Involuntary commitment question

[DocArmy]

Hello. I have a conundrum and I’m trying to figure out if I’m simply misunderstanding the issue or if I’m witnessing wrongdoing.

I work in a government (US federal) hospital as an internist. We have psychiatry staff but they will only admit military patients who are actively suicidal or homicidal. They will not admit nonmilitary patients to their inpatient service for any reason.

What we get very often is that an unfunded/uninsured civilian patient will be brought to the ER by the police with active suicidal Ideation or homicidal ideation. In the county, they must be evaluated by a psychiatrist within 12 hours to justify the emergency detention and within 48 hours by the county court to issue an order of protective custody (involuntary commitment for up to 14 days).

Here’s my problem: the psychiatry department will evaluate these patients and write in their chart that they “lack capacity.” And are “admitted voluntarily,” while also writing that, because they lack capacity, the cannot leave AMA and should be physically restrained if they try. This often results in multi day admissions to a medical ward without psychiatric treatment.

But they refuse to provide any treatment or see the patient while inpatient. Often they will also refuse to apply for an order of protective custody for the patient. This means that at the expiration of 48 hours, I am forced to either release them or to force them to stay at the risk of breaking the law.

I have clarified before with our legal council that we are not a psychiatric facility and these patients should not be admitted, but sent to an appropriate facility.

I’ve pointed out to several psychiatry attendings that their recommendations could be considered as violating the patient’s civil rights (involuntary commitment without legal due process). They consistently ignore me and refuse to change their documentation.

Am I not understanding the law here? Does the phrase “voluntary admission but lacks capacity for AMA” really absolve them of following the legal requirements for OPC?

Thanks for your input.

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[Fan_of_Meehl]

Hello. I have a conundrum and I’m trying to figure out if I’m simply misunderstanding the issue or if I’m witnessing wrongdoing.

I work in a government (US federal) hospital as an internist. We have psychiatry staff but they will only admit military patients who are actively suicidal or homicidal. They will not admit nonmilitary patients to their inpatient service for any reason.

What we get very often is that an unfunded/uninsured civilian patient will be brought to the ER by the police with active suicidal Ideation or homicidal ideation. In the county, they must be evaluated by a psychiatrist within 12 hours to justify the emergency detention and within 48 hours by the county court to issue an order of protective custody (involuntary commitment for up to 14 days).

Here’s my problem: the psychiatry department will evaluate these patients and write in their chart that they “lack capacity.” And are “admitted voluntarily,” while also writing that, because they lack capacity, the cannot leave AMA and should be physically restrained if they try. This often results in multi day admissions to a medical ward without psychiatric treatment.

But they refuse to provide any treatment or see the patient while inpatient. Often they will also refuse to apply for an order of protective custody for the patient. This means that at the expiration of 48 hours, I am forced to either release them or to force them to stay at the risk of breaking the law.

I have clarified before with our legal council that we are not a psychiatric facility and these patients should not be admitted, but sent to an appropriate facility.

I’ve pointed out to several psychiatry attendings that their recommendations could be considered as violating the patient’s civil rights (involuntary commitment without legal due process). They consistently ignore me and refuse to change their documentation.

Am I not understanding the law here? Does the phrase “voluntary admission but lacks capacity for AMA” really absolve them of following the legal requirements for OPC?

Thanks for your input.

A lot of this is heavily dependent on the exact language of the actual laws/statutes in your jurisdiction as applied to involuntary hospitalization.

One of the things that our document REQUIRES is a signature from the physician/professional executing the involuntary hospitalization procedure that is underneath a statement UNDER PENALTY OF PERJURY that the individual is either UNABLE (which incapacity would speak to?) or UNWILLING to be admitted voluntarily.

And, of course, any informed consent (for admission) that the patient would sign would involve the implicit assumption that they have the 'capacity' to sign themselves into the hospital under a voluntary admission.

I'm curious what these psychiatrists who are--supposedly--admitting them under 'voluntary admission but lacks capacity for AMA' are actually writing on the paperwork and signing their names to. Depends on how the paperwork/ form is constructed but it should have been constructed in parallel with the actual statutes on the books covering voluntary and involuntary psychiatric hospitalization. Take the involuntary commitment form and place in on the left side of your desk, print out the state statutes governing psychiatric hospitalization and place them on the right side of your desk and see if they align. This would probably tell you if what they are putting in the paperwork and signing is in line with the state laws, unless I'm missing something.

