What do you think of this situation?

[nancysinatra]

So I have to take call in a small inpatient unit in a small town. The state I'm in has a severe bed shortage and we get referrals from all over the state. The patient will be in some rinky dink small town ER 200 or 300 miles away, and an ER doc (a family practice doc, usually) will call our unit at 3am to ask us to take them.

Almost in every single case, the patient is "on a hold." We have 72 hour holds in this state. The paperwork requires the signature of an MD and no other explanation about why the hold has been placed.

The ER docs (or nurses actually, it's the nurses from the ER who call the nurses in our unit who call me) will usually spin the case to sound worse than it really is. So for example someone who makes the most remotely suicidal comment while intoxicated will be described as "suicidal." Mitigating factors like the intoxication, the lack of a plan, a non-lethal plan (like a morbidly obese man saying "I'm going to starve myself to death if the you don't get me a new group home") etc, are often minimized or never mentioned. It's hard to do doc-to-docs because often it's been many hours since the ER doc that saw them actually saw them, and honestly, doc-to-docs make it harder, not easier, to refuse the patient. What we end up going on is mostly nursing comments.

Then these patients come to us. I find that many of them are not people I would have admitted in residency, when I worked in a psych ER. Actually I worry that they are being held involuntarily without very good reason in some cases. So here is my question - are we violating people's right to liberty by utilizing the involuntary commitment process in this way?

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[MacDonaldTriad]

Yes, but there is a lot of pressure to violate their rights, and they is almost no chance of any negative consequences for you or the referring doctor if you continue to do this. There isn’t a lawyer in the world who would take a case like this on. They would have to prove that the referring doctor should have been unconcerned enough to not make the referral. Whereas your letting the patient go does carry a risk of a bad outcome; a very low risk, but more risk than the referring doctor had to take.

 

[nancysinatra]

Thanks. Yeah, I actually discussed this with our risk management attorney in the process of discussing some other things. It would be way better to err on the side of holding someone harmless rather than letting someone dangerous go and they shoot up a school. I'm really just wondering what people think about the fairness and ethics of it. Now, these patients mostly come into the ER on their own accord or because of dumb things they've done while intoxicated. The doctors and nurses are just trying to help. It's not like we're going around, rounding harmless innocent people up. But anyway, in America it seems like we frame all these issues in terms of being sued. But there's another aspect to it, which is that we're very "protective" of people, to the point where with some of these cases, I just feel like, good grief.

 

[notdeadyet]

Actually I worry that they are being held involuntarily without very good reason in some cases. So here is my question - are we violating people's right to liberty by utilizing the involuntary commitment process in this way?

Who is the "we" in your question? Are you asking if your small inpatient unit is violating people's rights via participation in maintaining questionable holds by accepting these patients?

I work part-time at a rural inpatient unit that takes in transfers from more rural ERs (though not 200-300 miles away, you win on that one!). Even there, we require a transfer packet that precedes the doc-to-doc. It includes basic labs, the full ER doc note, the nursing note, vitals, a copy of the hold (though that seems thin, in your state's case), etc. If anything looks fishy, I push back for more detail (including a BAL, in some cases). I find that while docs and nurses at OSH try to "spin" on the phone, they are much less likely to do so in the chart, especially when they are in CYA mode, which tends to be the mode they're in when they're trying to transfer a questionable patient rather than discharge them.

 

[nancysinatra]

Who is the "we" in your question? Are you asking if your small inpatient unit is violating people's rights via participation in maintaining questionable holds by accepting these patients?

I work part-time at a rural inpatient unit that takes in transfers from more rural ERs (though not 200-300 miles away, you win on that one!). Even there, we require a transfer packet that precedes the doc-to-doc. It includes basic labs, the full ER doc note, the nursing note, vitals, a copy of the hold (though that seems thin, in your state's case), etc. If anything looks fishy, I push back for more detail (including a BAL, in some cases). I find that while docs and nurses at OSH try to "spin" on the phone, they are much less likely to do so in the chart, especially when they are in CYA mode, which tends to be the mode they're in when they're trying to transfer a questionable patient rather than discharge them.

