Suicidal and refusing blood draws?

[stochastic2]

alright..so i'd like some feedback on a case: i'm an ED doc btw.

While working in the ED, a patient is brought in by the ambulance after the son called 911 because he found the patient sleepy. The son said they had previously gotten into an argument during which the patient threatened to commit suicide. Later, when the son went to check up w/ the patient, he found the patient sleepy and the patient admitted to taking twice the patient's dose of benzo that evening (the dose itself, was not an extremely high amount). The son concerned of an overdose called 911. In the ED, the patient is obviously upset that 911 was called and threatens to contact a lawyer about being forced to go to the ED. In the ED, patient is a&0x 3, denies suicidality, and denies taking anything other than the BDZ. When interviewing the son, he states that the patient has threatened suicide before but has never attempted. The patient has recenlty gone through a divorce. The son is now wondering if he overreacted and they want to go home. When speaking to the patient about blood draws for a thorough evaluation (to check acetaminophen levels as this is a case of ?suicide and ingestion) the patient refuses. The patient, however, will not elaborate on the reasons behind the refusal and states it is a patients right to refuse and does not want bloods drawn. the patient otherwise gives a clear story.

My first Question is can a patient refuse blood draws to r/o life saving treatment if indeed an "ingestion" has occured in a case of ? suicide?
How does capacity fit into come into play?

We consulted psych and it was a weird dynamic. The resident felt the patient lacked capacity (documented so) while the attending on call officially documented that thes patient had capacity to refuse but should be admitted to psychiatry. This decision was confusing to me. if we can admit a patient against his/her will for danger to self (?suicide), then are we not obligated to ensure that there wasn't something more to the ingestion? How can a blood draw be refused? There is only 8 hrs to give the antidote, so certainly one cannot wait for a patient to develop symptoms, because by that time they will not benefit form the antidote.

What is your understanding of right to refuse in this case?

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[whopper]

My first Question is can a patient refuse blood draws to r/o life saving treatment if indeed an "ingestion" has occured in a case of ? suicide?
How does capacity fit into come into play?

We consulted psych and it was a weird dynamic. The resident felt the patient lacked capacity (documented so) while the attending on call officially documented that thes patient had capacity to refuse but should be admitted to psychiatry.

Certainly a difficult case, even if you're very confident if you know what you're doing because of the legal issues involved.

Does this person lack capacity? Well, of course the correct answer for me is I don't know because I'd have to interview the person myself, but taking your assessment as if the person was of clear mind, could concentrate, was not psychotic etc. It is possible.

Capacity & meeting actionable commitment criteria are 2 separate entities. While there is some overlap (e.g. a psychotic patient who denies she's diabetic & refuses treatment despite a proven history of itand her blood sugar is 700, while at the same time showing HTN crisis with a BP of 230/125--which is clearly both--lacks capacity & is commitable)....there will be cases where someone can have one, but not the other.

E.g. has capacity but is committable: person who is suicidal, was thinking of doing it that night, goes to the hospital only hoping to get an outpatient referral. She is offered inpatient, & does not want it. This is a case where doctor may commit--despite the irony that she wanted to get treatment herself (and this is a complicated case too, her seeking treatment on her own would put a doctor in a very uncomfortable grey zone. Other factors would have to be explored to see if she should be commited or not).

My first Question is can a patient refuse blood draws to r/o life saving treatment if indeed an "ingestion" has occured in a case of ? suicide?

Yes under certain circumstances. People have the right to die if they so wish so long as they are not suffering from a commitable Axis I disorder.
But what about the case of a committable Axis I disorder? Then what's going to have to happen is a forced medication/forced treatment hearing, the laws of which vary per state.

In the ER situation, I'd have psychiatry take this over once the person was medically cleared. While its difficult to determine medical clearance in a situation where the patient refuses a blood draw--the department heads--btw ER & psychiatry could decide in this difficult situation. The person certainly could not wait in the ER for several days before this went to court.

And add reality to the mix. Several patients refusing a blood draw who are of sound mind eventually give in because they realize its going to hold them up for several hours in an ER where they got nothing to do.

 

[Anasazi23]

Well, there's the textbook and then there's the reality of this particular case.

The most prudent thing to do would be what the attending suggests. That is, 2-pc or emergency admit (or whatever the equivalent is in your state) the patient to psychiatry. Then, take them to court for the inevitable retention and med-over-objection order. In that order, the docs and lawyer will ask for blood draws and certain treatments to be included in the court order.

