Pt refuses to go to recommended dispo.

[heyjack70]

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Psychiatric inpatient with schizophrenia, historically well managed, stable patient for years. Owned own home purchased with SSDI payments. Admitted after couldn't access meds x 2 months and decompensated. On the ward, occupational therapy administers ACL (Allen Cognitive Level) on second hospital day, and result is 4.0, suggesting pt needs 24 hour supervision. Pt reconstitutes over the next 10-14 days on meds. Repeat ACL 10 days later is 4.2 with continued recommendation for 24 hour supervision.

Pt, of course, refuses any option except for returning home. There is no family or supportive friends that can provide this level of care. Case management is present but no 24hr in home supervision available. What is our obligation as the treating physician to assure patient is going to someplace that will be safe for them? What do you do in this situation?

 

[nitemagi]

Psychiatric inpatient with schizophrenia, historically well managed, stable patient for years. Owned own home purchased with SSDI payments. Admitted after couldn't access meds x 2 months and decompensated. On the ward, occupational therapy administers ACL (Allen Cognitive Level) on second hospital day, and result is 4.0, suggesting pt needs 24 hour supervision. Pt reconstitutes over the next 10-14 days on meds. Repeat ACL 10 days later is 4.2 with continued recommendation for 24 hour supervision.

Pt, of course, refuses any option except for returning home. There is no family or supportive friends that can provide this level of care. Case management is present but no 24hr in home supervision available. What is our obligation as the treating physician to assure patient is going to someplace that will be safe for them? What do you do in this situation?

Interesting, I've never seen the Allen Cognitive Level at all (at least not named that), and I'm not aware of a medicolegal obligation directly associated with a number on it.

Even glancing at the ACL website seems to state that 4.2 is safe for discharge to street. But it seems from your post you're concerned the individual isn't going to do so well and will get readmitted? Or is this just a medicolegal question? If the latter, talk to risk management in your hospital.

 

[flash]

The way it works here is that we go to court (the court really comes to us in hospital via webcam) and the county attorney makes the case that pt suffers from a mental illness and, as a result of the illness, likely to harm self or others, or illness expected to progress to the point of unable to care for self without continued involuntary treatment, or unable to make rational treatment decision as a result of mental illness. In our set up the continued tx is at the state hospital. County lawyer works closely with us to make the case and filing legal stuff for continued commitment (we are "expert witnesses" during hearing), pt has a lawyer appointed too. Pt can request to be present but is not required to do so.

So we would probably pursue this avenue for the case you briefly described, IF our clinical judgement agreed with what OT's scale suggested. Our position is 'we're just expert witnesses', let the county and, ultimately, judge decide if any where near the fence from medicolegal POV.

Sometimes, we do discharge home with knowledge that there are risks.

 

[Therapist4Chnge]

If the latter, talk to risk management in your hospital.

+1.

We run into this on occasion w. TBI patients. Even after consulting with risk management, there are often no "good" options. Our social workers and discharger planners can sometimes pull something out of thin air, but usually it is trying to make the best of the available options...usually family.

 

[nitemagi]

The way it works here is that we go to court (the court really comes to us in hospital via webcam) and the county attorney makes the case that pt suffers from a mental illness and, as a result of the illness, likely to harm self or others, or illness expected to progress to the point of unable to care for self without continued involuntary treatment, or unable to make rational treatment decision as a result of mental illness. In our set up the continued tx is at the state hospital. County lawyer works closely with us to make the case and filing legal stuff for continued commitment (we are "expert witnesses" during hearing), pt has a lawyer appointed too. Pt can request to be present but is not required to do so.

So we would probably pursue this avenue for the case you briefly described, IF our clinical judgement agreed with what OT's scale suggested. Our position is 'we're just expert witnesses', let the county and, ultimately, judge decide if any where near the fence from medicolegal POV.

Sometimes, we do discharge home with knowledge that there are risks.

That's for an invol hold. The way I read the OP's post, the individual has reconstituted but still has some minor fxnl impairment, but may not be holdable.

To transpose this to a parallel question - if you had a medical pt. that required 24hr care but refused to go to a SNF or other facility and only wanted to go home, what would you do?

 

[Sneezing]

If the patient has capacity, isn't a threat to themselves, isn't a threat to others, and is capable of basic self care they must be discharged. The enemy of good is better. If there really are problems the patient will eventually be back and it can be used as a talking point for higher level of care or perhaps justification for pursuing a guardian.

 

[heyjack70]

That's for an invol hold. The way I read the OP's post, the individual has reconstituted but still has some minor fxnl impairment, but may not be holdable.

To transpose this to a parallel question - if you had a medical pt. that required 24hr care but refused to go to a SNF or other facility and only wanted to go home, what would you do?

Nitemagi is right about the nature of my post. Our ACL recommends 24 hour supervision up to ACL 4.4. I think at scores less than this, patients supposedly can't anticipate danger, like forgetting to turn off the stove after cooking resulting in a house fire. They also have difficulties taking their meds correctly.

4.8 is the usual cutoff for discharging to home, but pt's who are right at this level, usually get setup with weekly home visits, meds in blister packs, etc to simplify things as much as possible and provide some home supervision.

I would be interested if anyone had thoughts about Nitemagi's question that I bolded above.

 

[heyjack70]

If the patient has capacity, isn't a threat to themselves, isn't a threat to others, and is capable of basic self care they must be discharged. The enemy of good is better. If there really are problems the patient will eventually be back and it can be used as a talking point for higher level of care or perhaps justification for pursuing a guardian.

This sounds right. Document that patient has decisional capacity to accept the risk. And if they don't have capacity?