That's interesting - we too get packets like yours, but as far as what I want from that info, that gets into a different topic, which is our unit's criteria for accepting patients. We don't take aggressive patients, for example, or sex offenders, or demented geriatric patients. We don't in theory take medically unstable people either. Now since every OSH always wants me to say yes to every transfer, I view it as my job to look for reasons to say no. What I find in reviewing charts is that the OSH docs tend to under-document rather than over-document. No ER doc, for example, is going to document a patient's sex offense in the chart. They'll downplay dementia. Things like that. Therefore what I'm looking for when I request more info is not usually hard evidence like labs, but the kind of "soft" info that you can often get verbally nurse-to-nurse, like "oh yeah he's no longer endorsing suicide," or "he just punched a hole in the wall" or, "he can't feed himself." Now in situations where I question a patient's medical stability, then, yeah, I pour over the chart.

So really there are two issues here - how information gets "spun" on both ends during a transfer request, and then, whether resulting admissions are kosher in terms of civil liberties being upheld.

The "we" could be any of us. I think my question is more like this: if you're the patient, and you got put on a hold and some OSH recognized it, and the reason for the hold was that you made a comment to the effect that you "might kill yourself, blah blah blah" - would you feel this was overkill? Would you think this was overly paternalistic? The people who put the wheels in motion here are not psychiatrists, but overly busy ER docs, who really want those patients out of their ER.

 

[heyjack70]

Thanks. Yeah, I actually discussed this with our risk management attorney in the process of discussing some other things. It would be way better to err on the side of holding someone harmless rather than letting someone dangerous go and they shoot up a school. I'm really just wondering what people think about the fairness and ethics of it. Now, these patients mostly come into the ER on their own accord or because of dumb things they've done while intoxicated. The doctors and nurses are just trying to help. It's not like we're going around, rounding harmless innocent people up. But anyway, in America it seems like we frame all these issues in terms of being sued. But there's another aspect to it, which is that we're very "protective" of people, to the point where with some of these cases, I just feel like, good grief.

Do you ever get patients with borderline PD on these types of holds?

 

[Shikima]

All the time.

 

[smalltownpsych]

In my experience with mental health in small towns, sometimes the hold is just a way of giving the community a break from the individual or a desire to institute consequences in the hopes of altering some of their undesirable behaviors. A good example we experienced recently was a psychotic individual disturbing local businesses by demanding items from the store be returned that had been "stolen from him". He was not being dangerous, but was definitely causing problems for the community and they wanted us to do something about it, i.e., lock him up.

 

[heyjack70]

It's likely that putting patient's with dependent and borderline traits on holds, thus forcing them to be cared for by the system, only makes their condition worse in the long run.

 

[notdeadyet]

It's likely that putting patient's with dependent and borderline traits on holds, thus forcing them to be cared for by the system, only makes their condition worse in the long run.

Being borderline does not mean you ARE a danger to yourself and it does not mean you ARE NOT a danger to yourself on a particular night.

What takes lots of practice with borderline patients is learning to recognize the difference. There are psychiatrists that don't and this results in expensive and unnecessary psych hospitalizations or expensive and unnecessary medical hospitalizations and/or deaths.

 

[nancysinatra]

Do you ever get patients with borderline PD on these types of holds?

The vast majority of patients I see coming in on holds have a primary Axis II diagnosis, usually borderline, but often antisocial. They scare ER docs more than straight up Axis I depressed people by far.

The next biggest group, I think, is intoxicated people who may (or may not) have alluded to some kind of suidical thinking.

 

[nancysinatra]

The other day I had an interesting situation. A patient got admitted from our ER voluntarily. I was told the patient was psychotic and decompensated. (Ok, so technically, if that were true, then maybe he didn't have the capacity to sign in voluntarily, but in this job I have never once seen lack of capacity be used as a reason for a "hold." I think that may be because of the practices around here, but also because of the nature of our "hold" forms, which don't allow for that scenario.)

He had been brought into the ER from a group home where I think he'd been getting uncooperative. They had brought him to the ER several times recently and been sent home, and this time, finally, the ER pushed for the admission. There was almost nothing by way of specific collateral information. (In fact I was told he was catatonic, which seemed like enough information in its own right, until I learned it wasn't true.) Anyway he comes to our unit and, according to the nurses, did not seem decompensated or catatonic at all. He's just uncooperative. After a few hours he signed a letter demanding to leave. This requires me to go evaluate him and determine if he should a) be put on a hold or b) be discharged. Well, he wouldn't cooperate when I got there. He pretended to be sleeping and refused to open his eyes or say a word to me or anyone else. And it was the weekend and we couldn't get ahold of anyone who knew him.

