ER Doc frustrated by state's involuntary commitment process

[migm]

In my state, anyone can be committed by anyone else so long as you can sign a statement in front of a magistrate alleging whatever you want. They then come to me in handcuffs by way of LEO to the ED where I'm a single provider and I have to decide whether or not they're a danger to themselves or others. I have no psych help. Our hold times for the state hospital can exceed weeks.

One of the things you can be committed for is substance abuse. I cannot get anyone to give me a straight definition (not even our psych RN Screeners at a nearby referral center) of what the hell qualifies for this.

If you used heroin in an effort to get high but you forgot you didn't get your pharmd and accidentally injected too much or maybe you just don't care anymore so you just used what you had and you needed narcan to save your life - wouldn't that qualify? Yet we let these people go home after observation that the narcan is clear and they're still awake. There's a half hearted effort at offering resources but I doubt that sheet is anything more than trash.

Another situation that comes up is parents who are exasperated with their adult child's persistent use of drugs - IVC paperwork is filed out (usually after some other avenues are used and don't work), they come to the ED - pt states they want to get better and have no SI/HI... discharge? Let me tell you that does not make parents pleased. I feel a lot more comfortable keeping them when they're under 18 if there are serious concerns but once you're >18 it's really not clear what standard I am supposed to hold. It's also not fair to my small ED to hold all of the drug abusers for weeks on end while patients I can actually help are stuck in the waiting room while we're down beds.
What am I supposed to do here?

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[michaelrack]

In my state, anyone can be committed by anyone else so long as you can sign a statement in front of a magistrate alleging whatever you want. They then come to me in handcuffs by way of LEO to the ED where I'm a single provider and I have to decide whether or not they're a danger to themselves or others. I have no psych help.

What am I supposed to do here?

you can move to another state. In Mississippi, anyone can file for commitment, but then the county takes over and arranges for patient evaluation by a psychiatrist.
This sometimes means waiting in jail, depending on patient insurance and/or county willingness to pay a private hospital

 

[wolfvgang22]

migm,
Are you saying that in your state a patient can be involuntarily hospitalized by a non physician? I was not aware that was the case anywhere.

 

[migm]

you can move to another state. In Mississippi, anyone can file for commitment, but then the county takes over and arranges for patient evaluation by a psychiatrist.
This sometimes means waiting in jail, depending on patient insurance and/or county willingness to pay a private hospital

That's not really a tenable option. I guess the question is what truly qualifies for substance abuse commitment - if it really qualifies, I want to keep it. If it doesn't, I'd rather discharge.

 

[migm]

migm,
Are you saying that in your state a patient can be involuntarily hospitalized by a non physician? I was not aware that was the case anywhere.

You can force an involuntary evaluation by an MD (or I think licensed psychologist? but that doesn't happen) who may uphold or decline the commitment. yes, anyone can do it.

Often law enforcement fills them out because they are first responders on the scene that doesn't quite require emergent medical attention. Good way to get us to deal with their problem.

 

[wolfvgang22]

Oh, ok, that is common. So you aren't forced to commit anybody. You are just forced to evaluate the patient which takes up time and ER beds.

So either your employer hires staff evaluate these patients, or you get comfortable doing it yourself, or you move on to a different position. These are the options as I see them. Am I wrong?

 

[migm]

Employer won't hire folks (has talked the talk but it hasnt happened), and I can't easily move to a different position, so here I am making decisions on something I'm not comfortable with. Any tips?

 

[clausewitz2]

I would recommend that you read through the actual text of your state's law about this, as apparently you are going to be doing this whether or not you are comfortable with it. Adopt a strict reading of the law in question and uphold commitments that clearly meet the standards outlined in the law and reject any that do not. Be quite rigid about applying these - you are not a specialist and you are just trying to discharge your legal obligations, so it makes sense to be fairly literal about this. Imprisoning someone against their will (even if they might thank you for it later) is not something to do lightly, and don't kid yourself, that is what you will be doing when you uphold an involuntary commitment. We don't really have great evidence that involuntary inpatient hospitalizations make people all that much safer in many circumstances and the experience can be fairly traumatic, so honestly in your shoes I would do what the law requires and not an iota more.

