Psych 5150 Question

[thegenius]

Can someone on a 5150 refuse a medical workup? I had one last night who was a real a-hole. Came in on a 5150. First he was mute for several hours then after ativan 1mg IM he was yelling and screaming saying he wants a second opinion, wanted a lawyer, all this crap. Refused to give blood and urine for medical clearance.

I think they can...if they can make informed medical decisions then I think they can. But I don't know...and if they refuse to be cooperative then we can't medically clear them. Could potentially stay in the ER for thousands of hours, maybe longer.

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[gamerEMdoc]

By a 5150 you mean an involuntary hold (for those non-Californians out there). What this is called is state dependent.

They can't refuse as far as I know. In the end, if there's uncertainty, and you have a psychiatrist, consult them. Psychiatrists virtually never set foot in the ED because we do 99.999% of all these psych admits in terms of figuring out who should go home, who needs a voluntary admit, and who needs an involuntary hold upheld. But just like any member of the medical staff, if you consult them, they have to come see the patient. So if there's a difficult situation like this, and you legit don't know which way to go, consult them to see the patient. That's ultimately their job, and taking all the risk of either missing a suicidal patient on one hand vs violating someones rights on another, should not rest squarely on our shoulders if we don't know what to do since ultimately we are doing this for them.

I don't know if I've ever seen someone refuse clearance blood work (which is nearly always unnecessary, but for whatever reason trying to transfer someone without blood work is impossible). I mean I've seen many refuse, but never more than a few hours. In the end, they are there on a legal hold. They can't leave. The only way that legal hold goes forward is after their blood work is obtained and comes back. I just tell them, we can't even start the process of deciding whether you can go home or have to come in until we obtain this. If they refuse, they sit in a room with nothing to do staring at security for an hour or two. Then I ask again. If they refuse... rinse and repeat. In the end, these people just eventually give in.

 

[Rendar5]

If someone is floridly psychotic, they have no capacity to refuse. If someone is just an dingus, then they have the right to refuse and sit there nonstop for 72 hours until they realize they may as well just get bloodwork. Sometimes I’m lucky on nightshift and my psych ed will let me medically clear them the proper way and not require labs if not warranted.

 

[Rendar5]

Never had someone last more than 12 hours since they get a deal of food in response for cooperation.

 

[TooMuchResearch]

If someone is floridly psychotic, they have no capacity to refuse. If someone is just an dingus, then they have the right to refuse and sit there nonstop for 72 hours until they realize they may as well just get bloodwork. Sometimes I’m lucky on nightshift and my psych ed will let me medically clear them the proper way and not require labs if not warranted.

Exactly. If they seem to have capacity (aside from their desire to leave and kill themself), they can keep their autonomy. Violating it forcefully may be illegal.

It they don't have capacity for anything, then they can't refuse.

 

[thegenius]

Yea 5150 = involuntary psychiatric hold (California statue law 5150)

This guy was being a dingus. I said all those things above about cooperation, let's get you out of here, etc. I had a hard time determining if he was psychotic...at first I thought maybe he had psychiatric catatonia, but 1mg ativan would not have changed his behavior 180 degrees. And at the end of the day I said we are not giving you food or anything else until you cooperate.

Then my shift ended, signed him out, and went on my merry way.

10 hours later, I see looking in the computer that we got blood from him, cooperatively or not.

 

[thegenius]

5150 is a legal construct, not a medical one.

The law would have to say "If you are on a 5150, you cannot refuse medical evaluation and care." But I doubt it says that.

 

[Siggy]

"Rights for IndividualsIn Mental Health FacilitiesAdmitted Under the Lanterman-Petris-Short Act

Involuntary Patients
You have the right to refuse medical treatment or treatment with medications (except in an emergency) unless a capacity hearing is held and a hearing officer or a judge finds that you do not have the capacity to consent to or refuse treatment. The advocate or public defender can assist you with this matter. "
-Page 15

https://www.dhcs.ca.gov/services/Documents/DHCS_Handbook_English.pdf

The "Lanterman-Petris-Short act" is the official title for California Welfare and Institutions section that includes 5150.

Common myth: Patients on psych holds have no rights. Their legal rights might surprise you.

 

[thegenius]

"Rights for IndividualsIn Mental Health FacilitiesAdmitted Under the Lanterman-Petris-Short Act

Involuntary Patients
You have the right to refuse medical treatment or treatment with medications (except in an emergency) unless a capacity hearing is held and a hearing officer or a judge finds that you do not have the capacity to consent to or refuse treatment. The advocate or public defender can assist you with this matter. "
-Page 15

https://www.dhcs.ca.gov/services/Documents/DHCS_Handbook_English.pdf

The "Lanterman-Petris-Short act" is the official title for California Welfare and Institutions section that includes 5150.