In this particular case, the chances of dying from overdose are relatively small. Flumazenil would be helpful, but most patients do well with supportive medical therapy. In the worst case scenario, you can wait for respiratory arrest, then intubate as a life-saving measure against his will. He'll be in no position to argue since he won't be able to breathe. Then, you can also go to court to get an order. If the judge decides to honor the DNI, then it's basically off your back until the patient family sues you. Then pray that the judicial immunity will protect you, which it may not.

 

[whopper]

That is, 2-pc or emergency admit (or whatever the equivalent is in your state) the patient to psychiatry. Then, take them to court for the inevitable retention and med-over-objection order. In that order, the docs and lawyer will ask for blood draws and certain treatments to be included in the court order.

I'd imagine an upcoming argument or at least feeling of resentment towards both departments when the psychiatry dept does not want to accept a patient without labs as "medically cleared".

I've had patients on my forensic unit where we could not draw labs until the court ordered passed--then turned out they were diabetic with a blood sugar in the over 400 range. The court often times did not hear the case for weeks, while the person sat there, at a cost of almost $1000/day to the system.

The legal & medical systems do not interface well.

 

[stochastic2]

Thanks for the replies everyone.

Although whopper, I'm having a difficult time thinking of a scenario where,

"Yes under certain circumstances. People have the right to die if they so wish so long as they are not suffering from a commitable Axis I disorder."

In what circumstance can or has this occurred? I'm thinking if someone is suicidal that's almost pathognomonic of an Axis I disorder. Although, i know i'm oversimplifying.

In any case, in this scenario both departments were trying to find a happy medium. Psych was willing to admit the patient w/o a medical clearance, but the ED was not comfortable with that plan as we were unable to medically clear the patient of all emergent conditions: mainly tylenol overdose. Our concern wasn't over a BDZ overdose, but a co-ingestion of tylenol. In cases of suicide, it's standard of care to rule out coingestion of tylenol with a tylenol level because tylenol overdose not only lacks a toxidrome but has a very effective antidote when it is given w/in a predetermined time window. The issue of the patient's right to refuse a blood draw, therefore, was a time pressed issue because the time window required to treat a tylenol overdose is <8hrs. If treated before the 8 hrs, the success of the antidote is practically 100% while if given beyond the 8 hrs, the patient faced a real risk of developing irreversible liver damage requiring liver transplant and/or death. In the real world, waiting for a court order would not have been possible. I think it is plausible that by the time any court decision could be made, the window of administering the antidote would have passed making this a moot argument.
The ED's perspective in this situation was that it is reasonable that a patient w/ suicidal ideation might not admit to coingestions. We had hoped that psych would find the patient a danger to oneself and lacking capacity, but that was not the case here. Finding the patient able to refuse figuratively tied the hands of the ED doctors. It then became an administrative issue. What happens when the ED doctor (the primary doctor) finds the patient w/o capacity but the Psych doctor (the consult) disagrees. In our minds, we wouldn't have done our job if we allowed the patient to be admitted to the psych ward and he/she subsequently died of liver failure.



Another question i had was when evaluating capacity, can you say a patient does not have capacity if they refuse to explain their reasons behind their actions? (ie. refusing the blood draw) How do we know there isn't an irrational or paranoid reason behind it?

Although, i must admit, our impression of this patient was that she understood the scenario and was just being, like some patients are for whatever reasons, difficult and set with her agenda.

 

[nancysinatra]

What happens when the ED doctor (the primary doctor) finds the patient w/o capacity but the Psych doctor (the consult) disagrees. In our minds, we wouldn't have done our job if we allowed the patient to be admitted to the psych ward and he/she subsequently died of liver failure.

I can't answer your question but am curious--what was the exact reason for the psych consult?--was it for capacity evaluation, possible admission to psych, or both? If you, as the primary doctor, already found the patient to be lacking capacity to refuse the blood draw, why would you need a psych consult for capacity? It does seem that this patient would then be admitted to the pysch ward only to possibly die of liver failure there if indeed they were then granted capacity and refused the blood draw.

So, does psych trump ED when it comes to capacity? I have been told that all physicians can determine capacity. But psych does get called to do specific capacity evaluations.