 

[Jules A]

Sounds more like an EP (emergency petition)? Here anyone can sign it and at that point the patient requires an evaluation to decide if they meet criteria for inpatient hospitalization. Its up to the ED to decide whether they need to be certified, will sign in voluntarily or can be discharged with those virtually worthless outpatient resource sheets you mentioned. Like others noted EDs in my area always have psych staff usually social workers, sometimes residents, NPs or Psychologists who will evaluate and make a disposition recommendation. What about the psychiatrists on-call doing phone consults when you are struggling with the decision? I personally hate to be drug into a case when I'm not actually able to evaluate the patient but its often part of the deal. I'd also consider trying to get your facility to develop a relationship with local inpatient rehabs and see if you can't negotiate some sort of direct admission or emergency 24/7 evaluation type situation to at least move the SUD patients who are willing to sign themselves into rehab. Your team really should put some pressure on the admin because one lawsuit would more than pay them to hire a social worker to cover the ED.

The parents of the adult children are difficult because they often carry the guilt of the past and should be considered at high risk of litigation if things go south. As suggested I'd find out exactly what your state's requirement for involuntary hospitalization and follow it to the letter of the law.

 

[migm]

I would recommend that you read through the actual text of your state's law about this, as apparently you are going to be doing this whether or not you are comfortable with it. Adopt a strict reading of the law in question and uphold commitments that clearly meet the standards outlined in the law and reject any that do not. Be quite rigid about applying these - you are not a specialist and you are just trying to discharge your legal obligations, so it makes sense to be fairly literal about this. Imprisoning someone against their will (even if they might thank you for it later) is not something to do lightly, and don't kid yourself, that is what you will be doing when you uphold an involuntary commitment. We don't really have great evidence that involuntary inpatient hospitalizations make people all that much safer in many circumstances and the experience can be fairly traumatic, so honestly in your shoes I would do what the law requires and not an iota more.

Thank you for this post. I completely agree with your approach of discharging the legal responsibilities and no more. That said, I've come into conflict with what the law states (which I have reviewed in an attempt to answer my own question) "Substance abuse: Pathological abuse that produces Substance abuse: Pathological abuse that produces impairment in personal, social or occupational impairment in personal, social or occupational functioning; functioning;" and what actually happens in practice. Absent needing to be intubated in the ICU (where you can't walk away anyway), it is not clear to me what qualifies for the above and what doesn't. Seems like most substance abusers that use to the point that they find themselves seeing me might be considered to be impaired in their functioning.

So if my patient abuses narcotics to the point of needing narcan or else they're gonna snuff it, does that qualify?

Sounds more like an EP (emergency petition)? Here anyone can sign it and at that point the patient requires an evaluation to decide if they meet criteria for inpatient hospitalization. Its up to the ED to decide whether they need to be certified, will sign in voluntarily or can be discharged with those virtually worthless outpatient resource sheets you mentioned. Like others noted EDs in my area always have psych staff usually social workers, sometimes residents, NPs or Psychologists who will evaluate and make a disposition recommendation. What about the psychiatrists on-call doing phone consults when you are struggling with the decision? I personally hate to be drug into a case when I'm not actually able to evaluate the patient but its often part of the deal. I'd also consider trying to get your facility to develop a relationship with local inpatient rehabs and see if you can't negotiate some sort of direct admission or emergency 24/7 evaluation type situation to at least move the SUD patients who are willing to sign themselves into rehab. Your team really should put some pressure on the admin because one lawsuit would more than pay them to hire a social worker to cover the ED.

The parents of the adult children are difficult because they often carry the guilt of the past and should be considered at high risk of litigation if things go south. As suggested I'd find out exactly what your state's requirement for involuntary hospitalization and follow it to the letter of the law.

I have been unable to get any additional resources in my n of 1 when I tried to consult our local Psychiatrist by way of telephone. For this reason and the last paragraph you wrote, I keep a lot of people on IVC until a psychiatrist can sort it out if I can make a reasonable belief that they might pose a danger to themselves or others. My question is primarily with regards to what sort of drug abuse would qualify an individual to lose their rights to refuse treatment.

 

[Armadillos]

If it were me I would page hospital risk management/general counsel for advice every time this arises until they either hired someone to do this (can easily be done by tele psychiatry in some states) or fired me.

 

[Shikima]

If it were me I would page hospital risk management/general counsel for advice every time this arises until they either hired someone to do this (can easily be done by tele psychiatry in some states) or fired me.

I like it. Passive aggressiveness!

 

[migm]

If it were me I would page hospital risk management/general counsel for advice every time this arises until they either hired someone to do this (can easily be done by tele psychiatry in some states) or fired me.

I'd rather not lose my job but otherwise I find your idea highly entertaining. Am I correct in understanding that the lines are quite blurry here?

 

[clausewitz2]

I'd rather not lose my job but otherwise I find your idea highly entertaining. Am I correct in understanding that the lines are quite blurry here?

This appears to be a statute written to allow almost anyone to be involuntarily committed who has any behaviors that are problematic in the slightest. None of those clauses has some definition that is a well-agreed upon term of art or anything, no.

