Inpatient: how do some of you guys keep doing it?

[hebel]

I've been working outpatient for the past few years and am now doing inpatient work for about the next 6 months. How do you guys keep doing this long-term?

Compared to outpatient, it's so draining treating patients who don't want treatment or don't even want to be on the unit. It can feel pretty disheartening going from dealing with a severely agitated patient wanting to leave, to another patient who you've been working so hard to build an alliance with suddenly curse you out while demanding a transfer, to then having another patient accuse you of violating their rights and wanting to talk to patient advocacy.

This sucks!

 

[hebel]

Why did u change to doing inpatient work if you enjoy outpatient so much?

Ignore those details, I changed some details of the situation out of paranoia for anonymity haha.

 

[Merovinge]

Several things to remember:

1) The person is inpatient for a reason, they have the pathology, not you.

2) You are able to be the doctor with someone at their most vulnerable. The patient is in a right's restricted arena that is only exceeded by jail/prison, many are suicidial or psychotic, this is an intense time and you get to help them through it. I hear this all the time from heme/onc, surgeons, etc but rarely hear psychiatrists talk about this.

3) Some patients will get better because you listened to them, medicated them properly, made a correct diagnosis, spoke to their family, or set up appropriate care after the hospital. You won't always know about these down-stream effects, but they are happening.

4) Some patients won't get better, won't have insight, and won't cure a personality disorder over a week's time. Guess what, every field of medicine has patients who don't improve and most fields have interventions that can directly cause harm, even if they cause population benefit, we are physicians and not remotely unique in this respect. Remembering the patients that fall into 3 and moving on from these patients is paramount to your long-term ability to provide excellent care to thousands of other patients.

 

[Chimed]

It's funny because I always ask how people can do outpatient work. I love the ability to work at my own pace, have flexibility in my day, be able to spend more time on some patients that need it and less on the ones that don't. I also get very bored sitting in an office. I love working on a team. Sure, some parts of difficult, but in addition to what's written above, you just have to know your role is acute management.

 

[Armadillos]

I've been working outpatient for the past few years and am now doing inpatient work for about the next 6 months. How do you guys keep doing this long-term?

Compared to outpatient, it's so draining treating patients who don't want treatment or don't even want to be on the unit. It can feel pretty disheartening going from dealing with a severely agitated patient wanting to leave, to another patient who you've been working so hard to build an alliance with suddenly curse you out while demanding a transfer, to then having another patient accuse you of violating their rights and wanting to talk to patient advocacy.

This sucks!

I imagine $$$ per effort ratio is reason for most folks

I similarly am not a fan of inpatient In general, seems either the patients need to be there and don’t want to be OR they don’t need to be there and refuse to leave.

 

[sluox]

Some inpatient jobs can be ridiculously chill (i.e. state hospitals, certain VAs, certain detox/rehabs). The last detox/rehab I worked at I literally saw most of my patients once a week (and we are talking about 10-12 for a full-time gig), and the discharge notes are all copy forwarded, one to two admissions a week. All work must be done by 1PM. All med protocols are robotic. Yeah I start an SSRI here and there, but if someone's super-duper suicidal I transfer to dual diagnosis. Who cares? It's amazing! At state hospitals, you often see your patients once a month and have one admission per month at most!

 

[OldPsychDoc]

COVID has sucked a lot of the joy out of everything, but the reason I chose Inpatient over Outpatient is all about the teams.
I like working with my colleagues.

I also like walking off the unit in the afternoon and hearing that door close behind me. The problems stay there, for the most part.

 

[Chimed]

COVID has sucked a lot of the joy out of everything, but the reason I chose Inpatient over Outpatient is all about the teams.
I like working with my colleagues.

I also like walking off the unit in the afternoon and hearing that door close behind me. The problems stay there, for the most part.

Amen, to that! LOL.

 

[FatherPsychiatry]

I also like walking off the unit in the afternoon and hearing that door close behind me. The problems stay there, for the most part.

PREACH!!!

 

[clozareal]

Much of what disheartens you seems to be around the loss of autonomy on the inpatient unit and the boundaries of the hospitalization. I definitely don't feel good when the patient is communicating that my decisions are not in line with those of a physician, which is to help people. Even though I can blame it on the patient that they are making me feel that way, in the asymmetric role of a physician, I know it's up to me to contain it, digest it, and process their difficult emotions, not the patient. It's tough to work through the projective identification from the patient without help from others, mainly because it's unconscious. It may be that there are some specific pattern of topics that come up that feel difficult for you, but require lots of self-reflection and consultation with others to make the experience more tolerable.

Here are a few of my thoughts on the specific things you brought up:

draining treating patients who don't want treatment or don't even want to be on the unit.