I don't see how one can both 'lack capacity' but be able to be admitted under a formal voluntary (which requires them to sign informed consent documentation). It would seem to me that this would be a 'slam dunk' malpractice or even criminal situation for providers stupid enough to do so. Still, I also know that some providers are incompetent/unethical enough to do this (through hubris?) and that since they are often abusing indigent populations (who aren't gonna 'sue'), they may very well get away with it for a while. But...what happens when the family member of a competent attorney or physician gets 'admitted' under this nonsense?

I know that--at least in the VA system--there are many (published openly, online) Office of Inspector General (OIG) reports that go into detail about flawed mental health care procedures and practices when dealing with patients in crisis (suicidal/homicidal). I don't know if OIG regulates Army hospital systems. Would there be another equivalent agency? If so, you may want to consider describing the situation (and your concerns) in an email to your bosses and/or the administrator of the facility in that you're just trying to do them a favor by bringing this issue to their awareness since you would think that the facility would want to avoid becoming 'famous' in the newspapers as a result of an OIG (or equivalent) investigation/report. I would also include language that clearly suggests that whatever actual attorneys are associated with that hospital (or hospital system) be consulted, as well. THEY may not want their asses hanging out in the wind on this one.

 

[wolfvgang22]

Someone cannot lack capacity by being unable to make rational informed decisions about their psychiatric care or the safety of themselves and others and voluntarily agree to admission at the same time.

This sounds like an administrative issue more than anything. The VA and military hospitals can, with administrative approval, admit and treat civilians as a humanitarian act to the community in times of crisis. During COVID the VA admitted and treated some COVID patients. The issue you are seeing is that your facility's administration is failing to find an appropriate psychiatric facility to transfer these civilian patients to while they are in the ER, and the psychiatrists consulted to see these patients for evaluation in the ER lack the resources to find placement for these patients. And so they are coming up with ridiculous things like makinga a patient who lacks capacity voluntary. Your hospital needs to designate social workers or nursing whose job it is to place these patients elsewhere, or your hospital must admit and treat these patients.

You need to speak with your department chief and your colleagues about your safety concerns, and your chief needs to take these safety concerns and possible solution to the director of your facility. If they are not receptive and do not make some changes I would be looking for another job myself rather than practice unsafely.

 

[SmallBird]

I think the other interesting question in general is whether capacity evaluations are appropriate to restrict rights of psychiatric patients; certainly in states I have worked, it is very clear that the correct process involves a psychiatric hold followed by commitment for patients who are in a psychiatric crisis that causes a safety issue. For geriatric patients who lack the cognitive abilities to make these decisions, the capacity evaluation process is more often used but often these patients are also psychiatrically committed if there are prominent psychological or behavioral symptoms. The idea of keeping someone on a medical floor based on the process outlined by the OP seems hard to justify.

 

[G Sheb]

This is a bit of a 'bizarre' setup, but as mentioned I think it all depends on your specific jurisdiction.
Where I'm at, the concept of 'voluntary' or 'involuntary' hospitalization is only relevant for psychiatric admissions. You could certainly admit someone on the medical inpatient unit and argue that they don't have capacity to leave AMA. This is probably what is happening here, and 'voluntary' is thrown around for some kind of legal coverage.
It seems like this is an administrative issue. Neither the psychiatry nor the IM departments want to take ownership of these patients and direct them to where they should be.
The sad thing is that this is terrible care, and these patients are not getting the treatment they need. Maybe that is the basis of a lawsuit?

 

[Fan_of_Meehl]

This is a bit of a 'bizarre' setup, but as mentioned I think it all depends on your specific jurisdiction.
Where I'm at, the concept of 'voluntary' or 'involuntary' hospitalization is only relevant for psychiatric admissions. You could certainly admit someone on the medical inpatient unit and argue that they don't have capacity to leave AMA. This is probably what is happening here, and 'voluntary' is thrown around for some kind of legal coverage.
It seems like this is an administrative issue. Neither the psychiatry nor the IM departments want to take ownership of these patients and direct them to where they should be.
The sad thing is that this is terrible care, and these patients are not getting the treatment they need. Maybe that is the basis of a lawsuit?

