Involuntary commitment question

[Bartelby]

While the patient is in the hospital, you might be able to ensure that they are able to safely leave (e.g. walk alongside them to catch them if they fall) because you still have responsibility for their well-being while they are in the building.

Although if you do so while the person raves "get away from me" you've technically committed battery for unwanted contact. And as you watch them stumble in front of a truck on the road by the hospital you assigned yourself a slam dunk wrongful death case (and will probably get your hospital shut down by a regulatory agency).

It's an impossible situation where to hold people is false imprisonment/ battery and to fail to do so is very serious malpractice.

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[Stagg737]

" Here’s my problem: the psychiatry department will evaluate these patients and write in their chart that they “lack capacity.” And are “admitted voluntarily,” while also writing that, because they lack capacity, the cannot leave AMA and should be physically restrained if they try. This often results in multi day admissions to a medical ward without psychiatric treatment. "

Zinermon v. Burch?

Yea, as far as I'm concerned lacking capacity and "voluntary admission" are mutually exclusive. Patients lacking capacity who are admitted are admitted for medical necessity, not because they consent. That being said, consent (requiring legal capacity) and assent (general agreeableness) are not the same where I practice and patients without capacity can still assent to be admitted and then be stopped from leaving as they never had capacity in the first place.

 

[aim-agm]

Although if you do so while the person raves "get away from me" you've technically committed battery for unwanted contact. And as you watch them stumble in front of a truck on the road by the hospital you assigned yourself a slam dunk wrongful death case (and will probably get your hospital shut down by a regulatory agency).

It's an impossible situation where to hold people is false imprisonment/ battery and to fail to do so is very serious malpractice.

There actually is caselaw involving people who left the ED while drunk and got hit by cars then sued the ED, and the defense was able to show that the ED did not have legal right to hold the patient, which totally quashed any claim the plaintiff had on that front. So its actually the opposite: there's a slam dunk defense against that wrongful death suit.

But I agree that there is an impossible situation, at least ethically vs. legally.

 

[Bartelby]

There actually is caselaw involving people who left the ED while drunk and got hit by cars then sued the ED, and the defense was able to show that the ED did not have legal right to hold the patient, which totally quashed any claim the plaintiff had on that front. So its actually the opposite: there's a slam dunk defense against that wrongful death suit.

But I agree that there is an impossible situation, at least ethically vs. legally.

But didn't that case law involve an appropriate AMA discharge (where the person was assessed to have capacity to leave)? I could be mistaken on that. But I also suspect voluntary intoxication would likely be viewed differently by a jury versus delirium.

 

[aim-agm]

" Here’s my problem: the psychiatry department will evaluate these patients and write in their chart that they “lack capacity.” And are “admitted voluntarily,” while also writing that, because they lack capacity, the cannot leave AMA and should be physically restrained if they try. This often results in multi day admissions to a medical ward without psychiatric treatment. "

Zinermon v. Burch?

One noteable thing for this case is that Florida law requires "informed consent" for voluntary psychiatric admission, which plaintiff successfully argued he was not capable of giving, and therefore he was inappropriately not afforded the due process protections that an involuntary patient would receive.

This brings up a difficult problem, most particularly with patients that request or accept voluntary admission for whom it is uncertain if they meet criteria for such admission. If they don't meet criteria and there aren't as many due process protections for voluntary patients as compared to involuntary (which I think is universally true or nearly so), then you have violated their rights. If they do meet voluntary criteria, then admitting them involuntarily is also a violation of their rights because it may violate statutory protections and their right to treatment in the least restrictive setting they are appropriate for as (again, either universally or nearly so) voluntary commitment involves less curtailment of liberty than involuntary.

There are a couple of approaches to the problem. The one that is probably the best idea (especially if the patient meets involuntary criteria) is to voluntarily admit the patient while affording them both voluntary and involuntary due process protections as able.

