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

[clausewitz2]

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?

I think a missing piece is that we are not talking about "choice of treatment setting" in the sense of 'the office with the blue sofa v the office with the beige sofa." The idea that a patient could lack capacity to decide that but could make reasonable decisions about medications would indeed be incredible. But if voluntary v involuntsry treatment setting is a superordinate category of the treatment itself it is not at all strange that someone might lack the capacity to make the decision about hospital or no but would retain the ability to meaningfully decide amongst details that are a proper subset of the former decision.

A demented person might lack capacity to decide whether they should eat a meal today, but we have no trouble believing they have capacity to first eat the ham sandwich and then the applesauce or vice versa.

The choice the patient faces is 'given that these people will to a great extent physically prevent me from ending my life, which of these options of medication is most consistent with my desires?" Framed like this it is not that surprising that they mostly do not just choose the most lethal medication possible, at least absent an offer of a loading dose of sodium cyanide.

---

Members don't see this ad.

 

[clausewitz2]

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.

The question, though, is why should dangerous decisions stemming from mental illness be treated differently? Steve Irwin clearly made repeated and eventually lethal dangerous decisions but at no point did anyone suggest he should be imprisoned to prevent him from doing so. I do not think you can come up with a justification for treating the dumb **** people do that is attributable to a formal psychiatric diagnosis any differently than the dumb **** people do who don't qualify for one without reference to decision-making capacity. How the text of the statute chooses to specify the process is fairly immaterial.

Either we say that mental illness represents a special case of failure of faculties of reason and or/judgement that deserves a custodial and interventionist approach to a unique extent, or we say that they definitely have the ability to reason perfectly well about whether to live or die and we lock them up just because the State tells us to and obey orders. I am not sure how you live with yourself if you think the later is the actual fact of the matter and you work inpatient so I think the former is much more the charitable assumption...

 

[hamstergang]

Either we say that mental illness represents a special case of failure of faculties of reason and or/judgement that deserves a custodial and interventionist approach to a unique extent

This sounds to me to be precisely what the situation is. And that's why the involuntary commitment process is different from declaring a patient to lack capacity. The original question that created this discussion was about how you can let a patient sign in voluntarily if you were otherwise planning to involuntarily commit them. The answer is that the involuntary commitment process does not actually address the question of capacity -- we view this as something different because we view mental illness as something different. Whether that's reasonable or not, I believe it's the correct explanation.

 

[Desired Member]

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.

Hmm this is really interesting. I never thought about it that way. I think of involuntary commitment as someone needing to be in a secured environment due to risk of imminent harm, due to a psychiatric disorder or effect of a substance. I never thought of an involuntary commitment implying that the person lacks capacity. I see so many suicidal and/or homicidal personality disordered patients and I never thought of them not having capacity. I really think the elephant in the room is always the personality disordered patients, as I'm never sure we are helping them with admission, and I'm not sure that they don't have capacity. But they do appear to be at risk of imminent harm sometimes.

 

[clausewitz2]

This sounds to me to be precisely what the situation is. And that's why the involuntary commitment process is different from declaring a patient to lack capacity. The original question that created this discussion was about how you can let a patient sign in voluntarily if you were otherwise planning to involuntarily commit them. The answer is that the involuntary commitment process does not actually address the question of capacity -- we view this as something different because we view mental illness as something different. Whether that's reasonable or not, I believe it's the correct explanation.

Right. Set aside legal terms of art wrt 'capacity' or 'competence' for a momebt. We view mental illness as something different that robs a particular person of the ability to make ressonable choices that are genuinely motivated by their goals and values because it imposes some manner of uncharacteristic or pathological aberration of their faculties. They are thus not capable of making a decision on the particular question using a thought process that is sufficiently similar to some standard or set of standards defining acceptable modes of reasoning or decision-making. In other words, they are not capable of making this decision.

If you really believed that this was not the case, how do you justify stripping someone of very basic autonomy from a moral perspective?

 

[Desired Member]

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.