This is fascinating. But if they are admitted for obviously psychiatric reasons...wouldn't the laws having to do with psychiatric admissions (and the voluntary/involuntary distinction) HAVE to apply? As you say, it may depend on exactly how those laws are written in a specific jurisdiction. I couldn't imagine that it would be found to be justified to 'admit' someone for 'non-psychiatric' reasons when their presenting issue causing the need for admission is clearly psychiatric in nature (dangerousness to self/others, grave disability due to mental illness). The lawyers would have a field day.

I would think that--regardless of the nature of the unit on which they're being held against their will ('psychiatric,' or 'non-psychiatric medical'), at the end of the day, the legal authority that is being relied upon to keep them from leaving (should they wish to) is, ultimately, going to be found in the relevant state laws governing involuntary admission procedures relevant to mental illness (and attendant risks to self/other or grave disability arising from mental illness). These laws provide for the 'due process' (if followed). It may be considered a superficially 'clever' move to just, wave one's hand and say, 'they were admitted to a medical/non-psychiatric unit, therefore the voluntary/involuntary distinction does not apply,' but I don't think it's that easy from a legal perspective if any of this horse manure is ever actually challenged legally.

I mean, if they were being hospitalized because they presented as acutely suicidal but also just happened to have an unstable life-threatening cardiac condition as well, it may be more complicated. But to how many of these cases OP is describing would that apply?

 

[G Sheb]

This is fascinating. But if they are admitted for obviously psychiatric reasons...wouldn't the laws having to do with psychiatric admissions (and the voluntary/involuntary distinction) HAVE to apply? As you say, it may depend on exactly how those laws are written in a specific jurisdiction. I couldn't imagine that it would be found to be justified to 'admit' someone for 'non-psychiatric' reasons when their presenting issue causing the need for admission is clearly psychiatric in nature (dangerousness to self/others, grave disability due to mental illness). The lawyers would have a field day.

I would think that--regardless of the nature of the unit on which they're being held against their will ('psychiatric,' or 'non-psychiatric medical'), at the end of the day, the legal authority that is being relied upon to keep them from leaving (should they wish to) is, ultimately, going to be found in the relevant state laws governing involuntary admission procedures relevant to mental illness (and attendant risks to self/other or grave disability arising from mental illness).

I mean, if they were being hospitalized because they presented as acutely suicidal but also just happened to have an unstable life-threatening cardiac condition as well, it may be more complicated.

That is a good question. I'm not sure of the answer.
There are definitely 'social admissions' to the medical unit, where a patient is solely admitted to find a proper disposition for them rather than for any medical reason.
I've also seen psychiatric patients admitted to medicine for purely psychiatric reasons because they cannot be accommodated on a psych unit (having a cast for example, or being non-ambulatory). I don't believe paperwork for psychiatric admissions apply here. You admit them to the medical unit, consult psychiatry and argue that they do not have capacity to leave AMA - but I could be wrong on this one as these cases are fairly rare, and I do not remember dealing with one directly.

 

[Fan_of_Meehl]

That is a good question. I'm not sure of the answer.
There are definitely 'social admissions' to the medical unit, where a patient is solely admitted to find a proper disposition for them rather than for any medical reason.
I've also seen psychiatric patients admitted to medicine for purely psychiatric reasons because they cannot be accommodated on a psych unit (having a cast for example, or being non-ambulatory). I don't believe paperwork for psychiatric admissions apply here. You admit them to the medical unit, consult psychiatry and argue that they do not have capacity to leave AMA - but I could be wrong on this one as these cases are fairly rare, and I do not remember dealing with one directly.

I appreciate the discussion and have to admit that I am completely ignorant of the relevant laws and policies governing admissions for non-psychiatric reasons...so this helps me learn something, too.

 

[Stagg737]

Hello. I have a conundrum and I’m trying to figure out if I’m simply misunderstanding the issue or if I’m witnessing wrongdoing.

I work in a government (US federal) hospital as an internist. We have psychiatry staff but they will only admit military patients who are actively suicidal or homicidal. They will not admit nonmilitary patients to their inpatient service for any reason.