This is also draining for me because of the importance of autonomy. One of my attendings dealt with this by presenting two options to my patient once they have been determined to need an involuntary hold—they can either:
1) follow the appropriate treatment recommended by the psychiatrist which is likely to lead to shorter hospital stay, or
2) go through court to either obtain involuntary medications or leave AMA, which will likely lead to a longer hospital stay.

It can feel pretty disheartening going from dealing with a severely agitated patient wanting to leave

1. If I've determined that they meet criteria for a hold, then I tell them that leaving is not an option.
2. If they are severely agitated, I offer them a PRN medication and if they become more agitated to the point of violence, then I ready the nurse for potential emergent meds.
3. When they are too agitated to have a meaningful conversation, I immediately end the interview and leave the physical space to decrease the patient's environmental stimulation which can make the agitation worse.

to another patient who you've been working so hard to build an alliance with suddenly curse you out while demanding a transfer

A therapeutic alliance hinges on the treatment goals which is different on an acute inpatient unit than an outpatient one, where the goals are more aligned.
I tell them that transfers are not allowed unless we don't have a service that can be provided elsewhere (e.g., transfer to medicine or surgery, ECT, etc).

to then having another patient accuse you of violating their rights and wanting to talk to patient advocacy.

If you've determined in your clinical judgment that the person meets criteria for an involuntary hold, you are not violating their rights. This is within the law for all the states. You can be wrong in your clinical judgment, but that doesn't necessarily mean malpractice.

When a patient says this to me, I give them an outlet to address this frustration. I let them know next specific day (twice a week) they can see the behavioral health judge/officer to let the court decide if they don't meet criteria and that they will be represented by a public defender/attorney. If they want to be seen sooner, I give them the number for the public defender so the patient can talk to her/him over the phone.

When there's a really difficult patient that causes my emotions to stir up to the point that I am distracted by my previous patient when I am with my next patient, I will usually leave the unit for about 5 minutes to take a breather, then come back when my emotions are a bit less so I can think more clearly.

 

[Sushirolls]

Inpatient =hospitals =Big Box Shops =admin heavy =bureaucracy demand =call =D/C Summaries =C/L consults+/- =ED consults +/- ="doc to doc" for insurance authorizations for length of stay

No thanks. Its all that other stuff, not the patient care that is a pain with inpatient work. Clinic is the promised land.

 

[brazilianpsych]

I would do inpatient than outpatient anyday! For me its the complete opposite side.

Outpatient = most anxiety, very easy job.
Inpatient = every patient is interesting, lots of challenging cases. Some cases have an easy diagnosis but hard treatment, some are the opposite. It`s very nice to finally see someone completely psychotic doing great and leaving the hospital.

I love it.

 

[NickNaylor]

Personally I love the acuity and like having cases that can "turn around" over relatively brief periods of time. I do miss getting to see people at their best as you sometimes get to see in the outpatient setting, but I like the relative excitement of inpatient work.

At the end of the day, inpatient is no different than outpatient in that you can only do so much.

 

[Marasmus1]

I do not find treating somebody against their will a pleasurable experience.

 

[J ROD]

It's funny because I always ask how people can do outpatient work. I love the ability to work at my own pace, have flexibility in my day, be able to spend more time on some patients that need it and less on the ones that don't. I also get very bored sitting in an office. I love working on a team. Sure, some parts of difficult, but in addition to what's written above, you just have to know your role is acute management.

this.....I cannot stand being locked in a room for 30 minutes having to listen to basically I can't adult. Inpatient is done at my pace and schedule as long as I get the work done. And I get to think. Outpatient is boring............

 

[Armadillos]

Lol folks saying outpatient is boring or non acute need to work a job where your taking care of folks who genuinely need an actual psychiatrist.

 

[Nines]

I've been working outpatient for the past few years and am now doing inpatient work for about the next 6 months. How do you guys keep doing this long-term?

Compared to outpatient, it's so draining treating patients who don't want treatment or don't even want to be on the unit. It can feel pretty disheartening going from dealing with a severely agitated patient wanting to leave, to another patient who you've been working so hard to build an alliance with suddenly curse you out while demanding a transfer, to then having another patient accuse you of violating their rights and wanting to talk to patient advocacy.

This sucks!

I did inpatient work for two years before moving to my current outpatient job. Many days were exactly as you described and I found it difficult to deal with imposing my will on someone to force treatment that a patient didn't want or forcing them to stay in the hospital against their will and dealing with the hostility that often occured as a result. On the other hand it could be really satisfying to see a really sick patient get better and be discharged. I was surprised to find that the majority of patients would thank me for helping them by the end of the stay, even many of the ones that were intially very angry with being hospitalized or having meds forced. It seemed that in many cases even very psychotic patients with poor insight who disagreed with my treamtent could recognize on some level that I and the rest of the treatment team had helped them. That was an aspect I found surprising. I'm finding outpatient to be a whole different animal. Treatment is much more of a negotiation than an imposition which comes with a different set of challenges I think.