This is what I do too. I was just saying, I was taught that it is wrong to tell an imminent harm patient "if you don't sign in voluntarily, I'll have to commit you" regarding a patient that is able to engage with the facts but wants to leave (usually an angry borderline patient who just had a suicide attempt). If you think patient presents likelihood of imminent harm, they are able to engage with the facts and they want inpatient treatment, then I would have them sign voluntarily. If I think they present a likelihood of imminent harm, they are able to engage with the facts, but don't want inpatient treatment, I would then reveal to them that I am going to put them on a hold. Basically all I was trying to say is, the decision to stay for treatment should be up to the patient if possible. It shouldn't be a coercion, where they think, "Oh, I guess I have to sign in voluntarily because I don't want to be on a hold."

 

[Desired Member]

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

Yes, "enriched sample of non-adherent people" is a nice way of describing them. Also see a lot of meth induced psychosis, and not just in the intoxicated stage.

 

[comp1]

Teams!!! If you have a bad team, leave. The whole benefit is working closely with other professionals. I always prefer treatment by consensus, including the patient, of course, when you can. I found outpatient terribly lonely and hated having no one to bounce ideas off of.

 

[ArdorAyurveda]

For inpatient psychiatry, when do you refer to a different specialty vs. manage the patient's symptoms on your own?

For example, when do you refer a patient to cardiology or internal medicine?

Asking because I plan to work with not-so-healthy patients, and I want to be a good doctor.

 

[Shufflin]

For inpatient psychiatry, when do you refer to a different specialty vs. manage the patient's symptoms on your own?

For example, when do you refer a patient to cardiology or internal medicine?

Asking because I plan to work with not-so-healthy patients, and I want to be a good doctor.

That's what med school and residency was for.

 

[hamstergang]

Right. Set aside legal terms of art wrt 'capacity' or 'competence' for a momebt.

Well, whether or not we set aside legal terms depends on what was actually being asked and what we are actually trying to answer. I read the question that led to this line of discussion as being a legal question, not a philosophical one:

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?

I think we're not reaching a singular agreement because we're not addressing the same issue.

 

[JKinSC]

Well, whether or not we set aside legal terms depends on what was actually being asked and what we are actually trying to answer. I read the question that led to this line of discussion as being a legal question, not a philosophical one:


I think we're not reaching a singular agreement because we're not addressing the same issue.

My question was meant to be from a legal standpoint, yes. My assumption has always been that if someone is sick enough that I feel justified in taking away their civil rights, I am saying that they lack capacity to make their own decisions, even if not explicitly. If, big if, that’s the case, it’s unethical to refrain from making that declaration simply because they’re doing what I want. If that is wrong on it’s face, I’ve absolutely learned something - and if it varies by state, I’ll learn from that as well.
I’ve honestly enjoyed the back and forth, however. It’s one of the reasons I seriously considered doing forensics fellowship, before I remembered that I was older than tea.

 

[michaelrack]

In my day to day work I focus on dangerousness, in most cases in my state capacity isn't a practical way to look at civil commitment. Besides, what if a psychiatrist using a capacity standard comes to the conclusion that suicide is rational in a certain case (some countries even allow physician assisted suicide)?
As a licensed physician in the state of Tennessee, it's my duty to prevent severe harm resulting from mental illness in my patients. Often this is done utilizing the police power given to me by the state, under judicial supervision.

 

[romanticscience]

For those of you interested in forensic psychiatry. Here's a relevant landmark case (Ford, 2014).

ZINERMON V. BURCH, 494 U.S. 113 (1990)

Zinermon v. Burch, 494 US 113 - Supreme Court 1990 - Google Scholar

scholar.google.com

Question: Can an incompetent individual consent to voluntary hospitalization?

Answer: No.

Darrell Burch was admitted to a Florida state mental hospital in 1981 after being found wandering on a highway in Tallahassee while hallucinating, telling officials he was “in heaven.” He signed voluntary admission forms despite never having been evaluated for capacity. Voluntary admission in Florida required “express and informed consent.” He later brought a civil rights action claiming that the hospital had deprived him of liberty without due process as afforded by the Fourteenth Amendment. Mr. Burch alleged that state law was violated because the hospital should have known that he was incompetent to give informed consent to sign voluntary forms; hence he was entitled to procedural safeguards of an involuntary admission. The case was initially dismissed, but the U.S. Supreme Court ultimately agreed with Mr. Burch. It held that because the hospital’s staff had authority to deprive persons of liberty, the Constitution imposed on them the state’s duty to provide procedural protections. The Court contended that it was foreseeable that a person requesting treatment for mental illness might not be capable of informed consent, which should be specifically assessed at the time of admission. The state’s violation of the duty to investigate the patient’s competence was “fully predictable” and not a “random, unauthorized” violation of law as the state contended.