What we get very often is that an unfunded/uninsured civilian patient will be brought to the ER by the police with active suicidal Ideation or homicidal ideation. In the county, they must be evaluated by a psychiatrist within 12 hours to justify the emergency detention and within 48 hours by the county court to issue an order of protective custody (involuntary commitment for up to 14 days).

Here’s my problem: the psychiatry department will evaluate these patients and write in their chart that they “lack capacity.” And are “admitted voluntarily,” while also writing that, because they lack capacity, the cannot leave AMA and should be physically restrained if they try. This often results in multi day admissions to a medical ward without psychiatric treatment.

But they refuse to provide any treatment or see the patient while inpatient. Often they will also refuse to apply for an order of protective custody for the patient. This means that at the expiration of 48 hours, I am forced to either release them or to force them to stay at the risk of breaking the law.

I have clarified before with our legal council that we are not a psychiatric facility and these patients should not be admitted, but sent to an appropriate facility.

I’ve pointed out to several psychiatry attendings that their recommendations could be considered as violating the patient’s civil rights (involuntary commitment without legal due process). They consistently ignore me and refuse to change their documentation.

Am I not understanding the law here? Does the phrase “voluntary admission but lacks capacity for AMA” really absolve them of following the legal requirements for OPC?

Thanks for your input.

So are these people being admitted to the medical floor for medical stabilization or purely for psychiatric reasons? If it's the former, then everywhere I've worked (including VAs) the psych process is typically unnecessary as they lack capacity. It's not really a "voluntary admission" but the same level of legal scrutiny as a psych hold is not necessary because medical treatment is necessary. If they're being evaluated for a psychiatric hold, meet criteria for an involuntary psych hold AND NOT require medical treatment/stabilization, and then being deemed to "lack capacity" and admitted to medicine for psych treatment, then this indeed sounds pretty illegal. Maybe it's not, but I can't imagine a state would allow docs to initiate a "medical hold" (colloquial term, not legal) for a psychiatric reason and ignore the process for a psych hold in the ER just because they're going to a medical floor. I also imagine that the medical physicians accepting these patients to the medical floor are taking on a lot of legal liability as they're probably breaking the law without even realizing it.

Bottom line is that you need to look at the state laws though. This may actually be completely legal, though I'd be pretty shocked if it is.

That is a good question. I'm not sure of the answer.
There are definitely 'social admissions' to the medical unit, where a patient is solely admitted to find a proper disposition for them rather than for any medical reason.
I've also seen psychiatric patients admitted to medicine for purely psychiatric reasons because they cannot be accommodated on a psych unit (having a cast for example, or being non-ambulatory). I don't believe paperwork for psychiatric admissions apply here. You admit them to the medical unit, consult psychiatry and argue that they do not have capacity to leave AMA - but I could be wrong on this one as these cases are fairly rare, and I do not remember dealing with one directly.

I unfortunately deal with this on a fairly regular basis (at least weekly) where a patient needs a psych admission but can't go to psych (patient is psychotic/suicidal but has a suprapubic cath/is quadriplegic/is from SNF on lV abx/whatever exclusionary criteria for psych admission is met). In my state, these patients still have to go through the full involuntary process as they are being held for a psychiatric and not medical reason. If there is a medical reason they need to be held (ie, requires IV abx but refusing and lacks capacity) then we don't need to go through the psych process as they lack capacity, at least until they're medically stabilized at which point we reassess whether they need further psych treatment and pursue invol if needed.

 

[DocArmy]

A lot of this is heavily dependent on the exact language of the actual laws/statutes in your jurisdiction as applied to involuntary hospitalization.

One of the things that our document REQUIRES is a signature from the physician/professional executing the involuntary hospitalization procedure that is underneath a statement UNDER PENALTY OF PERJURY that the individual is either UNABLE (which incapacity would speak to?) or UNWILLING to be admitted voluntarily.

And, of course, any informed consent (for admission) that the patient would sign would involve the implicit assumption that they have the 'capacity' to sign themselves into the hospital under a voluntary admission.

I'm curious what these psychiatrists who are--supposedly--admitting them under 'voluntary admission but lacks capacity for AMA' are actually writing on the paperwork and signing their names to. Depends on how the paperwork/ form is constructed but it should have been constructed in parallel with the actual statutes on the books covering voluntary and involuntary psychiatric hospitalization. Take the involuntary commitment form and place in on the left side of your desk, print out the state statutes governing psychiatric hospitalization and place them on the right side of your desk and see if they align. This would probably tell you if what they are putting in the paperwork and signing is in line with the state laws, unless I'm missing something.