 

[nitemagi]

If the patient has capacity, isn't a threat to themselves, isn't a threat to others, and is capable of basic self care they must be discharged. The enemy of good is better. If there really are problems the patient will eventually be back and it can be used as a talking point for higher level of care or perhaps justification for pursuing a guardian.

👍

Bingo.

A capacity evaluation has to be made. I've had to discharge people in wheelchairs that refused to go to a dispo we had set up for them. They were homeless, had major medical issues, non-ambulatory. But they had capacity to make the decision to leave, recognizing the risks/benefits/alternatives of that decision. So we let them go.

If they don't have capacity then a surrogate decision-maker should be appointed -- which can be a family member if available, someone specific if they have a DPOA, or in an emergency setting a doctor until someone else can be appointed (say by the county or courts system).

 

[whopper]

Yep....

If they lack capacity go for a guardian.

If they have capacity, you discharge them so long as they don't meet the other involuntary commitment criteria.

If you're in a grey zone and you can't tell, you consult with colleagues, possibly get a second opinion or even call in a department meeting, but if you still can't, you hold them for court, let the court know what's going on and let the court decide. If they discharge, you're not responsible, the court did it. If they hold the patient, they will announce the ground on why they held them and at least you have some notion of what they expect.

If you have a guy and he only wants a disposition you can't provide, and he's not meeting involuntary criteria, but can survive in a homeless shelter you discharge there. If not, and from what you're telling us this seems to be the case, you get a guardian.

Trust me, in forensic psychiatry, this stuff is bread and butter simple.

I've had cases now and then where I could not take the case further then where it was and the patient was in a grey zone where I could not determine the safety of the case. I let the court decide. E.g. I had a guy with HIV and denies it. I can't tell if the denial of HIV is due to psychosis or merely an ego-defense. I showed the guy the labs and he still refuses to believe it. He has a history of psychosis but is on meds and I see no other signs of possible psychosis. The guy told me he will have unprotected sex and will not warn people he has it because he doesn't believe it. I cannot force different meds unless I show strongly convincing evidence he is psychotic and I wasn't sure.

I brought the case in front of the court, and they decided. The liability is on the court, not you so long as you adequately reported to the court what happened.

 

[Therapist4Chnge]

If they lack capacity go for a guardian.

If they have capacity, you discharge them so long as they don't meet the other involuntary commitment criteria.

If you're in a grey zone and you can't tell, you consult...(various ppl).

I agree with all of the above, but for many who don't regularly deal with these issues, it can feel much more complex. One of the biggest challenges is that people get caught up on only wanting to take the "ideal" choice, even though it often isn't really an option. Unfortunately not everyone will be able to get their first choice, but delaying a decision can be detrimental to the patient, hospital, and other patients (who could use that bed for treatment).

 

[nitemagi]

I agree with all of the above, but for many who don't regularly deal with these issues, it can feel much more complex. One of the biggest challenges is that people get caught up on only wanting to take the "ideal" choice, even though it often isn't really an option. Unfortunately not everyone will be able to get their first choice, but delaying a decision can be detrimental to the patient, hospital, and other patients (who could use that bed for treatment).

Fair point T4C, and I think part of the process of acclimating to the many unknowns we have, and the many gray areas that exist. I've lost a few nights sleep after sending someone out from the ED who had suicidality, which I didn't think at the time was severe enough to warrant hospitalization, but then questioned myself afterwards. It's tough sitting with uncertainty.

 

[heyjack70]

Yep....

If they lack capacity go for a guardian.
If they have capacity, you discharge them so long as they don't meet the other involuntary commitment criteria.

If you're in a grey zone and you can't tell, you consult with colleagues, possibly get a second opinion or even call in a department meeting, but if you still can't, you hold them for court, let the court know what's going on and let the court decide. If they discharge, you're not responsible, the court did it. If they hold the patient, they will announce the ground on why they held them and at least you have some notion of what they expect.

If you have a guy and he only wants a disposition you can't provide, and he's not meeting involuntary criteria, but can survive in a homeless shelter you discharge there. If not, and from what you're telling us this seems to be the case, you get a guardian.

Trust me, in forensic psychiatry, this stuff is bread and butter simple.

I've had cases now and then where I could not take the case further then where it was and the patient was in a grey zone where I could not determine the safety of the case. I let the court decide. E.g. I had a guy with HIV and denies it. I can't tell if the denial of HIV is due to psychosis or merely an ego-defense. I showed the guy the labs and he still refuses to believe it. He has a history of psychosis but is on meds and I see no other signs of possible psychosis. The guy told me he will have unprotected sex and will not warn people he has it because he doesn't believe it. I cannot force different meds unless I show strongly convincing evidence he is psychotic and I wasn't sure.

I brought the case in front of the court, and they decided. The liability is on the court, not you so long as you adequately reported to the court what happened.

To clarify some points. This hypothetical pt has a place to live, in fact a house they own, so they wouldn't be going to a shelter.

But by OT evaluation data, they would likely not fuction safely at home. This may be due to a mild dementia, or possibly chronic schizophrenia that is likely at baseline. So they probably will never improve to a level where OT says they can function well at home. OT eval recommends 24 hour supervision, but the pt only agrees to return home. What do you do? Detain them as gravely disabled and let it go to court? What happens if the court agrees that the patient can't return home safely, can the court force them into a supported living situation?

What seems hard in this case, is the patient has been functioning well enough on their own that they have not yet gotten into any trouble so from the patient's perspective there is no reason they should not go home. The pt is not able to understand and explain the potential risk of returning home. Also, they are not so ill and disoriented/detached that they cannot comprehend what is happening, as in, they will know if they are not sent home. If they were sent to another dispo they would probably just get on a bus back to their house. It would be easier if this patient was doing much better or much worse.