 

[Solideliquid]

A few months ago I went to the ICU for an admission consult. A young woman with a history of suicide attempts (more like gestures) overdosed on an unknown amount of tylenol. She had blood drawn in the ER and ICU while she was somewhat altered and could not refuse blood draw. She had an elevated tylenol level. She wakes up a short time later in the ICU and refuses to take mucomyst and I started wondering if we would have to restrain her and administer IV NAC. What ended up happening I threatened her with an involuntary admission to a state hospital if she didn't agree a voluntary admission to our psych unit. I let her think about it for 30 minutes and returned then. She agreed to take mucomyst and did so, and signed consent for admission. I wasn't able to send her to a state facility until she took the seventeen more doses of mucomyst and by that time she would have needed another evaluation to see if she still needed admission.

In your case if had been called to consult I may have recommended that the patient be kept in the ED on a psych hold for 24 hours, either until she agreed to the lab test or symptoms started appearing (as an alternative she could have been sent to psych, and mucomyst may be started on the unit). Since you don't really know if she had intent to kill herself or not, and the patient isn't cooperating with you I would recommend that she remain in the hospital. You are far far less likely of getting sued for holding someone for 24-72 hours than if she goes home and attempts again or suffers serious injury from an overdose.

So, does psych trump ED when it comes to capacity? I have been told that all physicians can determine capacity. But psych does get called to do specific capacity evaluations.

Not really, every physician can assess for capacity just like most psychiatrists should be comfortable treating simply HTN or diabetes when a primary physician isn't available. However primary physicians/internists don't assess for capacity every day. Another factor in capacity assessments, physicians including psychiatrists often don't want to be the only one to say someone doesn't have capacity. It's one of these things that you'd want another professional to back up your decision in case a legal process comes into play.

 

[Anasazi23]

I'd imagine an upcoming argument or at least feeling of resentment towards both departments when the psychiatry dept does not want to accept a patient without labs as "medically cleared".

I've had patients on my forensic unit where we could not draw labs until the court ordered passed--then turned out they were diabetic with a blood sugar in the over 400 range. The court often times did not hear the case for weeks, while the person sat there, at a cost of almost $1000/day to the system.

The legal & medical systems do not interface well.

You could medically admit them to psychiatry and place them on a 1:1. That's the other option...

 

[michaelrack]

The practical answer to your question is that a patient in the ER after a possible intentional overdose can not refuse "simple" interventions such as NG tube, blood draw, etc.
No need to do a formal capacity evaluation.
EMergency intubation is something you can also do if medically necessary.

In the first 4-16 hours after a possible suicide attempt, you can pretty much do what you think is necessary, though you should get surrogate consent (if the patient refuses) for invasive procedure such as central line, if possible.

This is the practical answer, not what you will find in textbooks.

 

[whopper]

"Yes under certain circumstances. People have the right to die if they so wish so long as they are not suffering from a commitable Axis I disorder."

If someone does not want to live, they'll most likely have at the very least Adjustment Disorder which is an Axis I, so a bit of a correction of what I stated. However there have been cases where people did not want to live and were not found to be psychiatrically committable by an ethics committee.

E.g. someone who gets into a car accident--becomes a quadriplegic, and says he does not want to live. He's not depressed but does not want to live because he views himself as useless to society.
Or someone oddly enough who is of a culture where death is not viewed in the same terms it is in the US. In eastern Asian countries for example, people haev been known to take their own lives and were not depressed or psychotic because it was viewed as a type of honor.
There's a documentary (forgot the name) of a medical doctor in Australia who teaches patients euthenasia, and one of the main people spotlighted was an elderly French lady (living in Australia) who wanted to die who clearly was not depressed, psychotic, manic, anxious etc. She felt she lived her life and did not wanted it to end. I don't even really think she had adjustment disorder.

I believe the movie was on the Sundance channel a few years ago.

Certainly rare, but it does exist. Not something you really have to worry about so much in your own field. These are zebras. I always wondered what I would do if I had a patient on this order, other than contact the hospital ethics committee.

The practical answer to your question is that a patient in the ER after a possible intentional overdose can not refuse "simple" interventions such as NG tube, blood draw, etc.

IMHO, I would in most cases categorize someone as having possibly overdosed just a few hours prior as requiring emergency medical intervention even without their consent. Cases which are not acute could be argued in court--but this situation IMHO would be too close to the event of question & IMHO would be acute. Of course I wouldn't be the ER doctor. It'd really be up to the ER doctor.

