hold they have the right to appeal before a judge) meets with counsel on the day he can have the hearing before a judge.

Either CA is the magic kingdom (and good for them if that actually happens) or that's an idealistic description of it.

No. It's the law. It's a patients rights thing. Like HIPAA. Docs can ignore it, but they'd be breaking the law. It's not idealistic. It's the law.

It's not about what options are technically there if you know to ask for them or blindly take the plunge and find out that the system is safeguarded after all. It's about how the options are PRESENTED to the patients, what they KNOW is available, and HOW the staff tries to persuade them to cooperate.

Sure. I see what you're saying. I'm just letting you know that in my experience at several hospitals, the patient doesn't have to ask for these rights. An outside entity, the court system and public defender, come to each that is eligible as a matter of course. We don't use court as a carrot/stick any more than we would water or heat: the patient has it and is going to get it. I haven't seen docs use court as some kind of leverage for patients because they have no control over it. Make sense? The examples you use about docs using court and seeing the judge as a threat is just something I haven't seen and doesn't make sense. It's probably not the blog problem you seem to think it is.

Anyway, I don't know if you're psych bound or not, but If you are, i think you'll find the judge/court thing isn't what you are thinking it is right now. I'll let this go back to its regular programming as I don't think this discussion is going to go anywhere.

 

[michaelrack]

Am I the only one in this thread wondering what the heck a "proctor" is in this context? Why does the OP, who says he's in private practice, have someone looking over his shoulder?

Agree.

 

[gibits]

Am I the only one in this thread wondering what the heck a "proctor" is in this context? Why does the OP, who says he's in private practice, have someone looking over his shoulder?

The sad fact is that if you are working inpatient, even as a privite attending, you have to deal some form of supervision. The proctor is someone who informs you of the culture of the hospital. What they want from the documentation how they can ensure payment etc. when you get previdges from a hospital you will get a proctor that goes over your charts and tells you what you need to improve on. It usually lasts a few months.
Then there is "peer to peer" or "doctor to doctor". Basically you need to explain to a insurance MD why the patient is justified to stay. If they disagree with you then they deny payment. Other times it's to discuss ways to prevent readmission to save the insurance company money.

I think mehc isn't disputing the procedure or facts of a WRIT hearing but how it can come off as a threat coming from the doctor. Indeed it is that perception that i was trying to avoid which was why i started this thread. He seemed to have witnessed an attending that was rather heavy handed in his use of the court. I personally have not witnessed this but I would not be surprised to hear it happening.

 

[michaelrack]

The sad fact is that if you are working inpatient, even as a privite attending, you have to deal some form of supervision. The proctor is someone who informs you of the culture of the hospital. What they want from the documentation how they can ensure payment etc. when you get previdges from a hospital you will get a proctor that goes over your charts and tells you what you need to improve on. It usually lasts a few months.
.

A proctor is not universal for psychiatrists who do inpt, even for hospital-employed psychiatrists. I hope you are getting a boat load of $, because your situation sucks

 

[gibits]

A proctor is not universal for psychiatrists who do inpt, even for hospital-employed psychiatrists. I hope you are getting a boat load of $, because your situation sucks

I'll find out of I'm making a boatload of money once collections comes through which is in 4-6 weeks. So far I have 3 proctors..... Only 2 hospitals have not assigned me a proctor of the 6 hospitals I have previdges in.
One of the psychiatrists in the practice told me: "**** them". Best advice ever.

 

[michaelrack]

One of the psychiatrists in the practice told me: "**** them". Best advice ever.

 

[mehc012]

Every patient on a 5250 (the involuntary hold they have the right to appeal before a judge) meets with counsel on the day he can have the hearing before a judge.

"on the day he can have the hearing before the judge" ≠ what I said. I read that the first 3 times you typed it, and I still find it irrelevant to the issue at hand.

No. It's the law. It's a patients rights thing. Like HIPAA. Docs can ignore it, but they'd be breaking the law. It's not idealistic. It's the law.

The law you have described does NOT state what I was asking...which was whether they all meet with counsel as soon as they're brought into the ward. The issue of "patient on the ward has no idea what their legal status is, how the court system works, what their rights are, or what their chances are in court" isn't changed by the fact that WHEN they bring up their court rights, THEN they get counsel. If you polled all first-time involuntaries on their first day in, how many do you think would know, 100% "I have the right to meet with counsel and discuss 1-on-1 whether going to court is a good option for me"? If that number isn't close to 100%, then in my opinion, THAT is the major problem with the whole setup.

Sure. I see what you're saying. I'm just letting you know that in my experience at several hospitals, the patient doesn't have to ask for these rights. An outside entity, the court system and public defender, come to each that is eligible as a matter of course. We don't use court as a carrot/stick any more than we would water or heat: the patient has it and is going to get it. I haven't seen docs use court as some kind of leverage for patients because they have no control over it. Make sense? The examples you use about docs using court and seeing the judge as a threat is just something I haven't seen and doesn't make sense. It's probably not the blog problem you seem to think it is.

Right, and that's fine...your experience is your experience, and I'm not trying to negate that...but the situations I put up were ones that I witnessed firsthand. It can and does happen, and even if it's not a common problem, I would argue that it's a big one when it occurs.
Either way, my main point was still that the judge is hardly something to bring up as a calming/conciliatory gesture.

Anyway, I don't know if you're psych bound or not, but If you are, i think you'll find the judge/court thing isn't what you are thinking it is right now. I'll let this go back to its regular programming as I don't think this discussion is going to go anywhere.

Fair enough...I think we've both said what we needed/wanted to say, and there's not much more ground to cover here! I'm most likely not psych bound, though I once thought I might be...it just seemed like every glimpse I got of the system made me want to run farther and farther away. The patients I can deal with...the setup not so much!