 

[Chimed]

Lol folks saying outpatient is boring or non acute need to work a job where your taking care of folks who genuinely need an actual psychiatrist.

The bottom line is it's a personality and personal preference. I thought *for sure* I was going to end up doing outpatient work and a lot of therapy. However, by the end of my 3rd year of residency, I looked back and found I loved my inpatient rotations. I felt more rewarded doing acute care. There are other issues as well. As @OldPsychDoc said above I suppose I also really liked feeling like once my day was done I could leave work at work. Could I do outpatient if it was my only option and be happy? Sure. Absolutely. I could find my niche and make it work. But it's just not where I gravitate toward. It was, honestly, a surprise to admit that.

 

[FlowRate]

Lol folks saying outpatient is boring or non acute need to work a job where your taking care of folks who genuinely need an actual psychiatrist.

I was about to say.. just started my attending outpatient job and I'm getting a lot of complicated folks.

 

[sluox]

I do not find treating somebody against their will a pleasurable experience.

I felt similarly. However, you need to be made aware that there are inpatient jobs that are pure voluntary patients. In particular, in addiction psychiatry, all patients are by definition voluntary unless you work at a dual diagnosis unit. This is also common for long term residential facilities for things like DBT, eating disorders, etc.

 

[Nines]

I felt similarly. However, you need to be made aware that there are inpatient jobs that are pure voluntary patients. In particular, in addiction psychiatry, all patients are by definition voluntary unless you work at a dual diagnosis unit. This is also common for long term residential facilities for things like DBT, eating disorders, etc.

It does seem like working on an acute detox unit is a pretty good gig. Where I trained we had a unit where pts would detox off opiates, etoh etc and then transition out to partial or OP. Totally voluntary and patients could leave AMA unless of course there were imminent safety concerns in which case they would be pink slipped and sent to the ED. The population with substance use disorders that is actually wanting treamtent is pretty different than the population you see in inpatient psych units where some won't even admit to using a substance that is showing up in their tox screen let alone want treatment. Repeated admissons for meth induced psychosis in a patient that has zero desire to stop using gets old after awhile.

 

[Desired Member]

This is also draining for me because of the importance of autonomy. One of my attendings dealt with this by presenting two options to my patient once they have been determined to need an involuntary hold—they can either:
1) follow the appropriate treatment recommended by the psychiatrist which is likely to lead to shorter hospital stay, or
2) go through court to either obtain involuntary medications or leave AMA, which will likely lead to a longer hospital stay.


If you've determined in your clinical judgment that the person meets criteria for an involuntary hold, you are not violating their rights. This is within the law for all the states. You can be wrong in your clinical judgment, but that doesn't necessarily mean malpractice.

Does anyone else feel it's slightly manipulative to present it this way to patients? It seems preferable to explain the process e.g. say, if you are still thought to present a likelihood of imminent harm after -X time period- then we will go to court to defend our treatment and the judge may allow us to force the treatment. It feels kind of slimy to say, "if you take these meds you can probably leave sooner." I'm just curious if anyone else feels this way.... or maybe it's just me lol.

One of the things that frustrates me about inpatient is the inability to truly use your "gut instinct". You may feel instinctively that a patient is at risk of imminent harm but don't have any evidence e.g. they are saying the right things, don't seem manic or psychotic, and don't have the past dangerous behavior patterns, and you know it will be impossible to defend in court, so you have to let them leave. Or a patient can be telling you they are suicidal and/or homicidal for days and you don't really believe them and think they are malingering or factitious. But you can't defend that either because there are no signs or pattern of behavior to back you up. So you end up keeping or discharging patients (mostly keeping) when you deep down think you should do the opposite. Does this happen to anyone else? Inpatient ends up feeling like a game, where you give medications that probably won't help, and people just get bored, start saying the "right things" to leave, and eventually leave. The personality disordered people certainly don't change. The psychotic patients stop taking meds when they leave. The drug intoxicated, truly depressed (rare), and manic (rare) patients are the only patients that I feel may actually benefit from hospitalization.

 

[Nines]

Does anyone else feel it's slightly manipulative to present it this way to patients? It seems preferable to explain the process e.g. say, if you are still thought to present a likelihood of imminent harm after -X time period- then we will go to court to defend our treatment and the judge may allow us to force the treatment. It feels kind of slimy to say, "if you take these meds you can probably leave sooner." I'm just curious if anyone else feels this way.... or maybe it's just me lol.

