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.
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.
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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."
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. 🙂
It sure isn't in the location I practice. Here, they have to have the specific means, specific and articulated plan, and intent. Without all three, it's not legit.
It has to be "I have this gun, I have bullets, I will shoot myself in the head at 4 pm today" or it will get thrown out. "I'll get a gun and shoot myself" doesn't qualify. Neither does "I will walk into traffic." "I will hang myself" usually gets it.
Of course, people will tell you otherwise because they've gotten away with it before, but there's no chance you'd actually win that unless the patient is continuing to clearly say suicidal statements in the hospital including the day of kangaroo court. Involuntarily hospitalizing an outpatient requires an in-person face-to-face visit. So even if my suspicion is that the patient actually will kill himself and is merely downplaying the statement at the time of the visit, it doesn't matter because the community response team won't go there unless they have satisfied their interpretation of the issue. Police won't go for a check without the community response team. They've even gone so far as to require that I file a police report about threatening statements that were reported by parents to me, but that I didn't actually hear, in order for them to even go evaluate the patient for homicidal statements.
You are misreading it. I don't know hope much more explicit it can be than "notwithstanding any other law, in no event may such person be retained against his or her objection beyond...", but in NY if someone is brought in because they are believed to be dangerous due to substance intoxication, there is no way to hold them once that is found not to be the case (or 72 hours). I've personally had a situation where someone was brought in due to intoxication and while sobering up they became very homicidal; we reviewed the statute with legal counsel, and the conclusion was unambiguous that there would be absolutely no way to retain them even if we fully expected people to die as a result of that.
You can retain them in the ED for a period, but you cannot admit them to a psychiatric unit.
Then the lawyers you’re working with don’t seem to understand their own laws:
“3. A person who comes voluntarily or is brought without his or her
objection to any such facility or program in accordance with this
subdivision shall be given emergency care and treatment at such place if
found suitable therefor by authorized personnel, or referred to another
suitable facility or treatment program for care and treatment, or sent
to his or her home.
4. The director of a treatment facility may receive as a patient in need of emergency services any person who appears to be incapacitated as
defined in this section.”
It literally says you can send these people to a treatment facility WHILE THEY ARE STILL INTOXICATED IF THEY ARE DEEMED INCAPACITATED (which directly goes against the recommendations of the American Academy of Emergency Psychiatrists). Meaning in NY you’re supposed to refer/send them to a treatment facility before they become sober. This is very blatant in the law you posted. I’ll look at other sections of the NY statute later, but it would be wild to me if there is not additional statute for protocols of if the patient still expresses SI while no longer incapacitated.
One thing I’ve learned at multiple hospitals is that lawyers, even healthcare lawyers, have a very poor understanding of mental health laws unless they’re regularly involved with these cases. I have personally had a hospital legal team give me advice that could have gotten me in big trouble (per multiple lawyers and the main judge involved in our state’s main forensics hospital) if I’d have followed it. This is why I asked for specific case examples, because unless they’re lawyers or court regularly deal with those kinds of cases that is typically what will be defaulted to.
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Sure, and those are specifics regarding the extent of SI. Many states aren’t that specific though and what they consider “a danger to themselves or others” is vague and left to interpretation. At least for your state you know the exact standard to be met.
Absolutely, I am much more interested in what a good forensic psychiatrist or academic psychiatrist that serves on the ethics/law committee of the hospital has to say than the JD the hospital has on retainer. I was shocked in residency how much more knowledgeable about mental health law my attendings were than the lawyers for the hospital. I have subsequently learned that the best and brightest of the class do not typically go to work at hospitals.
Tbf, our hospital attorney works solely for our hospital and is an MD/JD, but he was an internist who wasn’t particularly interested MH law. Though my (indirect) role with the ethics/risk management team probably exposes me to more of these situations than most other docs.
That all said, this has gotten a little tunneled on specific states. Bottom line is to know your state laws and if there are specific requirements like OA mentioned. However, oftentimes laws aren’t specific and are vague enough to be up to interpretation to some extent.
AAEP recommends that psychiatrists evaluate patients after they are “clinically sober” and recommend against using specific cutoffs in BAL to determine when to assess. Obviously if state law (like in NY) opposes this then follow the law. IMO it’s fine to do an assessment while intoxicated to see just how intoxicated/impaired they are initially, but psychiatrists should ALWAYS reassess once cognitively intact unless there is some law precluding this (like they’ve already been transferred to a treatment facility).
Seems like the gray zone between detaining someone who is intoxicated and at risk if discharged but doesn't meet inpt psych criteria is an involuntary medical hold. We don't see that term used much in real world and its not really well-defined in law/protocols.