Our hold forms are really simple. They just say that the person is an immediate danger to themselves or others. I guess those are the only conditions in this state under which we can initate the commitment process, even though commitment itself can be pursued for other reasons, like decompensation or lacking capacity. Well, in this case, I didn't know if the guy was an imminent danger to himself or not. Nor could I really tell just from that interaction if he was decompsenated to the point it could threaten his life. Plus even if I could, that's no an option on our hold form.

Anyway, what would you do in that case where you have no information but he's demanded to leave - hold him or not? Do you agree with me that basically, the guy acted up, so the group home staff exaggerated to the ER doc who exaggerated to me, and then I have to decide whether to exaggerate or not on the form?

 

[smalltownpsych]

My first thought is that there is no evidence from your post that would justify a hold. Being psychotic and uncooperative is nowhere near the standard for any state that i have worked in. The one point that would concern me is that maybe he communicated something that would qualify as grounds but you don't have access to that info for the reasons you mentioned and without cooperation from patient, that is the end of the road. The best answer for any of these types of dilemmas is to take reasonable steps and make logical decisions based on those and document, document, document.

To look at it another way, if you had a patient who told everyone that he was going to kill a bunch of people and had the means to do so and you had that corroboration, but would not cooperate with you, it would be a straightforward decision and if you didn't initiate the hold, then you would look really bad in the court case. There was a VA case like that not too long ago and if memory serves correctly, the court found the doc negligent for not making a reasonable effort to access collateral info that was readily accessible thanks to the EMR. It sounds like you are making a reasonable effort.

 

[nancysinatra]

Thanks smalltownpsych - it's helpful to hear your perspective. I did feel like I was in a different position with this patient than normal, however. Usually when a patient is admitted you should get an accurate report of what brought them to the ER and what happened while they were there. In this case both the group home staff and, I think, the ER doc, exaggerated the patient's state of decompensation to me. It was the unit nurses who tipped me off to this.

Ok so then he's admitted. He's voluntary. But he's admitted to the hospital. Discharge from a hospital is more serious than discharge from an ER, because he's already passed through the admission screen, presumably for good reason. My decision now becomes: discharge from the hospital without ever talking to him, or put him on a "hold" without ever talking to him. And there is conflicting information in the chart. And if I discharge him and he still refuses to get out of bed or talk to anyone, ok then what?

I don't know what the "standards" are for a hold in this state, because I didn't do residency here, and the state laws are opaque in this regard, and the hold forms contain nothing by way of guidance, and my colleagues seem confused about the matter. Even the risk management attorney doesn't seem all that aware...

So then what??? I actually do think this guy's rights were violated, but I don't see how it can be avoided with the situation we have here. In my previous job I would have discharged him. But here, the "standard of care" is to do a "hold" on almost anyone, and as people have mentioned above, no lawyer is going to take a case involving a patient who objected to that.

 

[heyjack70]

There's always a check/balance in the system. Even if you place a hold, he still gets to go to court and the judge can commit him or not. I say do what is in the best interest of the patient. Is it better for him in the long run to stay in the hospital to be observed for serious symptoms for a few days, or is it more important to get this guy back to his ultra productive life as a group home resident? I'd say the former, especially because several other professionals, including the staff at his group home (who arguably know him better than you ever will), and the ED physician thought he was bad enough to enter the hospital. With that much momentum behind the admission, I'm not sure what else you can do. If this person is not organized enough, or not willing enough, to engage in an interview with you he's not ready to go, because ultimately anything bad that happens is on you. I don't think you can confidently discharge him based on assumptions that he's just disruptive, or just antisocial. If you're wrong, you're opening yourself up for liability if there is a bad outcome.

 

[nancysinatra]

There's always a check/balance in the system. Even if you place a hold, he still gets to go to court and the judge can commit him or not. I say do what is in the best interest of the patient. Is it better for him in the long run to stay in the hospital to be observed for serious symptoms for a few days, or is it more important to get this guy back to his ultra productive life as a group home resident? I'd say the former, especially because several other professionals, including the staff at his group home (who arguably know him better than you ever will), and the ED physician thought he was bad enough to enter the hospital. With that much momentum behind the admission, I'm not sure what else you can do. If this person is not organized enough, or not willing enough, to engage in an interview with you he's not ready to go, because ultimately anything bad that happens is on you. I don't think you can confidently discharge him based on assumptions that he's just disruptive, or just antisocial. If you're wrong, you're opening yourself up for liability if there is a bad outcome.