One of the things that frustrates me about inpatient is the inability to truly use your "gut instinct". You may feel instinctively that a patient is at risk of imminent harm but don't have any evidence e.g. they are saying the right things, don't seem manic or psychotic, and don't have the past dangerous behavior patterns, and you know it will be impossible to defend in court, so you have to let them leave. Or a patient can be telling you they are suicidal and/or homicidal for days and you don't really believe them and think they are malingering or factitious. But you can't defend that either because there are no signs or pattern of behavior to back you up. So you end up keeping or discharging patients (mostly keeping) when you deep down think you should do the opposite. Does this happen to anyone else? Inpatient ends up feeling like a game, where you give medications that probably won't help, and people just get bored, start saying the "right things" to leave, and eventually leave. The personality disordered people certainly don't change. The psychotic patients stop taking meds when they leave. The drug intoxicated, truly depressed (rare), and manic (rare) patients are the only patients that I feel may actually benefit from hospitalization.

To your first point: I found explaining to patients the process of the involuntary hold vs signing vols vs probate court to be very difficult. It is very common im my experience for staff in the ED to basically lie to patients and tell them "you have to go to the hospital but you'll only be there for three days" to keep them quiet. But then they are sometimes super pissed when I would try to explain how it actually works and they don't want to hear it or say that I'm lying cuz they were told different by someone else. So I often would just say that I dont feel they are safe for discharge so if they want to fight me on that they can be assigned a lawyer and go to court. It sounds callous but I said it in a much nicer way than that always offered for patient advocate to meet with them etc. If I tried to be more nuanced about it they often just got more angry and frustrated. As to the part about meds, one thing the lawyers ALWAYS ask me on the stand is how long I think the patient would be in the hospital with meds vs without. So I guess that was something the court took into account. Briefest amount of time in a highly restrictive setting.

 

[whopper]

I've found inpatient very rewarding but only when the following happened.
1-I worked with a great team. Good nurses, therapists, other doctors, and social workers.
2-The unit was smart. Now what I mean by this is they aren't taking BS from patients but not overplaying their hand and being rude or insensitive.. E.g. if the patient is completely or totally cluster B everyone knows inpatient isn't going to help but instead of callously kicking the patient out the staff knows refers the patient to psychotherapy and discharge the patient in a respectful manner.
3-The corresponding other players, e.g. the IM consultant, the ER doctors/psychiatrists were also doing their thing.

I've never had 100% of the above, but when I had about 80% of it I was fine. I always had some whiney BS IM consultant who wouldn't show up and do the consult or a nurse who'd inject all the patients with Haldol PRN so she didn't have to do any real work during her shift, etc.

 

[Desired Member]

To your first point: I found explaining to patients the process of the involuntary hold vs signing vols vs probate court to be very difficult. It is very common im my experience for staff in the ED to basically lie to patients and tell them "you have to go to the hospital but you'll only be there for three days" to keep them quiet. But then they are sometimes super pissed when I would try to explain how it actually works and they don't want to hear it or say that I'm lying cuz they were told different by someone else. So I often would just say that I dont feel they are safe for discharge so if they want to fight me on that they can be assigned a lawyer and go to court. It sounds callous but I said it in a much nicer way than that always offered for patient advocate to meet with them etc. If I tried to be more nuanced about it they often just got more angry and frustrated. As to the part about meds, one thing the lawyers ALWAYS ask me on the stand is how long I think the patient would be in the hospital with meds vs without. So I guess that was something the court took into account. Briefest amount of time in a highly restrictive setting.

I ask patient if they want to be admitted. If they say no and I feel they definitely need to stay, I tell them that I am going to put them on a hold because I believe they present a risk of imminent harm and I explain why I think so. Unless of course they are so psychotic/manic/agitated that they won't understand or it will make them violent. I don't say "you can either sign in voluntarily, or I can put you on a hold" because that seems manipulative. I don't say, "if you take your meds, we may not have to go to court and you may leave sooner" because that seems manipulative. If some ED provider told them they would be there for 3 days only, I would say, that person must be misinformed because that is not the case. My experience is that some ED providers greatly exaggerate patient presentation just to dump patients on psych or explain holds incorrectly to make someone cooperative enough to transfer easily to psych.

 

[Nines]

I ask patient if they want to be admitted. If they say no and I feel they definitely need to stay, I tell them that I am going to put them on a hold because I believe they present a risk of imminent harm and I explain why I think so. Unless of course they are so psychotic/manic/agitated that they won't understand or it will make them violent. I don't say "you can either sign in voluntarily, or I can put you on a hold" because that seems manipulative. I don't say, "if you take your meds, we may not have to go to court and you may leave sooner" because that seems manipulative. If some ED provider told them they would be there for 3 days only, I would say, that person must be misinformed because that is not the case. My experience is that some ED providers greatly exaggerate patient presentation just to dump patients on psych or explain holds incorrectly to make someone cooperative enough to transfer easily to psych.