 

[Anasazi23]

The practical answer to your question is that a patient in the ER after a possible intentional overdose can not refuse "simple" interventions such as NG tube, blood draw, etc.
No need to do a formal capacity evaluation.

I'm not sure if this is entirely true without operating under the assumption that it's a life-threatening condition where consent is assumed and the patient is unable to communicate a choice in treatment.

It may also vary by state. These are not federal mandates, and states certainly vary in their standards of patients rights (or lack thereof).

 

[whopper]

I'm not sure if this is entirely true without operating under the assumption that it's a life-threatening condition where consent is assumed and the patient is unable to communicate a choice in treatment.

IMHO, a recent OD--just hours after the event, even if the person wakes up & refuses consent is still too close too the dangerous event & would justify emergency intervention.

My logic? The person could've taken multiple pills--in addition to benzos. E.g. acetaminophen, and may have suffered tremendous liver (or in the case of other meds the kidneys) damage that would require treatment & lead to further morbidity & mortality. The person also may have taken some meds where the maximum concentration in the serum may not have yet been achieved. Yes they woke up, but they still may be in the acute danger phase and would require emergency intervention. I would document that, & proceed with emergency blood draws even against the patient's consent.

Also a suicidal patient may not be giving an accurate medical history. The person for all you know may have a blood sugar of 600 in addition to other complicating factors that the overdose may have triggered. A suicidal patient refusing a blood draw IMHO gives enough justification to not trust the medical history they gave you.

That would also allow determination of medical clearance to the psychiatry ward, or determine the need to bring the person to the medical floor.

If I were a psychiatric C&L--I'm not sure if I'd say the person had capacity or not. I'd have to interview them myself and get the person to answer key questions that weren't addressed in the posts above. However I'd talk to the ER doctor off the record and tell them that in my opinion the person should have the blood draw anyway, regardless of capacity or not given the above argument. If the person didn't agree with me, and then tried to transfer to psyche-I'd hate to admit it but there'd be a showdown between both departments over this transfer if I was in charge of accepting the transfer. I'd argue the above, and claim there's not enough data to conclude medical clearance.

If I was overridden by my hospital superiors fine, then I'd put my objection on the record. There'd be a paper trail that states that I objected & giving the reasoning as to why. So if it turns out the patient did have extensive renal or liver damage, and the IVs weren't put in, or the mucomyst wasn't given, I have something that gives me a "get out of jail card".

As legalistic & self service as the above sounds, it really is in defense of the patient, and with the full intention of giving that person the best of care, while accurately putting into the record that I was concerned for the person's safety. And let's all be honest--psychiatrists, ER doctors, any practicing doctor has plenty of experiences where one department turfed to you in what you believed was in bad faith.

 

[kugel]

Much of this thread contains questions best addressed to an experienced risk management lawyer at your hospital.
Seriously, most physicians (me included) are not qualified to attempt to answer these difficult and complex legal questions - esp across state lines.
These risk mgt attorneys are here to help you provide the best care in a legal manner and one that helps protect the hospital (and that often includes you).

I've attached a couple of articles that may be of help.

In CA, it's not unheard of to have someone who meets criteria for a psych hold ("5150" here) but does not fail the test of capacity, i.e. is on a psych hold but CANNOT be forced to accept medical treatments. Even when the court approves involuntary psychiatric medications, this has essentially nothing to do with involuntary treatment for any other non-psych problem. Anorexia patients cannot (legally) be forced to undergo NG tube or G-tube refeeding, HTN patients cannot be forced to accept anti-HTN meds, patients who swallowed a fork cannot be forced to undergo surgery. Unless they have gone through a separate court procedure permitting such treatment or giving someone else substituted consent capacity.

I have no idea where someone would get the idea that pt's in the ED cannot refuse basic or simple interventions. They most certainly have that right. I got a referral Friday from an ED where the pt on a 5150 refused vital signs. They did, indeed, hold the patient until the pt relented and there were VS on record to corroborate a statement of "medically cleared."

There is also no standard permitting interventions against the patient's will just because the person has fallen unconscious. "Presumed consent" only exists when you do not have any evidence contradicting the assumption that anyone would want life-saving interventions. If "presumed consent" always existed once the pt is unconscious, then advance directives would have no validity. When the patient (who seems to have capacity) HAS stated he wants no interventions, waiting until he falls unconscious and then ignoring his request and intervening anyway could/should be considered medical battery.