I get the enemy of good is better argument. It just seems like there is a lot of potential liability here.

 

[heyjack70]

Yep....

If they lack capacity go for a guardian.
If they have capacity, you discharge them so long as they don't meet the other involuntary commitment criteria.

If you're in a grey zone and you can't tell, you consult with colleagues, possibly get a second opinion or even call in a department meeting, but if you still can't, you hold them for court, let the court know what's going on and let the court decide. If they discharge, you're not responsible, the court did it. If they hold the patient, they will announce the ground on why they held them and at least you have some notion of what they expect.

If you have a guy and he only wants a disposition you can't provide, and he's not meeting involuntary criteria, but can survive in a homeless shelter you discharge there. If not, and from what you're telling us this seems to be the case, you get a guardian.

Trust me, in forensic psychiatry, this stuff is bread and butter simple.

I've had cases now and then where I could not take the case further then where it was and the patient was in a grey zone where I could not determine the safety of the case. I let the court decide. E.g. I had a guy with HIV and denies it. I can't tell if the denial of HIV is due to psychosis or merely an ego-defense. I showed the guy the labs and he still refuses to believe it. He has a history of psychosis but is on meds and I see no other signs of possible psychosis. The guy told me he will have unprotected sex and will not warn people he has it because he doesn't believe it. I cannot force different meds unless I show strongly convincing evidence he is psychotic and I wasn't sure.

I brought the case in front of the court, and they decided. The liability is on the court, not you so long as you adequately reported to the court what happened.

To clarify some points. This hypothetical pt has a place to live, in fact a house they own, so they wouldn't be going to a shelter.

But by OT evaluation data, they would likely not fuction safely at home. This may be due to a mild dementia, or possibly chronic schizophrenia that is likely at baseline. So they probably will never improve to a level where OT says they can function well at home. OT eval recommends 24 hour supervision, but the pt only agrees to return home. What do you do? Detain them as gravely disabled and let it go to court? What happens if the court agrees that the patient can't return home safely, can the court force them into a supported living situation?

What seems hard in this case, is the patient has been functioning well enough on their own that they have not yet gotten into any trouble so from the patient's perspective there is no reason they should not go home. The pt is not able to understand and explain the potential risk of returning home. Also, they are not so ill and disoriented/detached that they cannot comprehend what is happening, as in, they will know if they are not sent home. If they were sent to another dispo they would probably just get on a bus back to their house. It would be easier if this patient was doing much better or much worse.

 

[nitemagi]

To clarify some points. This hypothetical pt has a place to live, in fact a house they own, so they wouldn't be going to a shelter.

But by OT evaluation data, they would likely not fuction safely at home. This may be due to a mild dementia, or possibly chronic schizophrenia that is likely at baseline. So they probably will never improve to a level where OT says they can function well at home. OT eval recommends 24 hour supervision, but the pt only agrees to return home. What do you do? Detain them as gravely disabled and let it go to court? What happens if the court agrees that the patient can't return home safely, can the court force them into a supported living situation?

What seems hard in this case, is the patient has been functioning well enough on their own that they have not yet gotten into any trouble so from the patient's perspective there is no reason they should not go home. The pt is not able to understand and explain the potential risk of returning home. Also, they are not so ill and disoriented/detached that they cannot comprehend what is happening, as in, they will know if they are not sent home. If they were sent to another dispo they would probably just get on a bus back to their house. It would be easier if this patient was doing much better or much worse.

That's the reason to talk to risk management. After that, you can document your recommendations, assess that the patient understands the risks (or doesn't) and then let them choose. Plenty of people choose to live homeless, for example, rather than in a shelter. Unfortunate but I've had probably dozens of patients that opt for this. Is it safe? No. Is it optimal? No.

If the individual really has some cognitive impairment impairing their ability to weigh those risks/benefits/alternatives, or you think the schizophrenia impairs this, then you've just done a capacity evaluation and in your opinion they don't have the capacity to make the decision. So you go down that road.

 

[BobA]

To clarify some points. This hypothetical pt has a place to live, in fact a house they own, so they wouldn't be going to a shelter.

But by OT evaluation data, they would likely not fuction safely at home. This may be due to a mild dementia, or possibly chronic schizophrenia that is likely at baseline. So they probably will never improve to a level where OT says they can function well at home. OT eval recommends 24 hour supervision, but the pt only agrees to return home. What do you do? Detain them as gravely disabled and let it go to court? What happens if the court agrees that the patient can't return home safely, can the court force them into a supported living situation?

What seems hard in this case, is the patient has been functioning well enough on their own that they have not yet gotten into any trouble so from the patient's perspective there is no reason they should not go home. The pt is not able to understand and explain the potential risk of returning home. Also, they are not so ill and disoriented/detached that they cannot comprehend what is happening, as in, they will know if they are not sent home. If they were sent to another dispo they would probably just get on a bus back to their house. It would be easier if this patient was doing much better or much worse.

If the issue is dementia, then in our state it would be treated like any other medical decision.

It would be a regurgitation of the most common consult question: Does the patient have capacity to refuse placement?

I've attached a copy of a tool to assist in making the capacity assessment. See page 10 for the actual form - the rest is just instructions.

If they don't have capacity, then they get a guardian and get placed against their will.

If they have capacity, then go home knowing the risks.

However, if the patient's illness were schizophrenia then it would be considered a "psychiatric illness" and everything would be completely different. We'd decide if they met involuntary criteria or not (probably wouldn't meet criteria by our state's high bar) and then we send them home.

If it's a really tricky case we might get an ethics consult to assist.