 

[aim-agm]

But didn't that case law involve an appropriate AMA discharge (where the person was assessed to have capacity to leave)? I could be mistaken on that. But I also suspect voluntary intoxication would likely be viewed differently by a jury versus delirium.

No, the case I am thinking about the patient absconded from the ED after telling the nurse they wanted to leave (nurse went to tell attending, when nurse returned patient was gone) and would have had an serum EtOH of ~.27% at the time.

 

[whopper]

" Here’s my problem: the psychiatry department will evaluate these patients and write in their chart that they “lack capacity.” And are “admitted voluntarily,” while also writing that, because they lack capacity, the cannot leave AMA and should be physically restrained if they try. This often results in multi day admissions to a medical ward without psychiatric treatment. "

It's already been settled in case law that if a patient lacks capacity in decision making (unless it's very limited capacity) they are not capable of being "admitted voluntarily." Nuts I'm forgetting the case. In that case a psychotic patient believed he was entering Heaven by going to the psych unit and the health providers, not wanting to do involuntarily commitment papers in the state of Florida (where allegedly at least at that time was a paper nightmare) enabled this delusion cause they just wanted him to be admitted and taken out of their hands. Patient sued even though he was successfully treated saying he remembered what happened and was highly disturbed that health providers willingly misled him. Plaintiff won. Bottom line-if a patient lacks capacity to be voluntarily admitted it's not a voluntary admission.

Aside from this I've been in this situation several times. You want to do the hold papers anyway cause such patients are too flippant to be trusted once admitted on a voluntary basis. Whenever I had a patient that met involuntary criteria, unless that patient had very good insight and I was confident they wouldn't flip on a dime, I do the hold papers anyway. I remember several times other doctors not doing it during admissions and being woken up in the middle of the night while on call, and that 2 AM awakening would've been completely avoidable had my colleague done what I would've done.

 

[mistafab]

Whenever I had a patient that met involuntary criteria, unless that patient had very good insight and I was confident they wouldn't flip on a dime, I do the hold papers anyway. I remember several times other doctors not doing it during admissions and being woken up in the middle of the night while on call, and that 2 AM awakening would've been completely avoidable had my colleague done what I would've done.

This is exactly what I do, and what I encourage my juniors to do.

They are cutting corners due to "assent" and tossing a hot potato to the inpatient team. They shave off 15 minutes of their work, and cause problems down the road that can cost hours, or worsen the care provided.

 

[whopper]

Yes I believe that's it.

Zinermon v. Burch, 494 U.S. 113 (1990)

Zinermon v. Burch

supreme.justia.com

My forensic board certification is going to expire soon and I don't feel the motivation to keep certified especially since I felt about 20% of the exam questions were BS. E.g. Rape Syndrome. Someone came up with that diagnosis on their own, it's not in the forensic board exam prep course, it's not recognized among the profession, and someone put it in a textbook that the board uses for questions. I don't feel like spending over $1000 on an exam where I feel the questions are BS.

 

[aim-agm]

It's already been settled in case law that if a patient lacks capacity in decision making (unless it's very limited capacity) they are not capable of being "admitted voluntarily." Nuts I'm forgetting the case. In that case a psychotic patient believed he was entering Heaven by going to the psych unit and the health providers, not wanting to do involuntarily commitment papers in the state of Florida (where allegedly at least at that time was a paper nightmare) enabled this delusion cause they just wanted him to be admitted and taken out of their hands. Patient sued even though he was successfully treated saying he remembered what happened and was highly disturbed that health providers willingly misled him. Plaintiff won. Bottom line-if a patient lacks capacity to be voluntarily admitted it's not a voluntary admission.

Are you referring to Zinermon v. Burch? Because there the plaintiff's lack of decision making capacity is only pertinent because state law required it for voluntary patients. If the state hadn't required it, he would have had no case. So much of practice in this area is so dependent on state laws that its hard to give any general advice other than (a) "know your state laws" and (b) "really know your state laws."