I've been told (by a hospital risk mgt attorney) of a case in which a patient refused emergency medical treatment, then fell down in the parking lot. As soon as he became unconscious, the ED staff scooped him up, returned him to the ED and provided emergency medical treatment and saved his life - only to be successfully charged with medical battery. Now, I haven't seen the case myself, so it remains in the "rumored but from a responsible source" category for me.

I'm not saying such things never happen, just that I've discussed these issues with a number of Risk Mgt attorneys and Ethics Committees - and these are the conclusions I draw every time. I'm also not saying that these conclusions are what the situation "should be," only that it's "what is."

 

[kugel]

more interesting resources:

http://www.pubmedcentral.nih.gov/picrender.fcgi?artid=1486469&blobtype=pdf

http://www.churchlawtoday.com/private/library/pcl/p18f.htm

http://www.psychiatrictimes.com/display/article/10168/51551

Depression, competence, and the right to refuse lifesaving medical treatment
Sullivan and Youngner Am J Psychiatry.1994; 151: 971-978

http://psychrights.org/articles/rightorefuse.htm

THE RIGHT TO REFUSE PSYCHIATRIC TREATMENT
Psychiatric Clinics of North America
Volume 22, Issue 1, 1 March 1999, Pages 173-182

Algorithm for the Right to Refuse Medical Treatment
http://www.ascensionhealth.org/ethics/public/alg_refuse.pdf

Algorithm - Surrogate Decision Makers
http://www.ascensionhealth.org/ethics/public/alg_sdm.pdf

 

[whopper]

Much of this thread contains questions best addressed to an experienced risk management lawyer at your hospital.

True,

but in several cases--especially on a Friday night, the lawyer will not even touch the case till Monday morning at the very earliest. (Even then the reality is they won't touch it till Monday afternoon).

Of course its a good thing to consult the hospital ethics committee, and other sources such as the lawyer, but in several other situations, such as a patient who just woke up after a suicide attempt and what she ingested was unknown....

An interesting conundrum. The person has capacity but is suicidal & depressed. The law on one hand says that if they are a danger to themself or others, the doctor has the responsibility to treat them, and keep them committed until they are no longer a danger to themself or others. However if they have capacity, they're not supposed to be treated.

I'd still stand by my opinion in the above case because timing is of the essence (of course I would however talk to the hospital administration about this too because this is a complicated case, and I wouldn't be the one making the decision to treat--the person is still in the ER dept's responsibility), but in the case where there is time to discuss this and have the ethics committe & lawyer work on it, I'd most definitely would want to hear their input.

 

[kugel]

Thanks, Whopper.
I respect your posts enormously and I always try to read them very carefully.

I'm suggesting these questions can be put your Risk Mgt attorney before the next case. They generally want to help avoid having to do damage control on Monday afternoon.

The Ethics committee may well have a procedure for reaching them in an "emergency," like when a decision has to be made quickly about organ donation.

It's important in these "grey area" cases to separate the issues of
A) "detention" for danger to self/others and
B) treatment against stated wishes
Most states (maybe not all) separate these two and meeting criteria for a psych hold is not the same thing as overriding the right to refuse treatment.

Then there is the third issue which is the difference between "emergency psychiatric treatment" (as in Haldol and Ativan for someone actively attempting to hurt self/others) and overriding the refusal of medical treatment. Overriding refusal of treatment demands that you can document your reasons to believe that the patient is incapable of cosent ("lacks capacity"). The fact that the patient wants to die is NOT the same at all as lacking capacity.

Since patients are presumed to have capacity, not answering the questions about capacity would rarely be grounds for presuming lack of capacity.
If, however, you had a close friend or family member stating that the patient is acting bizarrely and contrary to his normal self, then you might have enough to override the presumption of capacity.

Since the son in this case was stating he believes his father is not suicidal and is not acting in a way that seems "unnatural" for him, I don't think you'd have enough to defend against a medical battery charge.

But, again, I'm NOT an attorney and these things are best answered by an attorney - ahead of time.

 

[whopper]

these things are best answered by an attorney - ahead of time.

Aw geez, the magic words--"ahead of time" and what a great situation to be in if it wasn't answered ahead of time.

I had a moderate MR person who had nothing acutely wrong with him. He wandered off to the casinos and didn't remember his way back home, so he stayed in the casino. He was enchanted with the flickering lights, the girls in the skimpy outfits and the atmosphere.