 

[nitemagi]

If they don't have capacity, then they get a guardian and get placed against their will.

If they have capacity, then go home knowing the risks.

That's really all there is to it.

Getting a second opinion or ethics consult could be helpful but probably not necessary.

I would add that you're always in sounder medicolegal territory to have a 2nd physician evaluation that also agrees the pt does/doesn't have capacity.

 

[BobA]

I would add that you're always in sounder medicolegal territory to have a 2nd physician evaluation that also agrees the pt does/doesn't have capacity.

I agree in theory - but in practice it's rarely done here (only for the most difficult cases).

 

[whopper]

but for many who don't regularly deal with these issues, it can feel much more complex

Very much agree and please do not take my comments as condescending. I was not trying to be so. I mentioned these were simple in forensic psychiatry because many things people never encounter at first are somewhat mystifying and scary, but when you've done it a lot, you realize there really wasn't much to it. Of course, while it may be simple, people only realize it after they've crossed the mental journey. This is a reason why people in this field need supportive mentors to guide the way and make what is usually a difficult journey much simpler.

But by OT evaluation data, they would likely not fuction safely at home. This may be due to a mild dementia, or possibly chronic schizophrenia that is likely at baseline. So they probably will never improve to a level where OT says they can function well at home. OT eval recommends 24 hour supervision, but the pt only agrees to return home. What do you do? Detain them as gravely disabled and let it go to court? What happens if the court agrees that the patient can't return home safely, can the court force them into a supported living situation?

My recommendation is the same as stated above. I really hate saying this, and I'm doing it because I'm inferring this case is tugging and your heart-strings, you'll likely thinking this is terrible. The guy has a house, it's his home, he's being discharged, and he can't go home? Unfortunately that will have to be the situation if he cannot get better and does not have the capacity to live and manage the home on his own.

People often criticize psychiatry as being easy....that real docs go into stressful jobs such as surgery. No, psychiatry can be difficult, especially in cases like this . Any good doctor will want to slam dunk a case of a very sick person, get them better, and bask in the seemingly selfless glory of healing, while at the same time have a feeling so enjoyable that few could experience unless in this field it's almost selfish. Unfortunately, while good doctors will enjoy such experiences more often, you will come across cases where the best thing you could do was to simply keep the person in a nursing home while they see their possessions such as a home be lost from their control.

If the person cannot truly get better and cannot manage their home, it's then up to the court to try to find the best guardian appropriate to do what the person would've wanted and/or what's in the person's best-interests. It need not specifically need be a legal guardian. Perhaps a good friend or family member? Just remember that sometimes friends and family in this situation could be dysfunctional. Someone in the court or treatment team needs to make sure the person taking over the home does it in an appropriate manner. I will say that I have seen some great guardians, ones that really take the time to get to know their client and try to take care of the person's estate in a manner that is dignified and respectful. E.g. in this case, perhaps the home can be maintained by the guardian and perhaps the patient could visit the home from time to time.

Speaking of hard cases, I had a nurse, fiercely independent, a superb CV and reputation, suffer a TBI in car accident, and now can't live independently. For better or worse, her fierce independence is still strongly intact, and I had to testify, not as a treating doctor (I never treated her) but as a court expert witness that she cannot be allowed to take care of herself, and that unless she gets better (and she likely will not), she will have to live in a supervised setting. The entire time I'm on that stand, I can see that woman about to cry, staring at me as if I'm the one taking away her independence, but I had to give my honest opinion. The judge ordered her to stay involuntary committed until a nursing home was placed. I felt physically ill for about an hour after that hearing.

 

[heyjack70]

If they don't have capacity, then they get a guardian and get placed against their will.

Who initiates pursuit of guardianship if the patient has no family? The hospital?

 

[whopper]

In most states, the Court handles it. A doctor will have to do a capacity assessment. In most treatment teams I've seen, the social worker, at the psychiatrist/psychologist's request, will contact the local probate court to initiate this course of action.

My PD taught me something that separates the good from the bad doctors when doing a capacity assessment when it comes to independence.

A bad/mediocre one will simply see a patient not being able to do tasks needed for ADLs such as counting money, handling bills, bathing, etc. and say they lack capacity, need a guardian, end of report.

A good one, if seeing the same person may come to the same conclusion that the person needs a guardian, but will try to find out what the person is capable of, and recommend to the Court the maximum amount of freedom and choice that person could still have even with a guardian.

E.g. my PD told me of a case where he had an evaluee who was a multimillionaire and became demented. The guy would go to local bars, and buy everyone in the bar a drink. It got to the point where people in the bar knew the evaluee would show up, bring in friends, get the most expensive things possible and then the bar staff would try to exploit the guys generosity by asking for clearly inappropriate tips. This guy would spend tens of thousands of dollars in one night, and it was something he clearly would not have done before he acquired dementia. Otherwise the guy, while demented, was still in a position where he could live at home (his family was there), and was not in any desire to do anything inappropriate.

The PD mentioned he didn't need a full guardian but simply needed to have a financial guardian who could establish a cap of about $100 per visit to the bar. That way he could, if he wanted, buy a few drinks for a few people, and that is something the guy did before he was demented. He otherwise was in no need for any further guardianship.

The point being the law will take away independence if the person lacks capacity, but the Court must also try to give the person the least amount of restriction that will still allow the person to be safe and without being exploited.

 

[BobA]

Who initiates pursuit of guardianship if the patient has no family? The hospital?

The Social Worker does. If the patient has family who are willing to be the guardian then around here the process takes a week or two. If they need a public guardian it can take a month or two months.

Whopper - I like that info about least restriction. I hadn't heard of that before.