 

[michaelrack]

ZINERMON V. BURCH, 494 U.S. 113 (1990)

Zinermon v. Burch, 494 US 113 - Supreme Court 1990 - Google Scholar

scholar.google.com

Question: Can an incompetent individual consent to voluntary hospitalization?

Answer: No.

Interesting case. I run into this problem sometimes, especially in patients with cognitive deficits. I have no problem getting the initial involuntary paperwork done, but problems sometimes come up with taking them to court (which currently due to covid is being done in the hospital- the judges and attorneys come down). I have been told by our legal person that some of our rotating judges won't want to see them and give us a hard time if they aren't acutely dangerous and are currently basically cooperative. You may be asking why are then still hospitalized- placement (often waiting for covid tests to come back ) and final stages of med adjustment. In these cases the patient signs in voluntarily and I try to discharge asap.

 

[Nines]

Where I worked we could petition the court to reject voluntary admission for a patient who attempted to sign in if we felt they didnt have capacity. However in practice the court would almost always let them sign in anyways unless they are refusng meds and being violent on the unit. This often led to difficult situations where a patient is allowed to sign by the court in but is refusing meds and you cant force meds on a "voluntary" patient.

 

[hebel]

Do some of you guys really think involuntary admission on its own is sufficient to determine that a patient lacks capacity to express choices related to their medications once admitted? Seriously?

 

[Armadillos]

Do some of you guys really think involuntary admission on its own is sufficient to determine that a patient lacks capacity to express choices related to their medications once admitted? Seriously?

Don’t think anyone is really making that blanket statement, but I would say if you feel like a very high percent of your involuntary admits have the capacity to provide adequate informed consent about meds during the first 24hrs of hospitalization then maybe your admitting too many folks involuntarily who potentially could have been treated in a less restrictive setting.

(Not saying you specifically obviously, just a general thought that maybe involuntary hospitalizations are somewhat over utilized, especially in regard to potential for suicide being the primary concern in a non-psychotic/manic patient).

 

[Desired Member]

For those of you interested in forensic psychiatry. Here's a relevant landmark case (Ford, 2014).

ZINERMON V. BURCH, 494 U.S. 113 (1990)

Question: Can an incompetent individual consent to voluntary hospitalization?

Answer: No.

We are talking about capacity, not competency. I thought only a judge could determine competency? I thought just because a patient lacks capacity to make one decision doesn't mean they lack capacity to make all decisions.

 

[Desired Member]

I run into this problem sometimes, especially in patients with cognitive deficits. I have no problem getting the initial involuntary paperwork done, but problems sometimes come up with taking them to court (which currently due to covid is being done in the hospital- the judges and attorneys come down). I have been told by our legal person that some of our rotating judges won't want to see them and give us a hard time if they aren't acutely dangerous and are currently basically cooperative. You may be asking why are then still hospitalized- placement (often waiting for covid tests to come back ) and final stages of med adjustment. In these cases the patient signs in voluntarily and I try to discharge asap.

I thought an involuntary psychiatric hold is not to be used for patients with cognitive disorders, e.g. dementia, intellectual disability? I thought that in those cases, a surrogate decision maker (e.g. family member or worst case scenario, chief of staff of hospital, etc.) consents to continued hospitalization. If they also have a diagnosable mental illness e.g. schizophrenia, and that is the reason for imminent harm/inability to care for self , that's why an involuntary psychiatric hold is used to keep them psychiatrically hospitalized.

 

[Sushirolls]

So much of involuntary vs voluntary, is state specific. Nuances of commitment process is state specific. Some of these details just don't transcend into practice across clinical lines. Know your state.

 

[OldPsychDoc]

So much of involuntary vs voluntary, is state specific. Nuances of commitment process is state specific. Some of these details just don't transcend into practice across clinical lines. Know your state.