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Sure you can send them to a treatment center, which can in no circumstance hold them when they are no longer dangerous due to incapacitation by a substance (or 72 hours from initial presentation, whichever comes first). In fact, you could about them to your psychiatric unit and start psychiatric as long as they met criteria, you just have to release them (or convert to informal status) when they are no longer dangerous due to incapacitation by a substance (or 72 hours from initial presentation, whichever comes first).
I didn't provide case law because there isn't for the specific scenario (found to be dangerous due to metal health after being brought in while intoxicated) but here a landmark case involving the law which does show how very, very particular the law is: Kowalski v. St. Francis Hospital and Health Centers, et al., No. 128 (https://law.justia.com/cases/new-york/court-of-appeals/2013/128.html) - the court finds that even if the plaintiff (who was intoxicated with alcohol and got hit by a car after he left the ED) had been an imminent danger to himself the ED couldn't have held him because he came in voluntarily under S22.09d and the provision for emergency treatment is under S22.09e - patients brought in over objection.
Let's say someone intoxicated with PCP charges into an ED in NYS and starts attacking people - you have absolutely no ability to provide emergency treatment for their PCP intoxication against their will. "Fine," the hypothetical you thinks, "they obviously lack decision making capacity so I will act as a surrogote and decide on their behalf to receive treatment." Then you run into the fact that the laws that allow for surrogaye decision making in setting of incapacity only apply while inpatient, and the ED is technically outpatient. In a moment of brilliance, hypothetical you makes a quick turn for the hospital doors as the patient, invigorated by the dust of the angels, chases you.* Now hypothetical you can agree to treatment on his behalf, except that the law explicitly requires a court order if the incapacitated person objects to it (or the finding of incapacity) and throwing hypothetical you across the room counts as objection because it is an act that resists treatment. So, hypothetical you sneaks up on them while they are distracted and jabs them with something to knock them unconscious and then they are kept unconscious until no longer incapacitated and dangerous (or 72 hours from presentation, whichever comes first) because the law doesn't necessarily require you to give them the opportunity to object to treatment.
*: Alternatively, if hypothetical you has good cardio, you keep the patient chasing you while you make for the border of a state with more sensible pertinent laws.
Exhausted, hypothetical you returns to the ED to find that the police have brought in over objection a patient incapacitated due to overdosing on nicotine who needs emergency treatment, and hypothetical you promptly releases them because the statutory definition of substance excludes alcohol and nicotine, and S22.09 applies to the intoxicated by a substance or alcohol, not a substance or alcohol or nicotine.
There is a gut reaction to read or interpret law in a way that makes sense clinically, or just makes any sense at all. It is important to remember that, in an apparent effort to be more legible to the mentally ill, the law is insane.
If someone remains suicidal after 72 hours from presentation, then in the case of alcohol, you can easily make the case that this is not intoxication any longer. There's a reason it's 72 hours.
Then we're dealing with substance-induced psychosis or mood disorder or a primary psychotic/mood illness. Any of these do not fall under the 'intoxication' label.
Please don't discharge suicidal patients because they 'first' presented intoxicated. This is complete nonsense.
Are you for real? If they are attacking people, then just call hospital police. It doesn't matter if they did it inside the ER or 5 m outside.
Then we're dealing with substance-induced psychosis or mood disorder or a primary psychotic/mood illness. Any of these do not fall under the 'intoxication' label.
Please don't discharge suicidal patients because they 'first' presented intoxicated. This is complete nonsense.
Are you for real? If they are attacking people, then just call hospital police. It doesn't matter if they did it inside the ER or 5 m outside.
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If this is the actual correct interpretation of the law, why is any psychiatrist practicing in the state of NY? These laws seem to be actively harmful to both patients and medical staff treating them and would be legitimately insane as you say in your last sentence.
My thoughts were always that I would have more liability if I released an intoxicated individual who had been brought to a hospital because others, usually law enforcement, were concerned about danger to self and others. My thought was, sleep it off and we’ll talk in the morning. I also practiced in rural western states. No 72 hour hold either, a 24 hour emergency detention and then the legal process would start. Drunk and suicidal typically never went past 8 hours and no court in those towns or state would take false imprisonment seriously for a case like that.
Edit to add: just to clarify since I didn’t really make the point I wanted. If I decided or recommended to the ED physician (which was how it was structured) to discharge someone who was still intoxicated and they killed self or others, surviving family might be likely to sue and a jury would probably be sympathetic. Thats why cops tend to hold onto drunks too is what the cops tell me.
Edit to add: just to clarify since I didn’t really make the point I wanted. If I decided or recommended to the ED physician (which was how it was structured) to discharge someone who was still intoxicated and they killed self or others, surviving family might be likely to sue and a jury would probably be sympathetic. Thats why cops tend to hold onto drunks too is what the cops tell me.
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So are you considering them no longer intoxicated when "clinically sober" or BAL=~0?