 

[Therapist4Chnge]

Very much agree and please do not take my comments as condescending. I was not trying to be so.

I didn't read it that way at all. I was pointing out that those of us who have had to do a lot of these can sometimes be a bit more "matter of fact" than other providers. It may come off as callous and/or inflexible, but I think far more damage can be done if proper evaluations are not done.

I still remember a consult I had a few years ago that involved a Veteran who had a pretty complex psych & substance abuse history. The resident, attending, nurses, and SW all wanted me to say that the Veteran did not have the capacity to make his own decisions. The problem was that the Veteran could make an informed decision, it was just in contrast to the medical recommendations. He wanted to drink, smoke, and be non-compliant with pretty much all of the medical recommendations. You can't take away someone's independence because you don't agree with how they choose to live their life.

A good one, if seeing the same person may come to the same conclusion that the person needs a guardian, but will try to find out what the person is capable of, and recommend to the Court the maximum amount of freedom and choice that person could still have even with a guardian.

This is a great point. I always try to make functional recommendations because a little bit of guidance can really make a difference in the outcome and eventual quality of life of the patient. The story about the millionaire in the bar was a great example of a functional recommendation that maximizes the patient's independence while also protecting them.

 

[heyjack70]

The Social Worker does. If the patient has family who are willing to be the guardian then around here the process takes a week or two. If they need a public guardian it can take a month or two months.

Whopper - I like that info about least restriction. I hadn't heard of that before.

What if the patient just chooses to leave the hospital? What legal mechanisms are in place to prevent this? Where I live, the only way a doctor can prevent a patient from leaving is if they meet inpatient psych criteria, or there is a medically emergent reason (as in imminent risk to life or limb that is foreseeable) if they were to leave the hospital.

 

[atsai3]

What if the patient just chooses to leave the hospital? What legal mechanisms are in place to prevent this? Where I live, the only way a doctor can prevent a patient from leaving is if they meet inpatient psych criteria, or there is a medically emergent reason (as in imminent risk to life or limb that is foreseeable) if they were to leave the hospital.

No mechanisms. If the patient has capacity she has the right to make bad decisions.

 

[kugel]

It just seems like there is a lot of potential liability here.

This is something different. When you are concerned about liability to the hospital, don't try to guess about this. Would you ask your malpractice lawyer for advice on which antibiotic to take for giardiasis? Probably not.

So when you are questioning liability, ask you hospital risk mgt attorney. A lot of docs don't seem to know there even is one, or that the attorney will answer questions about specific cases. They won't tell you what to prescribe, but will answer your questions about what actions are likely to expose the hospital to what liabilities.

 

[heyjack70]

thanks for the great replies.

No mechanisms. If the patient has capacity she has the right to make bad decisions.

I'm asking about a patient without capacity, but not psychiatrically ill, and without imminent medical emergency. Eg a patient with dementia. After a functional assessment is done you believe they should discharge to assisted living instead of to home. They fail the test for decisional capacity regarding refusing recommended placement, so you ask SW to begin the pursuit of a guardian. But then they get out of bed and walk out of the hospital. Can you stop this person? And if so, how? Where I live the only way to prevent a patient from leaving is an involuntary psych admit, or if they have a medical emergency two physicians can place a hold to force medical care. I don't think the dementia patient really qualifies for either one of these. Maybe gravely disabled psych admit?

 

[nitemagi]

thanks for the great replies.



I'm asking about a patient without capacity, but not psychiatrically ill, and without imminent medical emergency. Eg a patient with dementia. After a functional assessment is done you believe they should discharge to assisted living instead of to home. They fail the test for decisional capacity regarding refusing recommended placement, so you ask SW to begin the pursuit of a guardian. But then they get out of bed and walk out of the hospital. Can you stop this person? And if so, how? Where I live the only way to prevent a patient from leaving is an involuntary psych admit, or if they have a medical emergency two physicians can place a hold to force medical care. I don't think the dementia patient really qualifies for either one of these. Maybe gravely disabled psych admit?

That's incorrect. This comes up all the time in C/L. Internists are miseducated that someone who's delirious, for example, trying to get up and leave, has to be placed on a psychiatric hold to be able to keep them in the hospital. In California this is actually incorrect, as a psychiatric hold is for declaring someone should be psychiatrically hospitalized. The correct procedure is to do a capacity eval, document they don't have in writing, and order restraints (as necessary) to guarantee the patients safety due to "imminent risk of harm or death." In California, at least, you CAN pursue a conservatorship (guardianship) for demented patients both through the psychiatric involuntary detention process, or not.
Your best option (for dementia), if they have family members is:
1. Do a capacity eval. If they don't have capacity, document that.
2. Get the family member to get DPOA. Get the family to get a geriatric forensic psychiatry evaluation of the pt. to try to get them declared incompetent and appoint the family member DPOA (or conservator, or guardian, or whatever your state has)
3. The family member can then make decisions as to placement.

Dementia can be argued to be a psychiatric illness, and thus qualify for GD and a psychiatric hold. But talk with your attending because you're setting yourself for a long placement process.

 

[whopper]

I'm asking about a patient without capacity, but not psychiatrically ill, and without imminent medical emergency.

Dementia is psychiatric illness. The laws of involuntary commitment apply to someone who is demented and not able to care for themselves or danger to self or others.

The only exception to this is if one of the 50 states (it's not like I read every single's state's statutes) wrote their definition of mental illness in a manner that doesn't include dementia.

In Ohio, the law is something to the effect of...

If due to a disorder of mood, thought, orientation, or memory the person is an immediate danger to self or others, cannot care for onself in the community, or poses a significant risk of danger to the rights of themself or others, and if the law puts the person under a form of involuntary commitment, the least restrictive method must be used.