I don't see how one can both 'lack capacity' but be able to be admitted under a formal voluntary (which requires them to sign informed consent documentation). It would seem to me that this would be a 'slam dunk' malpractice or even criminal situation for providers stupid enough to do so. Still, I also know that some providers are incompetent/unethical enough to do this (through hubris?) and that since they are often abusing indigent populations (who aren't gonna 'sue'), they may very well get away with it for a while. But...what happens when the family member of a competent attorney or physician gets 'admitted' under this nonsense?

I know that--at least in the VA system--there are many (published openly, online) Office of Inspector General (OIG) reports that go into detail about flawed mental health care procedures and practices when dealing with patients in crisis (suicidal/homicidal). I don't know if OIG regulates Army hospital systems. Would there be another equivalent agency? If so, you may want to consider describing the situation (and your concerns) in an email to your bosses and/or the administrator of the facility in that you're just trying to do them a favor by bringing this issue to their awareness since you would think that the facility would want to avoid becoming 'famous' in the newspapers as a result of an OIG (or equivalent) investigation/report. I would also include language that clearly suggests that whatever actual attorneys are associated with that hospital (or hospital system) be consulted, as well. THEY may not want their asses hanging out in the wind on this one.

I’ve written a couple lengthy emails in the past describing the issue and sent it to leadership. And I’ve gone to the hospital legal office to make sure I was correct.

They just don’t seem to care enough to stop the psych team or educate other medicine physicians about it. And because it’s an Army hospital there is a deeply ingrained, and inaccurate, view that they can’t be sued for malpractice.

I will definitely sit down again with the paperwork in house and the law and review it point by point. And if need be, OIG is probably the next step.

Good call.

 

[DocArmy]

This is a bit of a 'bizarre' setup, but as mentioned I think it all depends on your specific jurisdiction.
Where I'm at, the concept of 'voluntary' or 'involuntary' hospitalization is only relevant for psychiatric admissions. You could certainly admit someone on the medical inpatient unit and argue that they don't have capacity to leave AMA. This is probably what is happening here, and 'voluntary' is thrown around for some kind of legal coverage.
It seems like this is an administrative issue. Neither the psychiatry nor the IM departments want to take ownership of these patients and direct them to where they should be.
The sad thing is that this is terrible care, and these patients are not getting the treatment they need. Maybe that is the basis of a lawsuit?

I agree.

Someone with a medical issue lacking capacity is something I’m comfortable with. But for them to claim they lack capacity purely for psychiatric concern while simultaneously classifying the admission as voluntary seems ethically dubious and like a great lawsuit.

 

[Fan_of_Meehl]

I’ve written a couple lengthy emails in the past describing the issue and sent it to leadership. And I’ve gone to the hospital legal office to make sure I was correct.

They just don’t seem to care enough to stop the psych team or educate other medicine physicians about it. And because it’s an Army hospital there is a deeply ingrained, and inaccurate, view that they can’t be sued for malpractice.

I will definitely sit down again with the paperwork in house and the law and review it point by point. And if need be, OIG is probably the next step.

Good call.

When you say that you've 'gone to the hospital legal office' do you mean that you just had verbal conversations about your concerns about what you've observed? Do you think that their response would be any different if you sent them a polite but articulate email laying out the specific state law (as you understand it and using the language in the statutes, with references (online?) to the publicly available state statutes and your confusion about how the practices that you've observed square with the actual law?

It would be real easy for a lawyer to dismiss a conversation with no record made (plausible deniability).
It would be harder for them to be comfortable with someone sending them an email documenting specific illegal actions and just ignoring it.

Not trying to suggest specific courses of action for you (only you can make those decisions in context)...just saying that--seeing it from the standpoint of an attorney, there's always plausible deniability that they knew of any wrongdoing when we're just talking about un-documented conversations (your word against theirs). But a documentation paper trail is something that they'd probably take more seriously.