 

[migm]

It's okay, our state's psychiatric system is.. top.. something, and there is no drug problem here. Nope, none at all.

 

[luckrules]

Med student here

My schools hospital is starting to initiate buprenorphine in the ED. I wanted to get involved in the project and got referenced a webinar by one of the PIs. It was specifically targeted for emergency department providers, and had a long list of additional resources. It doesn't answer your question specifically, but I thought it might be helpful snd jave pasted the link below:



Incidentally curious what you think of this approach.

 

[digitlnoize]

Agree with splik that the state would be helpful. I will say that the level of danger required to commit someone varies from location to location, even within the same state. In Virginia, for example, it's fairly easy to commit someone near me, but up in the DC suburbs, you have to be very, very sick to qualify. The doctors, judges, and magistrates are just too desensitized. Around here, substance use usually does not qualify someone for commitment unless they're in "imminent danger" such as alcohol/benzo withdrawal, DT's, etc. Shooting up heroin is typical seen as chronic danger, not imminent danger, so gets a pass around here.

 

[migm]

Im in North Carolina

 

[hamstergang]

I'd rather not lose my job but otherwise I find your idea highly entertaining. Am I correct in understanding that the lines are quite blurry here?

While maybe you don't call Risk Management or the malpractice lawyers every time to annoy them, going to them once to get some guidance wouldn't be a bad idea. They're the people paid to make sure you do things in compliance with the law to help prevent lawsuits.

 

[wolfvgang22]

Chronic drug abuse or drug dependence is no reason to involuntarily hospitalize anyone. Attempted suicide by overdose is.

 

[splik]

I'm not surprised! NC is one of the worst states for civil rights abuses of the so-called mentally ill. What your dilemma is comes from a mismatch between what the law actually allows and what is clinically possible. NC has one of the most liberal statutes for civil commitment, and includes commitment of people with substance abuse. The situation that you mentioned above (someone ODs on heroin and needing narcan would absolutely meet criteria for civil commitment in NC). The issue is that most psychiatric facilities are not geared up to take people with only a substance use disorder without another axis I disorder (i.e. mood or psychotic disorder or a substance induced mood/psychotic disorder), and the number of beds for those facilities for addiction are vanishingly rare. Further, involuntary treatment is rarely helpful for people with addictive disorders and inpatient/residential treatment is rarely helpful for addictive disorders anyway (despite all these luxurious clinics).

a parent coming in exasperated with their child's substance use is not enough if they aren't a danger to self/others/property and able to take care of their basic needs. The families aren't annoyed you wont commit them, but that you cant force them into treatment and to change. Having them linger in the ER for weeks is not helpful and clearly a violation of civil liberties even if allowed.

 

[ExcaliburPrime1]

Tough situation you're in without easy answers.

In DC, it's very tough to commit someone although law enforcement or physicians can fill out an "FD-12" which gets someone evaluated by a psychiatrist and held for up to 48 hours before it has to go before a judge. The vast majority of these people either voluntarily sign in later or are discharged, although on occasion the full process comes into play and typically the court agrees with involuntarily commitment because we screen extensively and have a high bar.

For your situation, I think you need an expert (either a lawyer specializing in this area or a psychiatrist with experience in the commitment process) to give you some definitive guidance. Ask for it through your supervisor because otherwise you are exposing yourself and your hospital to a lot of liability making decisions in an area which you admit you are not comfortable in. In the meantime, I agree with the above, try to be quite strict with applying the statute in your state and only involuntarily hold people who have active suicidal or homicidal thoughts. The temptation to lean the other way might reassure you ("at least they'll be alive!") but the reality is that they'll be imprisoned (essentially) for no good reason, the therapeutic alliance would be destroyed so when they are eventually hospitalized they probably won't get much out of it, and they'll likely be very reluctant to seek help in the future if they are really feeling suicidal.

 

[clausewitz2]

Tough situation you're in without easy answers.

In DC, it's very tough to commit someone although law enforcement or physicians can fill out an "FD-12" which gets someone evaluated by a psychiatrist and held for up to 48 hours before it has to go before a judge. The vast majority of these people either voluntarily sign in later or are discharged, although on occasion the full process comes into play and typically the court agrees with involuntarily commitment because we screen extensively and have a high bar.