The phrase I used the most for involuntary inpatients who were demanding to leave was "my goal is to get you out of here as fast as possible but I need to be sure that you are safe before you can leave. If we can't come to an agreement on a plan to do that and you want to leave before I feel you are safe enough to go home then you have the right to take your case to court for a judge to decide." Most of the time that worked well enough. Depending of course on their mental status and ability to process information I would then go through what we need to accomplish before discharge. This approach was usually more successful in suididal patients (no psychosis or mania) as there were more discreet steps i could tell them that needed to happend before discharge (e.g. get collateral from family, arrange follow up, ensure any firearms removed from home etc) and the patients often understood why I was keeping them even if they disagreed. Whole different ballgame with very manic or psychotic patients of course.

 

[clausewitz2]

Does anyone else feel it's slightly manipulative to present it this way to patients? It seems preferable to explain the process e.g. say, if you are still thought to present a likelihood of imminent harm after -X time period- then we will go to court to defend our treatment and the judge may allow us to force the treatment. It feels kind of slimy to say, "if you take these meds you can probably leave sooner." I'm just curious if anyone else feels this way.... or maybe it's just me lol.

One of the things that frustrates me about inpatient is the inability to truly use your "gut instinct". You may feel instinctively that a patient is at risk of imminent harm but don't have any evidence e.g. they are saying the right things, don't seem manic or psychotic, and don't have the past dangerous behavior patterns, and you know it will be impossible to defend in court, so you have to let them leave. Or a patient can be telling you they are suicidal and/or homicidal for days and you don't really believe them and think they are malingering or factitious. But you can't defend that either because there are no signs or pattern of behavior to back you up. So you end up keeping or discharging patients (mostly keeping) when you deep down think you should do the opposite. Does this happen to anyone else? Inpatient ends up feeling like a game, where you give medications that probably won't help, and people just get bored, start saying the "right things" to leave, and eventually leave. The personality disordered people certainly don't change. The psychotic patients stop taking meds when they leave. The drug intoxicated, truly depressed (rare), and manic (rare) patients are the only patients that I feel may actually benefit from hospitalization.

Correction: the psychotic patients who repetitively present to inpatient units stop their meds immediately upon leaving. A lot of folks with a primary psychotic disorder are have an index hospitalization or two and then never again for the rest of their lives. You have an enriched sample of non-adherent people up in there

You want excitement, though...try seeing your Friday 4 o'clock on your own in an office and they show up barely sleeping talking about the connection between their birthday and 9/11 that they always get preoccupied with before things go south, and they refuse to go to the ED. No grounds for involuntary commitment.

That's when you really sweat.

 

[Bartelby]

I don't say "you can either sign in voluntarily, or I can put you on a hold" because that seems manipulative.

Put bluntly in that way, it could be manipulative. There is nothing wrong, though, with giving a patient the choice along with education about their options if they have the capacity to make the decision. Because in truth, they *can* choose to sign in voluntarily and will not be placed on a hold (if you deem that route appropriate / acceptable). That may mean they do not have an involuntary hold on their records, which may have implications for future licensing / employment / security clearance, for owning a firearm, etc. It also sometimes leads to a more collaborative treatment relationship. Whenever I say something along the lines of the above it is not because I want to avoid the work involved with doing a hold, or to somehow cheat them out of their rights. It is just offering a legitimate choice.

This of course presumes that you view allowing them to sign in on a voluntary basis as a legitimate option; given that you mentioned you ask if they want to be in the hospital and place a hold if they say "no" I presume you are referring to patients who could sign in if they so chose.

Basically, telling them about the available options (one of which is a hold) isn't a threat. It's just a statement of fact.

 

[Nines]

I've found inpatient very rewarding but only when the following happened.
1-I worked with a great team. Good nurses, therapists, other doctors, and social workers.
2-The unit was smart. Now what I mean by this is they aren't taking BS from patients but not overplaying their hand and being rude or insensitive.. E.g. if the patient is completely or totally cluster B everyone knows inpatient isn't going to help but instead of callously kicking the patient out the staff knows refers the patient to psychotherapy and discharge the patient in a respectful manner.
3-The corresponding other players, e.g. the IM consultant, the ER doctors/psychiatrists were also doing their thing.

I've never had 100% of the above, but when I had about 80% of it I was fine. I always had some whiney BS IM consultant who wouldn't show up and do the consult or a nurse who'd inject all the patients with Haldol PRN so she didn't have to do any real work during her shift, etc.

Agree with this totally. At my last job the quality of staff was very uneven. Some staff was awesome and some were terrible. Huge difference as well between first and second/third shifts (probably because the unit docs weren't around then). Somtimes, for a time, the stars would align and I would have a team of good nurses, social workers and techs and it would be great. But other times there would be really bad support staff and it would be awful. Inpatient felt like a roller coaster. Could be really interesting and even fun at times. At other times it could be terrible due to a combination of lousy staff and difficult patient mix. Sadly the really good staff tended to leave at the first opportunity because they were not valued by admin and ended up shouldering the burden of their incompetent and lazy coworkers.