Now speaking cynically (and realistically), the powers-that-be are not going to be happy if this comes to light. They are NOT going to want to face up to the history of wrongdoing happening under their noses (if, indeed, this is the case), so tread carefully. I also am not that impressed with the protection of Federal 'whistleblowers' in the past. Maybe let them know of your discomfort with the situation, document it, and they may offer to reassign duties that you object to and give them to someone who won't ask questions? I'm just being realistic here after decades of working in state/Federal government-run hospitals. They're generally corrupt once you get above direct care positions with caseloads. They are going to look out for THEIR interests in a situation like this...not yours.

Also, you may want to confer more heavily with your physician colleagues (especially those perhaps at other facilities like your own and in the same roles). The medical codes of ethics and things the medical licensing boards emphasize may be unique. Good luck!

 

[DocArmy]

The exact text from one of the psychiatry notes reads as such:

“-Voluntary, however, patient should NOT leave AMA due to ongoing psychotic symptoms (auditory, hallucinations, paranoia, delusions, homicidal ideation).
-If patient attempts to leave AMA call PMO/Code Green if attempts to elope.”

*PMO is the provost Marshall/hospital police.

And that is where I think they break the law. You can’t be voluntary to stay, but involuntary to leave. But they won’t file an OPC because it’s “voluntary.”

I’ll take this up with leadership again this week, but if it goes nowhere it may end up being a whistleblower situation before someone gets hurt (nurse, staff, patient).

 

[Fan_of_Meehl]

The exact text from one of the psychiatry notes reads as such:

“-Voluntary, however, patient should NOT leave AMA due to ongoing psychotic symptoms (auditory, hallucinations, paranoia, delusions, homicidal ideation).
-If patient attempts to leave AMA call PMO/Code Green if attempts to elope.”

*PMO is the provost Marshall/hospital police.

And that is where I think they break the law. You can’t be voluntary to stay, but involuntary to leave. But they won’t file an OPC because it’s “voluntary.”

I’ll take this up with leadership again this week, but if it goes nowhere it may end up being a whistleblower situation before someone gets hurt (nurse, staff, patient).

Could they possibly be confused/ignorant of the specifics of the law or even be making incorrect assumptions? A lot of this depends on what the relevant law actually states.

I've had an urgent care physician, in the past, tell me that she 'handles this sort of situation every day' and then go on to quote me things she (incorrectly) THOUGHT were the procedures/statutes pertaining to the involuntary commitment situation (in our state) but she was simply flat out wrong. Now, whether she was acting (ignorantly) in good faith at the time or whether she knew she was lying to me (hoping that I was ignorant of state law), I'll never know.

Also, I'm a bit surprised (maybe not) that there aren't local hospital/organizational policies or procedures that speak to this.

Maybe that's a tack you could take with leadership and/or the attorneys in your organization. Maybe frame it as you trying to be helpful and help everyone avoid liability and ensure that what is being done is consistent with the law. Like, 'why don't we have policies/procedures that cover these situations?' Based on what you've already written, I'd guess they would poo-poo that idea but, hey, if you have a written record of you trying to be constructive to address the situation...that may be a good thing to do. Does your hospital have an 'ethics' committee?

 

[Bartelby]

To clarify, are they being admitted to treat their psychiatric issue or a non-psychiatric one? For example, if the person is delirious from pneumonia (but also making homicidal statements) then admitting them to a medical ward without a psychiatric hold might be appropriate if they lack decision making capacity.

 

[Candidate2017]

What we get very often is that an unfunded/uninsured civilian patient will be brought to the ER by the police with active suicidal Ideation or homicidal ideation. In the county, they must be evaluated by a psychiatrist within 12 hours to justify the emergency detention and within 48 hours by the county court to issue an order of protective custody (involuntary commitment for up to 14 days).

Here’s my problem: the psychiatry department will evaluate these patients and write in their chart that they “lack capacity.”

The psychiatrists are playing nice by seeing these ED patients. But this is an ED problem. 110%. The EM docs need to transfer out these patients. Whatever EM decides to do, IM needs to stand firm and refuse to admit these patients. If you choose to admit to IM, it's 100% your problem now.

But I get it, everyone loves to play blame psychiatry (a.k.a. pin the tail on the donkey), even the SDN psych board. No good deed goes unpunished.

 

[G Sheb]

The exact text from one of the psychiatry notes reads as such:

“-Voluntary, however, patient should NOT leave AMA due to ongoing psychotic symptoms (auditory, hallucinations, paranoia, delusions, homicidal ideation).
-If patient attempts to leave AMA call PMO/Code Green if attempts to elope.”