 

[whopper]

While the patient is in the hospital, you might be able to ensure that they are able to safely leave (e.g. walk alongside them to catch them if they fall) because you still have responsibility for their well-being while they are in the building.

People fall in buildings. The building owners only have responsibility if they "unreasonably" didn't keep the place safe enough. If someone on hospital property intentionally does a Jackass style stunt and hurts themself the hospital is not responsible so long as they weren't "unreasonable." Such standards if met such as clean floors, warnings to patients they have a fall risk, etc, the building and the providers shouldn't have liability.

You are correct in Z v B, but the wording of the decision is such that it's likely to be used in any state as an argument. Further intentionally misleading any patient, regardless of good intent, has already been well established in all 50 states as unacceptable.

 

[aim-agm]

People fall in buildings. The building owners only have responsibility if they "unreasonably" didn't keep the place safe enough. If someone on hospital property intentionally does a Jackass style stunt and hurts themself the hospital is not responsible so long as they weren't "unreasonable." Such standards if met such as clean floors, warnings to patients they have a fall risk, etc, the building and the providers shouldn't have liability.

The case I'm thinking about involved a delirious patient who exited the hospital via his window and died from the fall, in which the hospital was found liable. I have to look over the case again for the exact nature of the duty the judge found the hospital to have (and whether it was a general finding or particular to the state), but my takeaway is that best practice is to safely escort the patient off the property. This isn't necessarily different from what you are saying, and might have been a tactic to prevent an attempted suit (because proving "reasonableness" could be messy).

You are correct in Z v B, but the wording of the decision is such that it's likely to be used in any state as an argument. Further intentionally misleading any patient, regardless of good intent, has already been well established in all 50 states as unacceptable.

Agreed, and it is a particularly momentous case for my state which forbids involuntarily admitting patients that have made an application for voluntary admission and are suitable therefore. Especially because there is minimal relevant state caselaw.

 

[whopper]

Involuntary commitment in almost all states just isn't are they going to physically harm themself or others but also can the person care for themselves-and if not is it due to a mental illness?

If the person lacks capacity due to a mental illness they usually meet involuntary commitment criteria and hold papers should be done for reasons I mentioned elsewhere. You don't, and the patient tries to leave you're now pushing what could be a 2-3 hours emergency down the road when you could've nipped it in the bud here and now for 5-10 minutes of work.

The case I'm thinking about involved a delirious patient who exited the hospital via his window and died from the fall, in which the hospital was found liable. I have to look over the case again for the exact nature of the duty the judge found the hospital to have (and whether it was a general finding or particular to the state), but my takeaway is that best practice is to safely escort the patient off the property. This isn't necessarily different from what you are saying, and might have been a tactic to prevent an attempted suit (because proving "reasonableness" could be messy).

I haven't read the case but if someone is delirious they need to have the appropriate safeguards. Anyone delirious can't be trusted with things such as sharp objects or windows that could be opened and large enough for a person to use as an exit.

 

[DocArmy]

Your persistence on pursuing this should be commended.
Most people would have given up or found another job.
Let us know how this pans out and if administration will seriously respond to your concerns.

Thanks homie.

Whenever I have a question about what is the best course of action, I imagine explaining the action and my reasoning to a judge and the patient’s widow. If I feel uncomfortable after that thought exercise, then the course of action usually isn’t the right thing to do.

I’ve banged enough pots and pans this time that it looks like it’s got traction headed up the chain. So hopefully official guidance will come back.

If not, that’s fine. I’m not gonna break the law anyway and will keep pushing to send all of them away immediately (once medically cleared).

But I appreciate the insights here and it’s good to be validated that what I thought sounded sus was indeed sus.

 

[whopper]

I’ve banged enough pots and pans this time that it looks like it’s got traction headed up the chain. So hopefully official guidance will come back.

I worked in a hospital where the administration wanted the psych unit moved to a building outside the main hospital. Reason-they converted the psych unit to a more profitable surgery floor. OK fine, the new psych unit was placed in an older hospital that was just bought out by the new hospital and then guess what? No consults wanted to drive to the new hospital. So we were in effect CONSULTLESS. Add to this at the time I was running a geriatric unit in the new psych units so we needed consults A LOT!