 

[NickNaylor]

Re: patients coming to the inpatient unit voluntarily or involuntarily, my approach when I'm working in our ED depends on the situation. If someone is entirely unable to engage in a reasonable conversation about hospitalization - e.g., they're simply too psychotic and have no ability to understand what's going on - then I'm going to involuntarily hospitalize them regardless. For patients that are able to understand hospitalization at least to some degree, I will explain to them my recommendation. For someone that needs to go to the hospital and meets criteria for involuntary hospitalization, I will offer hospitalization on a voluntary basis, but if they refuse, I will tell them that going home at this point isn't an option, and if they choose not to sign-in voluntarily then I will file involuntary paperwork and they will go regardless (often with the cost of more time spent in the very uncomfortable ED). Is this manipulative? I don't know, maybe, but I don't present it with the intention of being manipulative - it is simply the reality of the situation, and I want them to have the ability to make choices based on the reality of the situation.

 

[hebel]

I appreciate everyone's responses.

Another issue I'm running into, is meds for mania and psychosis (more for psychosis) often take time to have a therapeutic effect. Especially for psychosis...once you get to a therapeutic dose you can be looking at 1-2 weeks at a minimum for substantial effect.

This is frustrating, because by then the psychotic or manic patients want to go and it's been long enough that perhaps they are no longer committable if you strictly apply the danger to self or others standard. So they come in, are pissed at you for being admitted, then you finally start seeing improvement but then they technically gain the right to leave, but are still symptomatic enough that the admission (and all the BS they put you through) feels like a waste.

 

[Armadillos]

I appreciate everyone's responses.

Another issue I'm running into, is meds for mania and psychosis (more for psychosis) often take time to have a therapeutic effect. Especially for psychosis...once you get to a therapeutic dose you can be looking at 1-2 weeks at a minimum for substantial effect.

This is frustrating, because by then the psychotic or manic patients want to go and it's been long enough that perhaps they are no longer committable if you strictly apply the danger to self or others standard. So they come in, are pissed at you for being admitted, then you finally start seeing improvement but then they technically gain the right to leave, but are still symptomatic enough that the admission (and all the BS they put you through) feels like a waste.

Try to get patients in this situation started on a LAI

 

[JKinSC]

Can one of the forensics folks here address this topic of offering a patient a choice? If I were to decide someone needed to be involuntarily committed, isn’t that basically saying that they don’t have decision-making capacity? If that’s the case, and they don’t have the capacity to refuse treatment, then they don’t have the capacity to agree to it, either, do they?

That is to say, if you think they’re committable, you commit them, right? Of course, this may just be a result of my training in a very paternalistic state...

 

[michaelrack]

Can one of the forensics folks here address this topic of offering a patient a choice? If I were to decide someone needed to be involuntarily committed, isn’t that basically saying that they don’t have decision-making capacity? If that’s the case, and they don’t have the capacity to refuse treatment, then they don’t have the capacity to agree to it, either, do they?

That is to say, if you think they’re committable, you commit them, right? Of course, this may just be a result of my training in a very paternalistic state...

Many people who are made involuntary do have decision making capacity... commitment is usually about dangerousness rather than inability to care for self.

 

[J ROD]

Can one of the forensics folks here address this topic of offering a patient a choice? If I were to decide someone needed to be involuntarily committed, isn’t that basically saying that they don’t have decision-making capacity? If that’s the case, and they don’t have the capacity to refuse treatment, then they don’t have the capacity to agree to it, either, do they?

That is to say, if you think they’re committable, you commit them, right? Of course, this may just be a result of my training in a very paternalistic state...

The two are separate processes. Capacity is determined at a point in time does that person meet it. Some folks that are psychotic do have capacity and can sign in voluntarily. Now, many let them sign in even if it may be in doubt or borderline if they do actually have capacity to consent to voluntarily treatment. They need treatment and get it. IVC someone is usually if someone is SI/HI, acutely psychotic/mania and a harm to themselves or others, or their symptoms are so severe they are unable to care for themselves in the basic sense. Having or not having capacity is not IVC criteria necessarily.

 

[splik]

Can one of the forensics folks here address this topic of offering a patient a choice? If I were to decide someone needed to be involuntarily committed, isn’t that basically saying that they don’t have decision-making capacity? If that’s the case, and they don’t have the capacity to refuse treatment, then they don’t have the capacity to agree to it, either, do they?

That is to say, if you think they’re committable, you commit them, right? Of course, this may just be a result of my training in a very paternalistic state...

Well in many areas you have to meet criteria for involuntary hospitalization (in terms of dangerousness to self or others) to qualify for voluntary hospitalization. You are correct however, that contrary to the above posts, if you are hospitalizing someone involuntarily you are basically saying they do not have the capacity to consent to hospitalization vs discharge and that is the basis for taking away their rights. Similarly, if a patient does not have a reality based concept of voluntarily hospitalization but are agreeing to it, that is not valid and they should be made involuntary.