For your situation, I think you need an expert (either a lawyer specializing in this area or a psychiatrist with experience in the commitment process) to give you some definitive guidance. Ask for it through your supervisor because otherwise you are exposing yourself and your hospital to a lot of liability making decisions in an area which you admit you are not comfortable in. In the meantime, I agree with the above, try to be quite strict with applying the statute in your state and only involuntarily hold people who have active suicidal or homicidal thoughts. The temptation to lean the other way might reassure you ("at least they'll be alive!") but the reality is that they'll be imprisoned (essentially) for no good reason, the therapeutic alliance would be destroyed so when they are eventually hospitalized they probably won't get much out of it, and they'll likely be very reluctant to seek help in the future if they are really feeling suicidal.

Also, for homicidal thoughts, important to briefly explore why they are having these thoughts. Wanting to kill someone because they stole your car or can't keep your name out their mouth is not really a psychiatric matter.

 

[smalltownpsych]

Just realized this last weekend that almost every single consult I get called in on at the emergency department involves an extremely difficult legal, ethical, practical, and clinical decision. Fortunately I can bounce my thoughts off the EM doc if they aren't too busy with a critical case. I hate feeling like I am alone in the decision and know that if someone ends up dead, the hindsight bias and the hospital and the legal system will throw me right under the bus. Sometimes if the EM doc isn't available I'll bounce my thinking off the nurses that can also help clarify that my thinking is at least reasonable and explainable to another person.

 

[OldPsychDoc]

Just realized this last weekend that almost every single consult I get called in on at the emergency department involves an extremely difficult legal, ethical, practical, and clinical decision. Fortunately I can bounce my thoughts off the EM doc if they aren't too busy with a critical case. I hate feeling like I am alone in the decision and know that if someone ends up dead, the hindsight bias and the hospital and the legal system will throw me right under the bus. Sometimes if the EM doc isn't available I'll bounce my thinking off the nurses that can also help clarify that my thinking is at least reasonable and explainable to another person.

"Never worry alone."

 

[northernpsy]

I would really try to push for the employer to look into getting telepsych coverage for the ED.
I definitely don't think it is fair to you that you are being expected to make this decision without the guidance of someone who was trained in assessing these situations, just as I wouldn't want to be expected to stabilize patients who need an EM doctor's expertise. We specialize for good reasons. Sometimes it's very obvious what disposition someone needs but there are many ambiguous situations that really should be assessed by psych.

 

[wolfvgang22]

Are there psychiatrists who want to be on call for ER telepsychiatry? I know I don't.

 

[Shikima]

Are there psychiatrists who want to be on call for ER telepsychiatry? I know I don't.

I would for a rate of $250/hour. Whether I work or not.

 

[migm]

First off, thank you all for these supportive messages. I'm not sure if that was your intent, but that's the way I found them. I'm glad I'm not the only one that's not sure how to best balance patient care and legal liability in this setting.

I'm not surprised! NC is one of the worst states for civil rights abuses of the so-called mentally ill. What your dilemma is comes from a mismatch between what the law actually allows and what is clinically possible. NC has one of the most liberal statutes for civil commitment, and includes commitment of people with substance abuse. The situation that you mentioned above (someone ODs on heroin and needing narcan would absolutely meet criteria for civil commitment in NC). The issue is that most psychiatric facilities are not geared up to take people with only a substance use disorder without another axis I disorder (i.e. mood or psychotic disorder or a substance induced mood/psychotic disorder), and the number of beds for those facilities for addiction are vanishingly rare. Further, involuntary treatment is rarely helpful for people with addictive disorders and inpatient/residential treatment is rarely helpful for addictive disorders anyway (despite all these luxurious clinics).

a parent coming in exasperated with their child's substance use is not enough if they aren't a danger to self/others/property and able to take care of their basic needs. The families aren't annoyed you wont commit them, but that you cant force them into treatment and to change. Having them linger in the ER for weeks is not helpful and clearly a violation of civil liberties even if allowed.

Agree with the above - but I question if there is a bad outcome (say a successful but accidental OD in a chronic user) after I overturn an emergency petition am I at risk? The state's lack of resources is, to me, a secondary concern. I'd rather not get my pants sued off for discharging Lawyer Bob's cocaine addict 20 year old live at home kid when he manages to have a huge MI from that 8 ball and sedative he mixed.

Tough situation you're in without easy answers.
..
For your situation, I think you need an expert (either a lawyer specializing in this area or a psychiatrist with experience in the commitment process) to give you some definitive guidance. Ask for it through your supervisor because otherwise you are exposing yourself and your hospital to a lot of liability making decisions in an area which you admit you are not comfortable in. In the meantime, I agree with the above, try to be quite strict with applying the statute in your state and only involuntarily hold people who have active suicidal or homicidal thoughts. The temptation to lean the other way might reassure you ("at least they'll be alive!") but the reality is that they'll be imprisoned (essentially) for no good reason, the therapeutic alliance would be destroyed so when they are eventually hospitalized they probably won't get much out of it, and they'll likely be very reluctant to seek help in the future if they are really feeling suicidal.