Dementia certainly would be a disorder of thought, orientation, and memory. If it progressed enough it could be a disorder of mood.

In some states, not including Ohio, but NJ was in this lot, if someone was involuntarily commitable due to dementia, they could not be placed on a psychiatric unit. They either had to be placed in a medical floor or nursing home, but not a psychiatric unit. In Ohio, they put the demented patients in with all the other psychiatric patients.

There used to be a website that had all 50 states on the screen, you clicked on the state, and it showed all the psychiatric related laws in the state. Unfortunately that site is no longer in operation.

 

[heyjack70]

In the dementia pt without decisional capacity to refuse dispo, you decide to pursue guardianship. This could take months. What do you do in the interim if he tries to leave the hospital? How do you force him to stay?

 

[billypilgrim37]

In the dementia pt without decisional capacity to refuse dispo, you decide to pursue guardianship. This could take months. What do you do in the interim if he tries to leave the hospital? How do you force him to stay?

We have security detain them. If they don't have capacity to leave the hospital, then they seriously CAN'T make the decision to leave the hospital. And they don't need a psychiatric commitment.

 

[whopper]

This could take months. What do you do in the interim if he tries to leave the hospital?

The least restrictive environment. If they can't take care of themselves, you do group or nursing home or go home only if they have adequate resources there to take care of them such as family that can realistically accommodate the person's needs.

Until such a disposition is found-the hospital--even if it takes months. Hopefully it shouldn't.

 

[heyjack70]

We have security detain them. If they don't have capacity to leave the hospital, then they seriously CAN'T make the decision to leave the hospital. And they don't need a psychiatric commitment.

It's illegal to prevent someone from leaving like that. A determination of lack of decisional capacity does not prevent the patient from leaving. The hospital is not a jail. The hospital has to have a legal route to deny the person their civil rights of leaving. I'm interested in everyone's opinion on this; where I live the only ways we can force someone to stay in the hospital is on a psych hold, or 2 physician signatures for emergent medical care (delirium falls into the latter). I don't really see this patient as falling into either category very well, no medical emergency. The best option, from my perspective, is the psych hold, even though it's imperfect. There is no dementia hold.

I'm really trying to clarify this point, because even though it may very rarely come up, if it does it could be very problematic.

 

[heyjack70]

The least restrictive environment. If they can't take care of themselves, you do group or nursing home or go home only if they have adequate resources there to take care of them such as family that can realistically accommodate the person's needs.

Until such a disposition is found-the hospital--even if it takes months. Hopefully it shouldn't.

Hopefully is right. And how do you legally keep this person from leaving the hospital when they are adamant about going home? Someone has to declare them incompetent (in this example we're waiting for the judge to do that and appoint a guardian, but while we're waiting I feel like there is no good answer). A lack of decisional capacity does not decide legal incompetence. There is no medical emergency. I think a psych hold is the only way.

 

[nitemagi]

Hopefully is right. And how do you legally keep this person from leaving the hospital when they are adamant about going home? Someone has to declare them incompetent (in this example we're waiting for the judge to do that and appoint a guardian, but while we're waiting I feel like there is no good answer). A lack of decisional capacity does not decide legal incompetence. There is no medical emergency. I think a psych hold is the only way.

A capacity determination is a temporary evaluation, and will need to be done serially. The idea being that the person is at imminent risk of harm based on xyz, and doesn't recognize the risks of their decisions. Someone with delirium may not have capacity now, but might in 2 hours. It's an interesting forensic question as to the legal basis for capacity evaluations overriding individual rights.

 

[billypilgrim37]

It's illegal to prevent someone from leaving like that. A determination of lack of decisional capacity does not prevent the patient from leaving. The hospital is not a jail.

Nothing illegal about it. The hospital isn't a jail. But it does have a duty to treat. And if you don't have capacity to make the decision to leave the hospital, then you can't leave.

The hospital has to have a legal route to deny the person their civil rights of leaving.

Being denied the opportunity to make a decision you do not have the capacity to make is not a violation of civil rights.

The best option, from my perspective, is the psych hold, even though it's imperfect. There is no dementia hold.

I don't understand why it is a better option to use an inappropriate hold compared to simply maintaining the lack of capacity to make a decision to leave.

Laws may vary by state in these matters. In mine, this is how it works. You cannot place a psych hold for a non-psych issue. People do it sometimes, but it is inappropriate. If someone does not have capacity to make a decision, they cannot make the decision.

 

[heyjack70]

Nothing illegal about it. The hospital isn't a jail. But it does have a duty to treat. And if you don't have capacity to make the decision to leave the hospital, then you can't leave.



Being denied the opportunity to make a decision you do not have the capacity to make is not a violation of civil rights.



I don't understand why it is a better option to use an inappropriate hold compared to simply maintaining the lack of capacity to make a decision to leave.

Laws may vary by state in these matters. In mine, this is how it works. You cannot place a psych hold for a non-psych issue. People do it sometimes, but it is inappropriate. If someone does not have capacity to make a decision, they cannot make the decision.

I believe you are wrong. It is illegal to force someone to stay in the hospital based solely on a lack of decisional capacity. The patient must be found incompetent, otherwise you are breaking their civil rights (false imprisonment, I think). A doctor cannot declare someone incompetent (at least where I live) unless it is to render emergent medical treatment, which isn't the case here.

 

[michaelrack]

I believe you are wrong. It is illegal to force someone to stay in the hospital based solely on a lack of decisional capacity. The patient must be found incompetent, otherwise you are breaking their civil rights (false imprisonment, I think). A doctor cannot declare someone incompetent (at least where I live) unless it is to render emergent medical treatment, which isn't the case here.