If you have a patient who is in suicidal crisis, is coming voluntarily for treatment, agrees they need treatment and hospital is the best place for them, then even though they may meet civil commitment criteria, they usually should be allowed to be voluntarily if they have the capacity to be voluntary.

If you have a patient agreeing to hospitalization but they believe that the inpatient unit is the 7th circle of hell where they will be justly persecuted and tortured for their sins, that assent would not be valid and they would need to be involuntarily hospitalized because they lack capacity to consent.

It gets more complicated because in some states there is a distinction between civil commitment and involuntary treatment, so there is this legal fiction that patients admitted involuntarily may still have the right/capacity to refuse treatment absent a specific finding they lack capacity to consent to said treatment.

 

[J ROD]

How about folks that tried to kill themselves that I IVC after a suicide attempt and want to just walk out the hospital. They have capacity.

 

[splik]

How about folks that tried to kill themselves that I IVC after a suicide attempt and want to just walk out the hospital. They have capacity.

well if they have capacity to decline hospitalization why are you involuntarily detaining them? You are detaining them because, presumably, you believe that they have an ongoing elevated risk of harming themselves and cannot appreciate that enough to agree to ongoing hospitalization. You are making the assessment that the suicide attempt indicates their judgement is impaired by their mental state. Which is to say, they they do not have capacity to refuse hospitalization. Otherwise you would let them go.

 

[michaelrack]

I do not find treating somebody against their will a pleasurable experience.

well if they have capacity to decline hospitalization why are you involuntarily detaining them? You are detaining them because, presumably, you believe that they have an ongoing elevated risk of harming themselves and cannot appreciate that enough to agree to ongoing hospitalization. You are making the assessment that the suicide attempt indicates their judgement is impaired by their mental state. Which is to say, they they do not have capacity to refuse hospitalization. Otherwise you would let them go.

"well if they have capacity to decline hospitalization why are you involuntarily detaining them?" Because the patient's situation is unclear, and depending in which of 3 states I am practicing in I can admit them involuntarily for 3-7 days before deciding whether to bring the patient before a judge or make them voluntary. Less than 25% of my involuntary patients (in Shelby County TN) end up going to court- and I am much more likely to go to court for dangerousness to others than for to self.


I

 

[michaelrack]

It gets more complicated because in some states there is a distinction between civil commitment and involuntary treatment, so there is this legal fiction that patients admitted involuntarily may still have the right/capacity to refuse treatment absent a specific finding they lack capacity to consent to said treatment.

Most of my involuntary patients are eager for treatment- just not on an inpatient basis. I have had a few frustrating situations, however, with a few persons with schizophrenia who are absolutely opposed to treatment. After they have had their involunatry court hearing, I can force short-acting medication ( will typically give an order for scheduled oral zyprexa or haldol with IM if oral refused), but can't force LAI (but can do this if patient has conservator)

 

[michaelrack]

I've been working outpatient for the past few years and am now doing inpatient work for about the next 6 months. How do you guys keep doing this long-term?

Compared to outpatient, it's so draining treating patients who don't want treatment or don't even want to be on the unit. It can feel pretty disheartening going from dealing with a severely agitated patient wanting to leave, to another patient who you've been working so hard to build an alliance with suddenly curse you out while demanding a transfer, to then having another patient accuse you of violating their rights and wanting to talk to patient advocacy.

This sucks!

A good patient advocate can help diffuse the situation, and may be able to identify something that can be done to make the patient less dissatisfied.
If you are providing appropriate treatment, the patient advocate is no one to fear.

 

[J ROD]

"well if they have capacity to decline hospitalization why are you involuntarily detaining them?" Because the patient's situation is unclear, and depending in which of 3 states I am practicing in I can admit them involuntarily for 3-7 days before deciding whether to bring the patient before a judge or make them voluntary. Less than 25% of my involuntary patients (in Shelby County TN) end up going to court- and I am much more likely to go to court for dangerousness to others than for to self.


I

Precisely. Did they or did they not want to kill themselves. I am not sure. Need time to gather collateral, etc. IVC and let them get some treatment while the details come together. Many are substance related and clear up. But, at that moment, I cannot say...yeah just let them leave. Now they lack judgment and insight....but capacity to make bad decisions.

 

[splik]

Precisely. Did they or did they not want to kill themselves. I am not sure. Need time to gather collateral, etc. IVC and let them get some treatment while the details come together. Many are substance related and clear up. But, at that moment, I cannot say...yeah just let them leave. Now they lack judgment and insight....but capacity to make bad decisions.

if you are saying someone lacks insight and judgement regarding these matters you are implicitly saying they lack capacity.. That is the entire legal basis for depriving patients of their liberty. It is not simply dangerousness, it is dangerousness on the basis of mental impairment. Which is why I can discharge patients who are threatening to kill others if I don't think they have a major mental disorder.