Yeah I know - this is one of those times where I am doing something wrong no matter what I do. If I let him go I'm opening myself up to malpractice liability. If I keep him I may be guilty of false imprisonment. The former is more likely to happen than the latter (about a 0.01% chance vs a .00001% chance), but the latter is criminal and you can go to jail, and also, it's just ethically wrong. Oh well I kept him. I was well aware his prognosis was exactly the same either way.

 

[slappy]

Yeah I know - this is one of those times where I am doing something wrong no matter what I do. If I let him go I'm opening myself up to malpractice liability. If I keep him I may be guilty of false imprisonment. The former is more likely to happen than the latter (about a 0.01% chance vs a .00001% chance), but the latter is criminal and you can go to jail, and also, it's just ethically wrong. Oh well I kept him. I was well aware his prognosis was exactly the same either way.

How do you guesstimate that? Has any psychiatrist ever been indicted with such a charge in any state?

 

[heyjack70]

Yeah I know - this is one of those times where I am doing something wrong no matter what I do. If I let him go I'm opening myself up to malpractice liability. If I keep him I may be guilty of false imprisonment. The former is more likely to happen than the latter (about a 0.01% chance vs a .00001% chance), but the latter is criminal and you can go to jail, and also, it's just ethically wrong. Oh well I kept him. I was well aware his prognosis was exactly the same either way.

I don't think it's false imprisonment when there are multiple other providers before you saying the person is a risk, and then the person refuses to talk to you. Based on the information, which is only available from people saying he needs to be in the hospital, you had a reasonable belief that he was not going to be safe if discharged.

 

[nancysinatra]

I don't think it's false imprisonment when there are multiple other providers before you saying the person is a risk, and then the person refuses to talk to you. Based on the information, which is only available from people saying he needs to be in the hospital, you had a reasonable belief that he was not going to be safe if discharged.

They didn't say he was a risk though. They either exaggerated or misdiagnosed him and said he was catatonic. When he came up to the unit he was walking and talking, so, not catatonic. The nurses documented that. So the chart is useless. It might as well have been written about another patient. That's why I'm saying I had nothing to go on in making the decision.

 

[michaelrack]

The answer is simple (at least in my state- MS). Put them on a hold, continue to evaluate, and then drop the hold if indicated. I do weekend psych coverage, and I occasionally will drop a patient's hold, and then discharge them (usually against medical advice). Monitoring a person overnight can provide a lot of additional info.

 

[nancysinatra]

How do you guesstimate that? Has any psychiatrist ever been indicted with such a charge in any state?

I must admit it's just something I either heard or have always thought. I have no idea if any psychiatrist has ever gone to jail for that - you'd think such a thing would be legendary. But when the police falsely imprison people, they get charged with something serious. Anyway the risk must be on the order of 1 in a billion or so. Which makes my decision to "hold" the patient seem even smarter now.

If jail is not a threat, then what disincentive do we have to not abuse civil commitment? It's been abused in other countries. I believe China and the USSR, right, they used to put or do put political protestors in mental hospitals? I think the reason I always thought it was "criminal" to be charged with false imprisonment is that I assumed we had some law in place here that would prevent us doing things like that.

 

[nancysinatra]

The answer is simple (at least in my state- MS). Put them on a hold, continue to evaluate, and then drop the hold if indicated. I do weekend psych coverage, and I occasionally will drop a patient's hold, and then discharge them (usually against medical advice). Monitoring a person overnight can provide a lot of additional info.

This is the answer! The AMA discharge!! I totally did not think of that. We do it so rarely. But here it would have fit perfectly. Thank you!

 

[heyjack70]

They didn't say he was a risk though. They either exaggerated or misdiagnosed him and said he was catatonic. When he came up to the unit he was walking and talking, so, not catatonic. The nurses documented that. So the chart is useless. It might as well have been written about another patient. That's why I'm saying I had nothing to go on in making the decision.

I agree that at the end of the day the only information you have is the guy got admitted somehow. The ER physician (presumably an MD/DO) thought he needed to come in, the Psych RNs said he looked okay when he arrived on the unit, and you get the silent treatment. So it's a frustrating gray area. When it's gray, I say place the hold because our job is to protect patients. It buys us time to make a good assessment, and if we still think there's a risk, the court can decide if the criteria are met. I think we're on the same page.