Interesting question. Situation I ran into sometimes as a consult attending. Realistically, a doc can declare a lack of decisional capacity and act on this while waiting for the slow legal system to act...UNLESS the patient is rich and has a lawyer (or family has a lawyer) who is actively opposing you... or UNLESS the patient looks "normal"... eg, a young TBI pt.

 

[BobA]

I believe you are wrong. It is illegal to force someone to stay in the hospital based solely on a lack of decisional capacity. The patient must be found incompetent, otherwise you are breaking their civil rights (false imprisonment, I think). A doctor cannot declare someone incompetent (at least where I live) unless it is to render emergent medical treatment, which isn't the case here.

Have you done a consult rotation yet? This is consult 101.

The consult question is "capacity to refuse placement." If the patient doesn't have capacity to make this decision then they can't refuse. Now this determination is task specific, and is NOT the same as competence. A judge makes that determination.

 

[billypilgrim37]

Interesting question. Situation I ran into sometimes as a consult attending. Realistically, a doc can declare a lack of decisional capacity and act on this while waiting for the slow legal system to act...UNLESS the patient is rich and has a lawyer (or family has a lawyer) who is actively opposing you... or UNLESS the patient looks "normal"... eg, a young TBI pt.

Well, hopefully if the pt has awesome resources like that, then the family can actually help with these decisions either way.

 

[Therapist4Chnge]

the consult question is "capacity to refuse placement." if the patient doesn't have capacity to make this decision then they can't refuse. Now this determination is task specific, and is not the same as competence. A judge makes that determination.

bingo!

 

[heyjack70]

Interesting question. Situation I ran into sometimes as a consult attending. Realistically, a doc can declare a lack of decisional capacity and act on this while waiting for the slow legal system to act...UNLESS the patient is rich and has a lawyer (or family has a lawyer) who is actively opposing you... or UNLESS the patient looks "normal"... eg, a young TBI pt.

Could you clarify what you mean by realistically? Do you mean it seems to work this way in practice? I'm trying to get an answer about the legality of holding a patient who has not been deemed incompetent by a court.

The sense I'm getting from this thread is that patient's are being held and essentially no one cares if there are legal grounds or not, but that's just the way it's done and it seems to work. From a practical standpoint, if it's in the best interest of the patient, I think that's probably the best thing to do, but I'd like to be educated on this issue if possible.

Have you done a consult rotation yet? This is consult 101.

The consult question is "capacity to refuse placement." If the patient doesn't have capacity to make this decision then they can't refuse. Now this determination is task specific, and is NOT the same as competence. A judge makes that determination.

To clarify, I'm asking for the legal way to hold someone in between the time of deciding they lack decisional capacity to refuse placement and ultimately getting guardianship. I apologize if I'm coming across as annoying, or dense, but I don't see how a doctor determining lack of capacity has legal bearing on a patient. I could see a doctor's rationale and opinion being valuable for a judge when determining competency, but saying "this is consult 101" does not answer this question.

Psychiatrists can place patients on psychiatric holds because it is written into the law. And to prevent infringement of civil rights we all know there are specific criteria for psychiatric holds, and there is a system of checks in place to prevent/limit abuse of this system. From where I sit, it seems there must be a law to hold non-psych patients. What is it? If there is no law, what is there to prevent the potential abuse of this type of decisional capacity hold. Patients could be held involuntarily for months awaiting guardianship.

If this patient calls the police from his hospital bed, they'll show show up and ask the doctor why he is being held, the doctor will say, "Well I did an evaluation, and it's my opinion that he doesn't have capacity to refuse placement so we're holding him here until we can get a nursing home bed." The officer is going to ask under what law is the patient be involuntarily held.

And it seems like there is no answer. Am I wrong here?

 

[BobA]

Could you clarify what you mean by realistically? Do you mean it seems to work this way in practice? I'm trying to get an answer about the legality of holding a patient who has not been deemed incompetent by a court.

The sense I'm getting from this thread is that patient's are being held and essentially no one cares if there are legal grounds or not, but that's just the way it's done and it seems to work. From a practical standpoint, if it's in the best interest of the patient, I think that's probably the best thing to do, but I'd like to be educated on this issue if possible.



To clarify, I'm asking for the legal way to hold someone in between the time of deciding they lack decisional capacity to refuse placement and ultimately getting guardianship. I apologize if I'm coming across as annoying, or dense, but I don't see how a doctor determining lack of capacity has legal bearing on a patient. I could see a doctor's rationale and opinion being valuable for a judge when determining competency, but saying "this is consult 101" does not answer this question.

Psychiatrists can place patients on psychiatric holds because it is written into the law. And to prevent infringement of civil rights we all know there are specific criteria for psychiatric holds, and there is a system of checks in place to prevent/limit abuse of this system. From where I sit, it seems there must be a law to hold non-psych patients. What is it? If there is no law, what is there to prevent the potential abuse of this type of decisional capacity hold. Patients could be held involuntarily for months awaiting guardianship.

If this patient calls the police from his hospital bed, they'll show show up and ask the doctor why he is being held, the doctor will say, "Well I did an evaluation, and it's my opinion that he doesn't have capacity to refuse placement so we're holding him here until we can get a nursing home bed." The officer is going to ask under what law is the patient be involuntarily held.

And it seems like there is no answer. Am I wrong here?

You'd need to consult a legal text in your state to see what the actual law is, but physicians in all patient-care related fields of medicine do this routinely (and most consult psychiatrist do this daily).

The officer will probably know what law it is because they enforce it routinely.