I will try to seek out some of our psychiatrists and see what they say.

Also, for homicidal thoughts, important to briefly explore why they are having these thoughts. Wanting to kill someone because they stole your car or can't keep your name out their mouth is not really a psychiatric matter.

In the state of north carolina, I'm not sure it isn't based on statute. Criteria for commitment include: "Within the relevant past the individual has: 1. inflicted, attempted to inflict, or threatened to inflict serious bodily harm on another and there is a reasonable probability that this conduct will be repeated, or 2. acted in a way that created a substantial risk of serious bodily harm to another and there is a reasonable probability that this conduct will be repeated, or 3. engaged in extreme destruction of property and there is a reasonable probability that this conduct will be repeated..."

Just realized this last weekend that almost every single consult I get called in on at the emergency department involves an extremely difficult legal, ethical, practical, and clinical decision. Fortunately I can bounce my thoughts off the EM doc if they aren't too busy with a critical case. I hate feeling like I am alone in the decision and know that if someone ends up dead, the hindsight bias and the hospital and the legal system will throw me right under the bus. Sometimes if the EM doc isn't available I'll bounce my thinking off the nurses that can also help clarify that my thinking is at least reasonable and explainable to another person.

thanks for this - I feel the same way but I have to say I thought this was relatively cut and dry and easy for psychiatrists. I figured my lack of training in same was what was holding me back.

I would really try to push for the employer to look into getting telepsych coverage for the ED.
I definitely don't think it is fair to you that you are being expected to make this decision without the guidance of someone who was trained in assessing these situations, just as I wouldn't want to be expected to stabilize patients who need an EM doctor's expertise. We specialize for good reasons. Sometimes it's very obvious what disposition someone needs but there are many ambiguous situations that really should be assessed by psych.

We have pushed hard for telepsych. Despite much talk it hasn't materalized after years. It's probably going to take a horrible outcome to make it so which is terrible, but true. I find myself keeping the ambiguous situations on IVC - I am sure that some of the ones i've discharged you would keep, and vice versa.

 

[smalltownpsych]

Just wanted to clarify that I am not a psychiatrist and also that the reason it is not so cut and dry is that these are the more critical cases that tend to involve more legal and ethical issues than either outpatient or inpatient. Also, because most psychiatrists and psychologists don't specialize in emergency psychiatry, we are kind of like family medicine docs covering the ED, we can do it, but not as well as someone who does it every day and has more specialized training in this arena. I have been getting the experience over the last couple of years, but unfortunately the training component has been lacking which is one reason I like to participate so actively on this board since psychiatrists tend to have more expertise in this area.

 

[thoffen]

Agree with the above - but I question if there is a bad outcome (say a successful but accidental OD in a chronic user) after I overturn an emergency petition am I at risk? The state's lack of resources is, to me, a secondary concern. I'd rather not get my pants sued off for discharging Lawyer Bob's cocaine addict 20 year old live at home kid when he manages to have a huge MI from that 8 ball and sedative he mixed.

The best advice I've ever received here is "you don't have to be right; you just can't be negligent." You're really not at different risk (so long as an ED physician providing this psychiatric assessment is standard of care for your community) than if someone comes in with chest pain whom you workup and feel does not have ACS goes home and dies from a huge MI 3 days later. You are not expected to be god. You are expected to meet standard of care for assessing this risk and documenting your reasoning for the decisions you make.

In the state of north carolina, I'm not sure it isn't based on statute. Criteria for commitment include: "Within the relevant past the individual has: 1. inflicted, attempted to inflict, or threatened to inflict serious bodily harm on another and there is a reasonable probability that this conduct will be repeated, or 2. acted in a way that created a substantial risk of serious bodily harm to another and there is a reasonable probability that this conduct will be repeated, or 3. engaged in extreme destruction of property and there is a reasonable probability that this conduct will be repeated..."

I haven't looked at the statute, but it's hard for me to imagine that the criteria also doesn't include: "patient is exhibiting signs of mental illness AND ...". This is what differentiates criminal homicidality from a psychiatric emergency. You may still be obligated to warn or protect the target of such a threat, but this does not mean you should do so via psychiatric hospitalization if it is not a product of mental illness.

Globally, though, it seems you are uncomfortable with your expertise in providing this evaluation. That's not good. Theoretically I am ACLS certified, but I would never want to be asked to run a code. I think you either need to make this not part of your job expectations or find a way to get more expertise.