Common myth: Patients on psych holds have no rights. Their legal rights might surprise you.

sweet!

 

[GonnaBeADoc2222]

If they wanna refuse labs I let them refuse.

 

[Birdstrike]

Can someone on a 5150 refuse a medical workup? I had one last night who was a real a-hole. Came in on a 5150. First he was mute for several hours then after ativan 1mg IM he was yelling and screaming saying he wants a second opinion, wanted a lawyer, all this crap. Refused to give blood and urine for medical clearance.

I think they can...if they can make informed medical decisions then I think they can. But I don't know...and if they refuse to be cooperative then we can't medically clear them. Could potentially stay in the ER for thousands of hours, maybe longer.

If you have someone on a psych hold that refuses your tests, this is what you must tell him, "Sir, all month I have been trying to convince patients they don't need a single one of these pointless ED tests for their self limited viruses, hypochondriasis and imagined illnesses and you're the first one to refuse every damn single one of them. Not only am I immediately declaring 100% sane, but I'm giving you the Most Sane Patient of the Month Award. Here's your medal, Chap. You're discharged. Happy trails! And thank you!"

 

[GeneralVeers]

If you have someone on a psych hold that refuses your tests, this is what you must tell him, "Sir, all month I have been trying to convince patients they don't need a single one of these pointless ED tests for their self limited viruses, hypochondriasis and imagined illnesses and you're the first one to refuse every damn single one of them. Not only am I immediately declaring 100% sane, but I'm giving you the Most Sane Patient of the Month Award. Here's your medal, Chap. You're discharged. Happy trails! And thank you!"

Step 1 is determining if there's even a valid 5150 in the first place. In Nevada our police don't even know the criteria in the legal statute and put every drunk, homeless person, and meth head on a hold. The statute in my state forbids a legal hold if they are clearly intoxicated, under 18, have dementia, or normally lack capacity to make decisions. I routinely clear holds on "hallucination", "anxiety", "inability to care for self", and "agitated " people and discharge them home as they don't meet criteria to be placed on a hold. The statute clearly states there must be IMMINENT danger to themselves or others.

 

[thegenius]

Step 1 is determining if there's even a valid 5150 in the first place. In Nevada our police don't even know the criteria in the legal statute and put every drunk, homeless person, and meth head on a hold. The statute in my state forbids a legal hold if they are clearly intoxicated, under 18, have dementia, or normally lack capacity to make decisions. I routinely clear holds on "hallucination", "anxiety", "inability to care for self", and "agitated " people and discharge them home as they don't meet criteria to be placed on a hold. The statute clearly states there must be IMMINENT danger to themselves or others.

L M A O
That's funny I hear ya

In CA I think you can be put on a hold for SI, HI, or gravely disabled. I don't know what the exclusion criteria are. Although I'm surprised that your state would permit people, who are brazenly intoxicated, to run around in society being actively suicidal, jumping off bridges, shooting themselves in the head, and swallowing 100 pills. I'm sure a sizable percentage of completed suicides occur because the person was acutely intoxicated.

 

[GeneralVeers]

L M A O
That's funny I hear ya

In CA I think you can be put on a hold for SI, HI, or gravely disabled. I don't know what the exclusion criteria are. Although I'm surprised that your state would permit people, who are brazenly intoxicated, to run around in society being actively suicidal, jumping off bridges, shooting themselves in the head, and swallowing 100 pills. I'm sure a sizable percentage of completed suicides occur because the person was acutely intoxicated.

If someone is intoxicated or "chemically impaired" an L2K (our name for 5150) isn't valid. The protocol is supposed to be observe them until sobriety, then re-assess for SI. If not SI once sober, then can D/C.

 

[thegenius]

Yea...I guess in CA if you come in intoxicated with SI, we put them on a 1799, which is another CA law allowing us to involuntarily hold someone for up to 24 hours in order to get them a psych consult to determine if they need a 5150.

One way or another, there is legal framework to keep these asshats in the safety of the ED

 

[Siggy]

L M A O
That's funny I hear ya

In CA I think you can be put on a hold for SI, HI, or gravely disabled. I don't know what the exclusion criteria are. Although I'm surprised that your state would permit people, who are brazenly intoxicated, to run around in society being actively suicidal, jumping off bridges, shooting themselves in the head, and swallowing 100 pills. I'm sure a sizable percentage of completed suicides occur because the person was acutely intoxicated.

The problem is that I've seen Baker Acts (Florida's version) where the narrative is "We've been called out here three times tonight. The patient is constantly intoxicated. His intoxication makes him a danger to himself." However the Baker Act law specifically excludes substance abuse disorders. So "I'm going to drink myself until I'm dead" is likely a good hold. "I just like alcohol and can't control how much I drink and what I do when I drink" isn't.