The EDs I worked in typically wouldn’t call us in until someone was BAL was zero. That being said, it was always a judgement call so if the doc wanted me to evaluate someone who had had a few but he or she felt was lucid enough to talk, I would probably come in and evaluate. If we could come up with a reasonable plan, then we might discharge. What is funny is that the nurse practitioner who liked to try and throw her weight around would get called in at 2:00 am to evaluate drunks, whereas the nurses and doctors would wait for the drunk to sleep it off and call me in the morning. She was always complaining about it and wanted a policy to stop them from calling her. The more she complained, the more they did it. 😜
Old mental health support board I used to post on in the early-mid 2000s had a number of incidents where someone would decide they were going to off themselves, start drinking to make sure the pills they planned to take would be extra lethal, then end up getting way too inebriated and start drunk posting 'goodbye cruel world' notes and/or drunk dialing people they knew from the forum IRL. The admins had the ability to track any forum member's address via their IP, so there were more than a few ambulance/police welfare check calls made. Around 80% of the time these were genuine suicide attempts, the person just overestimated the amount of alcohol they decided to down in preparation. and ended up being too drunk to follow through. And yes folks were almost never happy to have ambos and/or police suddenly lob onto their door step at some (usually) ungodly hour, but it's not like they really gave the forum managers much choice. If it was a case of legit suicidality then you could maybe hope the person would pass out drunk and then have changed their mind when they woke up, but you also equally ran the risk of the person eventually sobering up enough to try and complete the act. And it wasn't like any of us could tell who was serious and who was just potentially attention seeking in a situation like that.
phantasmagoric
Full Member
Bumping this thread, but a quesiton about scenario in which a patient comes in with serious suicide attempt while intoxicated.
After being medically cleared, they deny SI , any dangerousness to themselves, and there is no evidence of primary mood/anxiety/psychotic disorder. Do we still recommend inpatient psychiatry for them after medical clearance given severity of their attempt - and at least so that they are safe for a while CD eval can be performed during inpatient stay?
After being medically cleared, they deny SI , any dangerousness to themselves, and there is no evidence of primary mood/anxiety/psychotic disorder. Do we still recommend inpatient psychiatry for them after medical clearance given severity of their attempt - and at least so that they are safe for a while CD eval can be performed during inpatient stay?
Yeah, I generally do. This is very rare compared to the huge number of SI presentations, although it happens. Accidents that are confused for suicide attempts are much more common. There is a significant risk difference between SI, which many (if not most) people have at some point in their life and a serious attempt. I do wonder a little how serious it was exactly if they aren't being admitted to a medical floor at least briefly? You didn't say the method. Serious attempts often leave some sort of injury behind. But just taking what you are saying, I would admit for 3 days of observation. The exact length would vary by state. We'd do some motivational interviewing, try to get to rehab, etc. Depending on the exact situation I might consider a discharge direct to residential rehab, but not home right away. If there was a med floor stay, I would not necessarily transfer to the psych unit.
phantasmagoric
Full Member
Right, I should clarified that the context was that we were consulted post-extubation while he was staying at a med floor. The attempt was very serious indeed - hanging which almost killed him. Would you still not necessarily transfer to psych unit after med floor stay? I would say there was some suspicion about minimizing, poor insight etc.
I'm sure there are reasonable people who may disagree, but I'd generally favor discharge to inpatient psych at least initially. It might be a short stay but I don't trust inpatient medicine to arrange appropriate aftercare following a serious suicide attempt. Maybe your CL service gets very involved in discharge planning, in which case maybe it's more feasible.
Just drunken suicidal statements, discharge. That kind of serious attempt, I would recommend admission to a psych unit.
I would admit. Too many unknowns. The only thing known is they did try to hang themselves and almost died. Hard to really know if there's an underlying mood disorder if they've been intubated 2-3 days and basically are just now getting medically cleared. Would be different if it was a 1-2 week medical course and C/L has been following since day 2. Many folks have poor insight and it takes a while to get to the bottom of what's really going on.
I would admit. I would feel much less concerned if the person voiced a narrative that acknowledged XYZ than I would in a patient who says "I'm perfectly fine" after a serious suicide attempt.
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I would try to do the evaluation, observation for stability, get some collateral. If the medical team is working things for 2-3 more days and I can do it myself might just discharge if it checks out. If there's stuff left to do I'd send to psych. Basically I'd do the inpatient things on CL and if I finish before medicine clears I'd discharge and if not send to psych.
phantasmagoric
Full Member
Appreciate all of your insights. That was my inclination as well, but good to get your perspectives.
Depends how long they’re on the medical floor for. If they’re there for 4-5 days our team and CM is able to accomplish most of the things we would accomplish through and acute inpt psych admission. Medicine is usually fine with keeping them for that long. If it’s for example an OD attempt and they’re stabilized after one day then we try to get to inpatient psych. Either way we always offer it, but whether we potentially pursue involuntary is highly situational.