And can even be county-specific, depending on attitude of county attorneys and judges toward mental illness

 

[Nines]

I thought an involuntary psychiatric hold is not to be used for patients with cognitive disorders, e.g. dementia, intellectual disability? I thought that in those cases, a surrogate decision maker (e.g. family member or worst case scenario, chief of staff of hospital, etc.) consents to continued hospitalization. If they also have a diagnosable mental illness e.g. schizophrenia, and that is the reason for imminent harm/inability to care for self , that's why an involuntary psychiatric hold is used to keep them psychiatrically hospitalized.

In the state I practice the distinction between the legal processes to deal with involuntary hospitalization and treatment is made by setting of treatment, not by diagnosis. For example, think of a catatonic patient who needs ECT. If that patient is on the medical floor and NOT in a psych unit or psych hospital then if the patient does not have capacity to consent to or refuse ECT decision making would be deferred to the patient's legal guardian and if no guardian then to patient's healtcare POA or next of kin and ECT can be forced via that consent process with no probate court involvement. If same patient is in a psych unit then none of that applies. If patient has no capacity and has no guardian then decision to force ECT must come through the probate court. In my county the court NEVER forces ECT. If patient medically decompensates and transfers to medical floor then the former applies.

 

[Stagg737]

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.

Seems like the statement was hyperbolic, but I can see where J Rod is coming from. Anxiety is probably my least favorite thing to treat, and imo a fair amount of the people I've seen don't need meds at all, they need to develop coping mechanisms and learn to deal with reality their affluenza. This isn't to say there aren't many who truly need treatment for anxiety, but I do think with the increased awareness of MH in society has led to certain reactions and thought processes to be seen as pathological when they really aren't.

I also think setting obviously makes a huge difference, as my outpatient rotations in med school (relatively stable/low acuity, financially stable/insured) were VERY different than most of my outpatient experiences as a resident. Even with my current patients though (much more of the people you're referring to), there's still a lot of BS that I'd rather not deal with that generally doesn't exist on the inpatient/consult side of things.

The question, though, is why should dangerous decisions stemming from mental illness be treated differently? Steve Irwin clearly made repeated and eventually lethal dangerous decisions but at no point did anyone suggest he should be imprisoned to prevent him from doing so. I do not think you can come up with a justification for treating the dumb **** people do that is attributable to a formal psychiatric diagnosis any differently than the dumb **** people do who don't qualify for one without reference to decision-making capacity. How the text of the statute chooses to specify the process is fairly immaterial.

Except they aren't. If Steve Irwin were just some random guy who decided spur of the moment to jump into a lake of crocodiles, the police and other people would stop him. If it were something that were planned out and reasons given like Irwin did, they wouldn't. MH is only different because there should be a treatable condition directly causing the individual to think in an illogical manner. Whether a person has a h/o MH or not, if they try and kill themselves or say they are going to, they're going to be brought in against their will for an eval. If the threat is towards someone else, the same thing would happen. The only difference is the one with MH problems is likely going to get taken to a hospital while the other one gets involuntarily detained by the police.

So I don't think there really is a difference in situations where someone is being admitted involuntarily d/t dangerousness. I do think that your argument is valid for those admitted d/t lack of self-care though, as those without a MH problem would likely not be admitted until they start to medically decompensate while those who were psychotic or depressed would be admitted to psych before they developed medical problems.

 

[clausewitz2]

Seems like the statement was hyperbolic, but I can see where J Rod is coming from. Anxiety is probably my least favorite thing to treat, and imo a fair amount of the people I've seen don't need meds at all, they need to develop coping mechanisms and learn to deal with reality their affluenza. This isn't to say there aren't many who truly need treatment for anxiety, but I do think with the increased awareness of MH in society has led to certain reactions and thought processes to be seen as pathological when they really aren't.

I also think setting obviously makes a huge difference, as my outpatient rotations in med school (relatively stable/low acuity, financially stable/insured) were VERY different than most of my outpatient experiences as a resident. Even with my current patients though (much more of the people you're referring to), there's still a lot of BS that I'd rather not deal with that generally doesn't exist on the inpatient/consult side of things.