In these cases where you are hedging and need more time you are saying the risk at that point is great enough to assume the patient's decision-making capacity is impaired. We may be splitting hairs here but I think a lot of people don't understand that the two are ineffably interwoven in civil commitment law. We don't explicitly talk about capacity when discussing civil commitment but it is actually the basis of it. This has been more clearly articulated for outpatient commitment (so-called "assisted outpatient treatment") but the same principles apply for inpatient commitment as well.

 

[hamstergang]

well if they have capacity to decline hospitalization why are you involuntarily detaining them? You are detaining them because, presumably, you believe that they have an ongoing elevated risk of harming themselves and cannot appreciate that enough to agree to ongoing hospitalization.

I disagree. Some patients fully appreciate that they are at an elevated risk for killing themselves upon discharge but don't care; they want to die. We would still involuntarily commit these patients because of this risk and not because of any determination we've made about their capacity.

 

[splik]

I disagree. Some patients fully appreciate that they are at an elevated risk for killing themselves upon discharge but don't care; they want to die. We would still involuntarily commit these patients because of this risk and not because of any determination we've made about their capacity.

well what is your basis for not allowing them to kill themselves? Why is it that society puts us in a position of trying to prevent people from ending their lives? It is because we have made a collective judgement (whether we as individuals believe in it or not) that people with mental disorders have impaired judgement and are acting in ways they would not otherwise. This is fundamentally what we are talking about when we talk about capacity. My point is that these determinations are not explicit, but implied. That is the legal and societal rationale for commitment.

 

[Armadillos]

Reading spliks post does make me think this is kind of one of those areas where society has thrown their hands up at the moral complexity of how to handle involuntary hospitalization of suicidal patients and expect doctors to just “do the right thing” without anyone really knowing exactly what that is.

For example, a suicidal patient is so dangerous to themselves that we determine must be detained for own safety, however then immediately hours or minutes later turn around and get informed consent about it they want abilify vs Wellbutrin augmentation of their SSRI.

Which from a purely philosophical/logical standpoint this is ridiculous because if they are so dangerous to themselves they need to be deprived of basic rights, then presumably they would just choose the drug most likely to kill them. However obviously that’s not what happens, the suicidal patient tends to actually engage in deciding what medication seems to be in their best interest.

At which point these two things are now philosophically inconsistent but from a practical standpoint it happens daily.

 

[michaelrack]

Parens Patriae (roughly government intervening for incompetence) is one of the 2 legal justifications for civil commitment.... the other is Police Power (roughly the state's right to protect the interests of its citizens). Competiting ethical principles include autonomy vs beneficence (for example, preventing from harming self).
If one looks at this from a capacity perspective, incapacity to choose treatment setting does not imply that the patient does not have the capacity to consent to treatment (medication)

 

[michaelrack]

I hate it when an Er makes a voluntary patient involuntary for transportation issues..... so the sheriff will provide transportation

 

[Armadillos]

If one looks at this from a capacity perspective, incapacity to choose treatment setting does not imply that the patient does not have the capacity to consent to treatment (medication)

I agree with you practically, but from devils advocate position if the reason we are saying the patient doesn’t have capacity to choose treatment setting is because they are going to imminently kill themselves otherwise, then why do we not feel that desire for imminent self harm will impact decision making on medication choices?

 

[hamstergang]

well what is your basis for not allowing them to kill themselves? Why is it that society puts us in a position of trying to prevent people from ending their lives? It is because we have made a collective judgement (whether we as individuals believe in it or not) that people with mental disorders have impaired judgement and are acting in ways they would not otherwise. This is fundamentally what we are talking about when we talk about capacity. My point is that these determinations are not explicit, but implied. That is the legal and societal rationale for commitment.

If we determine a patient to lack capacity, then a surrogate decision-maker is assigned, but with involuntary commitment the psychiatrist automatically makes the hospitalization decision. While the underlying rationale for the 2 processes may be similar, they are distinct processes nonetheless.

And the reasoning isn't the same in all situations. Someone who lacks capacity isn't just exhibiting poor judgment, we are determining that they don't properly understand the situation. In fact, we allow people to exhibit poor judgment, unless it's in the setting of dangerous behaviors resulting from mental illness. Someone with mental illness could have a poor understanding of their situation and exhibit poor judgment, but if they're not dangerous we don't involuntarily commit them. Someone with a non-mental illness who has a poor understanding of their situation and exhibits poor judgment could be determined to lack capacity. The standards for these two processes are just not the same. At least in NJ, the civil commitment statute makes no mention of capacity from my recollection.