The casino doesn't want someone wearing a helmet over his head drooling over high rollers (that's not meant as an insult to MR people, that's reality), and quickly got him out of the casino--> and into the hospital.

This guy's guardians were sick of him, and refused to pick him up. Not the first time he did it, and every time he did it, they'd have a panic episode. They weren't his biological parents. They were DDD (Department of Developmentally Delayed) state appointed guardians.

So its a Friday night, and the ER then dumps him to psychiatry (and I can't blame them either---there was nothing physically wrong with him). We can't admit him to inpatient simply for being MR. The guardians won't take him. There's a NJ law saying we can only keep him for 24 hrs. The ER doctor is saying he's going to street the guy if we turf him back to the ER. DDD isn't open on Friday nights, and won't be open to Monday. The guy obviously can't take care of himself.

The staff kept muttering--"the social worker should find him a place"-nope, no social workers or places we could refer to open on Friday night, "we need to call the ethics committee" nope-its Friday night, "we need to call the hospital lawyer"-no its Friday night, they're not back to Monday.

That & my idiot attending was home and didn't want to deal with it so he kept trying to push it into my hands. He really should've stepped up to the plate & involved himself more on this case.

Good thing for me was my shift ended. It became someone else's problem. I still don't know how that problem was settled. I would've kept the guy--which would've gotten some of the higher ups in the hospital not too happy with me, but good thing for me was I was saved by the bell.

 

[kugel]

Several similar situations.
MR pt brought back to the psych emerg service several times over 2 days b/c wandering.
When his MR wouldn't take him back, called Adult Protective Service and reported them as abandoning a disabled adult - and all the sudden they wanted him back (rather than lose their license forever).

Demented pt's wandering from the Nursing Home - same problem, same solution, same result.

Bipolar or Schizophrenic pt's who won't stop using drugs, but clear up just fine 10-14 hrs after hitting the PES, who are back every 1-2 weeks. Board and Care doesn't want them back, but won't hold that position when called by the state licensing office about why they are attempting to evict him illegally.

Had a police officer bring a similar pt back for the 3rd time in 24 hrs open the big book of state penal codes showing me, "Look. It says right here that 'a certified peace officer may take any person he believes is a danger to self or others due to a mental disorder to any licensed inpatient psychiatric facility.' So you have to take him according to state law!"
"Show me where in there it says that I have to keep him if I, as a licensed physician, determine that there is no emergency medical or psychiatric need for involuntary treatment."

Of course, it helps to work in concert with your medical ED.

now that we all know these situations are possible (likely and persistent as well), we can be discussing them with our attorneys on Monday.

You can see my stance on admitting pt's who don't need acute inpt psych care.

 

[whopper]

I like your style.

Adult Protective Services--that's what I figured out--after the event, when an attending that actually had half a brain heard about the case, and told me what he would've done. The attending I was on that night wasn't really guiding me, and the nurse manager from the psyche emergency department just loved grilling residents who didn't know what to do even though it wasn't their responsibility, while giving attendings free passes.

The attending I was on duty with that night also didn't mind dumping to inpatient because he never did any inpatient work. If the unit got mad at him, he didn't have the suffer the consequences.

 

[Thorazine]

does it matter if someone called 911 on the patient and they were brought in by ambulance, as opposed to the patient walking into the ED? i would imagine the former would be considered a more emergent situation and the doc would be given more leeway with treating. am i way off base?

 

[kugel]

does it matter if someone called 911 on the patient and they were brought in by ambulance, as opposed to the patient walking into the ED? i would imagine the former would be considered a more emergent situation and the doc would be given more leeway with treating. am i way off base?

Don't know of any reasons that would change the legal standards or implications of ignoring them.

 

[whopper]

does it matter if someone called 911 on the patient and they were brought in by ambulance, as opposed to the patient walking into the ED? i would imagine the former would be considered a more emergent situation and the doc would be given more leeway with treating. am i way off base?

Agree with Kugel, however someone walking in does imply better insight because they sought treatment on their own. The legal standards are the same, but there's a difference between someone who's found unconcious with a bottle of empty xanax by them and a suicide note and someone who voluntarily comes in & wants treatment.

Commitment criteria between the 2 different cases remain the same, but simply because someone says the word "suicidal" doesn't always mean they are committed. The associated risk factors also have to be weighed.