Except they aren't. If Steve Irwin were just some random guy who decided spur of the moment to jump into a lake of crocodiles, the police and other people would stop him. If it were something that were planned out and reasons given like Irwin did, they wouldn't. MH is only different because there should be a treatable condition directly causing the individual to think in an illogical manner. Whether a person has a h/o MH or not, if they try and kill themselves or say they are going to, they're going to be brought in against their will for an eval. If the threat is towards someone else, the same thing would happen. The only difference is the one with MH problems is likely going to get taken to a hospital while the other one gets involuntarily detained by the police.

So I don't think there really is a difference in situations where someone is being admitted involuntarily d/t dangerousness. I do think that your argument is valid for those admitted d/t lack of self-care though, as those without a MH problem would likely not be admitted until they start to medically decompensate while those who were psychotic or depressed would be admitted to psych before they developed medical problems.

My point may not have been clear. What I was saying was that the only way I can see, from a moral/ethical/philosophical standpoint, to justify involuntary treatment is that there is a defect in the capacity to reason from available information to conclusions in a way that is sufficiently similar to normative thought processes. It's not about the behaviors per se.

Suicide/suicidality is the one area where behaviors ipso facto may be reason enough because we reject the idea that suicide can be the conclusion reached by any reasonable process from a possible set of facts (bracketing off the euthanasia question for a moment). Interestingly enough this probably ends up capturing a whole lot of people without a recognized psychiatric condition, which really only strengthens the observation that behaviors are not sufficient for distinguishing the psychiatric from non.

 

[Desired Member]

Suicide/suicidality is the one area where behaviors ipso facto may be reason enough because we reject the idea that suicide can be the conclusion reached by any reasonable process from a possible set of facts (bracketing off the euthanasia question for a moment). Interestingly enough this probably ends up capturing a whole lot of people without a recognized psychiatric condition, which really only strengthens the observation that behaviors are not sufficient for distinguishing the psychiatric from non.

Could you discharge someone who is suicidal with plan if no mental illness was evident? Like they had capacity and were able to weigh pros and cons of killing themselves, etc. I've never actually had this situation arise, but I think it may be interesting to discuss

 

[michaelrack]

Could you discharge someone who is suicidal with plan if no mental illness was evident? Like they had capacity and were able to weigh pros and cons of killing themselves, etc. I've never actually had this situation arise, but I think it may be interesting to discuss

I can imagine myself doing this after a period of lengthy inpatient evaluation. Rational reasons for suicide could include avoiding a fate worth than death (in the mind of the patient)- worsening disability, the progression of a neurocognitive disorder, severe unrelievable pain.
I personally would be against suicide in all of the above circumstances, but that's based on my spiritual/religious beliefs. If, after a period of detailed evaluation I did not feel that the patient currently met criteria for involuntary hospitalization (ie, that mental illness was not causing the desire to die), I would discharge the patient.

 

[NontradCA]

As a resident who recently started outpatient year, I'd say inpatient is way easier and I can see how that would be appealing.

-You are responsible for resolving acute issues, much of which can be resolved with Ativan
-You can give IM injections of Ativan
-You don't have to check CURES before ordering Ativan

Among other things.

 

[michaelrack]

I sometimes give geodon or haldol/benadryl with the ativan

 

[NontradCA]

I sometimes give geodon or haldol/benadryl with the ativan

We tried to get our PD on board with having us get 5/2/50s as part of intern year for empathy purposes. For some reason he didn’t buy it

 

[michaelrack]

We tried to get our PD on board with having us get 5/2/50s as part of intern year for empathy purposes. For some reason he didn’t buy it

At the for profit free-standing psych hospital I work for, we get patients that are considered "too acute" (too aggressive) for University psych units or psych units that are part of general medical hospitals (in addition to these "acute" patients, we also get the standard depressed/suicidal etc patients). I say this as someone who has worked in pretty much every setting in existence. Sometimes it's necessary to sedate a patient quickly.

 

[NontradCA]

At the for profit free-standing psych hospital I work for, we get patients that are considered "too acute" (too aggressive) for University psych units or psych units that are part of general medical hospitals (in addition to these "acute" patients, we also get the standard depressed/suicidal etc patients). I say this as someone who has worked in pretty much every setting in existence. Sometimes it's necessary to sedate a patient quickly.

My place is in Meth capital of the world, no exaggeration. So I understand.