I'm not sure how an AMA discharge would work in this situation. Isn't one requirement that the person must have decisional capacity to choose to leave AMA? It sounds like this guy wasn't communicating at all.

 

[michaelrack]

I agree that at the end of the day the only information you have is the guy got admitted somehow. The ER physician (presumably an MD/DO) thought he needed to come in, the Psych RNs said he looked okay when he arrived on the unit, and you get the silent treatment. So it's a frustrating gray area. When it's gray, I say place the hold because our job is to protect patients. It buys us time to make a good assessment, and if we still think there's a risk, the court can decide if the criteria are met. I think we're on the same page.

I'm not sure how an AMA discharge would work in this situation. Isn't one requirement that the person must have decisional capacity to choose to leave AMA? It sounds like this guy wasn't communicating at all.

Here's how it works for me (this is a made up example): I come on Friday at 5 pm and get called at 5:30 pm about an admission that just arrived from an ER one hour away. Supposedly suicidal (and has a BAL of 195 and UDS positive for cocaine) and was voluntary, now saying he was forced into the admission and demanding to leave. I arrive at 6 pm and he is not very cooperative but denies being suicidal, demands to leave. I put him on a 72 hour hold and complete the admission. The next day he is more cooperative but still requesting to leave. His wife shows up during visiting hours and I get more info. I decide that he no longer meets criteria for a hold and drop the hold, but still recommend hospitalization. When he again asks to leave, I discharge AMA.

Decisional capacity rarely plays a role in psych admission/discharge decisions (although it can in placement)- a person either meets criteria for a hold/committment or he doesn't. Of course, if you have any doubt it's best to let the judge decide, and you can certainly bring lack of decisional making capacity into play at that time

If someone isn't communicating at all, I would keep the hold on the patient

 

[DrBebiHuey]

Abusing civil commitment has always been my policy too. There's absolutely nothing that can go wrong. False imprisonment is pretty much comparable to littering. Lock 'em up!

 

[michaelrack]

Abusing civil commitment has always been my policy too. There's absolutely nothing that can go wrong. False imprisonment is pretty much comparable to littering. Lock 'em up!

I kind of agree with you- but it is not psychiatrists who are abusing the system- the fault is on the system itself, on the governments of the individual states, and ultimately society. A few states (WV comes to mind) will bring a magistrate in within 24 hours to decide the status of the patient. The fault is on the states who are too cheap to pay judges/magistrates to decide cases in a timely manner (and therefore have 72 hour rather than 24 hour holds)

 

[heyjack70]

Here's how it works for me (this is a made up example): I come on Friday at 5 pm and get called at 5:30 pm about an admission that just arrived from an ER one hour away. Supposedly suicidal (and has a BAL of 195 and UDS positive for cocaine) and was voluntary, now saying he was forced into the admission and demanding to leave. I arrive at 6 pm and he is not very cooperative but denies being suicidal, demands to leave. I put him on a 72 hour hold and complete the admission. The next day he is more cooperative but still requesting to leave. His wife shows up during visiting hours and I get more info. I decide that he no longer meets criteria for a hold and drop the hold, but still recommend hospitalization. When he again asks to leave, I discharge AMA.

Decisional capacity rarely plays a role in psych admission/discharge decisions (although it can in placement)- a person either meets criteria for a hold/committment or he doesn't. Of course, if you have any doubt it's best to let the judge decide, and you can certainly bring lack of decisional making capacity into play at that time

If someone isn't communicating at all, I would keep the hold on the patient

But the example patient is actually talking to you.

 

[michaelrack]

But the example patient is actually talking to you.

Here's how it would work if he isn't talking to me: (this is a made up example): I come on Friday at 5 pm and get called at 5:30 pm about an admission that just arrived from an ER one hour away. Supposedly suicidal (and has a BAL of 195 and UDS positive for cocaine) and was voluntary, now saying he was forced into the admission and demanding to leave (otherwise refuses to say anything to the nursing staff). I arrive at 6 pm and he is not cooperative and doesn't talk to me at all. I put him on a 72 hour hold and complete the admission. The next day he is unchanged. On sunday he is unchanged. On monday the regular psychiatrist gets to deal with him (and the patient still has 72 hours on the hold because weekends don't count in many states).

Any other questions?