 

[billypilgrim37]

It may be best to look up some of the Appelbaum capacity papers, not sure of references but I think they can explain these issues better than we probably can.

And by the way, if anything, these are civil liberties issues, not civil rights issues. We're not holding the dude because he's a old homosexual African American Muslim, we're holding him because he doesn't have capacity to make the decision to leave.

 

[notdeadyet]

You'd need to consult a legal text in your state to see what the actual law is, but physicians in all patient-care related fields of medicine do this routinely (and most consult psychiatrist do this daily).

The officer will probably know what law it is because they enforce it routinely.

I definitely wouldn't assume that. At more than one hospital I've been in, the institutional police would not forcably hold someone who was being held for medical capacity issues. They would require a psychiatric hold with the appropriate legal paperwork. For folks with delirium or whatnot, they would allow medical staff to apply restraints but would not participate. If called, they would stand around until the patient made a move that could be considered threatening. Their reasoning was similar to heyjack's logic: a medical team can hold a patient on medical grounds for the patient's safety, but there aren't clear instructions to police for doing so without a legal hold or paperwork.

The state laws are very clear on psychiatric holds, but medical ones are much more broadly defined and the implementation seems to depend quite a bit on hospital policy. There's a reason why we almost never call in the ethics committee on a psychiatric hold, but occasionally need to for a medical one.

 

[heyjack70]

It may be best to look up some of the Appelbaum capacity papers, not sure of references but I think they can explain these issues better than we probably can.

And by the way, if anything, these are civil liberties issues, not civil rights issues. We're not holding the dude because he's a old homosexual African American Muslim, we're holding him because he doesn't have capacity to make the decision to leave.

Thanks for the civil liberties/rights distinction; that will probably prevent me making an idiot of myself in the future.

 

[heyjack70]

You'd need to consult a legal text in your state to see what the actual law is, but physicians in all patient-care related fields of medicine do this routinely (and most consult psychiatrist do this daily).

The officer will probably know what law it is because they enforce it routinely.

This is a good suggestion. I'll see what I can do. Do you know the name of the law in the state where you have been holding patients like this? I ask so I can look for similar wording/titles in my state's laws. Thanks in advance.

 

[notdeadyet]

I'm finding this discussion very refreshing. I knew psychiatry would have a few things that made me uneasy, but I've been pretty shocked by how cavalier holds are treated by bad psychiatrists.

I think it's easy to not look too deeply at how the hold system is great for the practitioner but can be a little unjust to the patient. In California, we have the 5150, under which you can put someone on a 72 hour hold for danger to self/others or grave disability. Makes sense and god knows we need it in psychiatry. But the patient has no right to protest this, so once it's thrown down, the opinion and word of one person can detain someone against their will. Great for us, but hard to reconcile the Fourteenth Amendment and the right to due process before denial of liberties.

Police officers issue them and there are some BAD uses of the 5150 that are completely misapplied. And while we throw down 5150's so often we think of them as meaningless, they have some consequences. A guy who works for Lockheed Martin can now lose his security clearance and therefore his job. A person loses the right to own firearms for 5 years.

I'm pro-psychiatry and pro-psychiatric holds, I just think discussion threads like these peeling back the layers to look at the ethics of some of what we do everyday is useful to prevent misapplication of powers.

 

[whopper]

I believe you are wrong. It is illegal to force someone to stay in the hospital based solely on a lack of decisional capacity.

It's not illegal to keep someone in the hospital who meets involuntary commitment criteria, and the commitment papers were filed. Then the court has to figure it out.

In most states, this is handled the same way it's handled with otherwise mentally ill patients who meet commitment criteria. In other states, for some reason, demented patients are sometimes put in another category, in which case there's a capacity evaluation that needs to recommend the patient cannot take care of himself or herself, then this will mandate the court do a competency hearing, but until that hearing, the patient is kept in the least restrictive environment-and that's usually the hospital.

If the court is very slow in this regard, this is not your fault or the fault of the hospital. Yes, the slowness will cause problems, but you have no control over this other than to have someone in the hospital (preferably the legal dept.) call the court up and request the hearing be pushed earlier.

The attending handling this case with you should hopefully guide you through this process. If your residency was like mine that wasn't happening with all the attendings. Many of them merely just wanted you to do the work they would've had to have otherwise done, then they signed it and didn't teach you the situation, what it meant, and it's implications, leaving the resident clueless.

 

[BobA]

I'm finding this discussion very refreshing. I knew psychiatry would have a few things that made me uneasy, but I've been pretty shocked by how cavalier holds are treated by bad psychiatrists.

I think it's easy to not look too deeply at how the hold system is great for the practitioner but can be a little unjust to the patient. In California, we have the 5150, under which you can put someone on a 72 hour hold for danger to self/others or grave disability. Makes sense and god knows we need it in psychiatry. But the patient has no right to protest this, so once it's thrown down, the opinion and word of one person can detain someone against their will. Great for us, but hard to reconcile the Fourteenth Amendment and the right to due process before denial of liberties.

Police officers issue them and there are some BAD uses of the 5150 that are completely misapplied. And while we throw down 5150's so often we think of them as meaningless, they have some consequences. A guy who works for Lockheed Martin can now lose his security clearance and therefore his job. A person loses the right to own firearms for 5 years.

I'm pro-psychiatry and pro-psychiatric holds, I just think discussion threads like these peeling back the layers to look at the ethics of some of what we do everyday is useful to prevent misapplication of powers.

I agree with everything you said, but if the issue is placement of someone with dementia, then we look at placement in rehab as a medical treatment. Thus, we are considering someone's capacity to accept or refuse medical treatment, not psychiatric treatment. Hence we don't use psychiatric holds in this situation.