So I joined this place and didn't know this was going on until thrust into the situation. I found out (but it was obvious this must've happened) that the attendings of the inpatient unit didn't want to be moved unless it was solid we got consults. We were promised it would happen.

But what did happen was despite that this hospital was only about 10 blocks away, in city traffic this could be well over a 30 minute drive depending on what time of day you drove, and parking, walking, going to the floor, just the travel would be just under an hour each way. Consults from other departments intentionally ignored the consults, When demanded to show up they more or less said "bite me."

So I told the hospital the $hit is going to hit the fan especially on a geri-unit. We needed consults daily. So the hospital got it so that an IM would be assigned there daily and even the IM guy who was physically here said we needed consults that were out of his league like a renal, surgery, infectious disease, etc. Those consults still refused to show up. Again we all said the $hit is going to hit the fan.

Well it hit the fan. Guy had a spinal cord infection from a surgery, surgery refused to take the guy as a transfer, they refused to show up, and infectious disease refused to show up. Got to the point where the guy would've had to be sent to the ER as a COBRA violation transfer or someone had to show up for consultation or transfer. No one was budging. I pulled the trigger and sent the guy as a COBRA-violation transfer to the ER. While in the ER, ER docs were ticked off that this guy wasn't getting earlier treatment as it was clear he had a spinal cord infection that was worse cause treatment was delayed. When surgery was called to show up to the ER the same a-hole surgeon who refused to show up as a consult was forced by his department head to show up, openly stated "psychiatry is bull$hit" and said he was certain when he checked the surgery site he'd be certain it'd be a clear case of us psychiatrists overreacting cause we don't have any "real" medical skills. He checked the site, jaw dropped and ordered the patient for immediate surgery. Patients' relatives (several were medical professional) were there and wrote all of it down and included it in their complaint to the medical board.

I told the hospital they could effing fire me if they wanted. I told my department head I had no choice as this guy had an infection of his spinal cord and no one was appropriately treating him. I told the patient and his family (filled with doctors, nurses and lawyers) to complain to the state medical board about what happened and make the complaint real real real thick and spicy. I told them I didn't care if they reported it cause it was the right thing to do and I did nothing wrong and others clearly did something wrong so we had to do it. The hospital got in trouble and it forced them to reform this system. They moved the psych unit, although not back in the main hospital but a hospital right across the street from the main one and now consultants willingly showed up.

My department (and this was a sign they were a solid employer) backed me up when the hospital administration wanted heads to roll. Heads did roll-that of consultants that refused to show up and the idiots who had the idea in the first place to transfer the psych unit to a 1 hour travel time away.

The entire ordeal, however, was a stressful, wake me up in the middle of the night, had this gone on for too long my health might've been effed situation. I wish I could say this wasn't the last time something like this happened. It did happen again and again and each time within an organization that was screwed cause hospital administration without medical training were trying to control doctors and nurses. I finally got away with from that bull$hit when I made my own private practice. Yeah I still deal with crap but in most cases I have an eject button-terminate patients (and yes I only terminate if the patient doesn't follow rules such as non-compliance, criminal behavior, etc).

 

[nexus73]

A person can have capacity to agree to stay voluntarily, while at the same time lack capacity to choose to leave AMA.

 

[comp1]

A person can have capacity to agree to stay voluntarily, while at the same time lack capacity to choose to leave AMA.

Completely agree. Capacity is a moving bar based solely on the risk and benefits involved with a specific choice. This is why we don't wring our hands about unconscious people who need emergent surgery. This whole idea can be extremely hard for other services to grasp and it makes them even more frustrated when we explain that they are in fact the experts at the risks and benefits of a given choice. Thus they are the ones tasked with determining capacity for that choice. They usually expect a global has capacity or doesn't have capacity stamp from some superpower psychiatrists have.