*PMO is the provost Marshall/hospital police.

And that is where I think they break the law. You can’t be voluntary to stay, but involuntary to leave. But they won’t file an OPC because it’s “voluntary.”

I’ll take this up with leadership again this week, but if it goes nowhere it may end up being a whistleblower situation before someone gets hurt (nurse, staff, patient).

Is there legal paperwork that is being filled out?
You can't admit voluntary unless the pt signs voluntary paperwork, at least where I'm at.

 

[ObsequiousAplomb]

Are they saying the patient has capacity to accept medical treatment but not capacity to leave AMA? Because those are two separate thresholds.

Otherwise, it sounds like none of these people should ever be getting past the ER and should be handled some other way (like not being transported to the ED for that cc in the first place)

 

[Celexa]

The exact text from one of the psychiatry notes reads as such:

“-Voluntary, however, patient should NOT leave AMA due to ongoing psychotic symptoms (auditory, hallucinations, paranoia, delusions, homicidal ideation).
-If patient attempts to leave AMA call PMO/Code Green if attempts to elope.”

*PMO is the provost Marshall/hospital police.

And that is where I think they break the law. You can’t be voluntary to stay, but involuntary to leave. But they won’t file an OPC because it’s “voluntary.”

I’ll take this up with leadership again this week, but if it goes nowhere it may end up being a whistleblower situation before someone gets hurt (nurse, staff, patient).

Interesting. I've worked in hospitals (who including VA hospitals, which I recognize are not the same as army) where security literally would not lay hands on patients unless there was active psychiatric commitment paperwork. This created a slightly different set of headaches, since delirious patients technically don't meet legal involuntary criteria as written but clearly can lack medical capacity.

The situation you describe, I have never encountered, and I agree with your assessment that something is deeply flawed. I sympathize with the psychiatrists not wanting these patients on their unit as the appropriate place for them is clearly a civilian hospital, but have not and would not ever write a note with the logic you described.

I agree with the other posters that this is in the end more an issue with the emergency room--they should be transferring these patients to a civilian hospital. Perhaps someone interpreted doing this as an EMTALA violation? I have no idea how EMTALA applies to military facilities. Another potentially appropriate route would be if these patients were transferred, once admitted, to inpatient psychiatric units at a civilian hospital--but in that case, the psychiatrists would need to be documenting the need for the psych hospitalization appropriately as involuntary. If I ever had gotten a note requesting to admit a patient documented as "voluntary" but unable to leave AMA due to psychiatric symptoms (unless they had an acute medical problem causing them, ie, delirium) I would have immediately refused.

 

[Stagg737]

And that is where I think they break the law. You can’t be voluntary to stay, but involuntary to leave. But they won’t file an OPC because it’s “voluntary.”

Where I'm at this is kind of correct, though it's kind of a Schrodinger's patient situation. Those patients would be just voluntary until they demand to leave and then would have to be made involuntary immediately and then follow the legal steps for a psych hold or have capacity reassessed and be determined to continue to lack capacity for medical reasons. Though your example of documentation is missing some lines if they're saying the patient needs to be held d/t psych reasons. My documentation for psych patients on medical floors looks something like this:

- Patient is currently agreeable to voluntary admission
- Continue constant observation (because if we aren't going to let them leave, they better have a CO)
- Should patient demand to leave, would initiate involuntary petition due to (insert reason for psych hold here)
- If patient attempts to leave AMA, please contact (insert whoever handles this here)

Of course, this is very bare bones and I include further details depending on patient acuity, reason for the hold, co-morbid concerns, etc as well as instructions to contact our team if there are further questions or concerns. This is also for patients who only require admission due to a psych reason. If we're talking about medical capacity, then it's an entirely different process in my state and there's more language about how capacity fluctuates and needs to be reassessed depending on the medical condition, patient's mental status, blah, blah, blah.

Perhaps someone interpreted doing this as an EMTALA violation? I have no idea how EMTALA applies to military facilities.

EMTALA does not apply to VA or military hospitals, but there are separate but essentially equal federal policies in place regarding evaluation and treatment as well as transfer of patients:

https://uscode.house.gov/view.xhtml?req=granuleid:USC-1994-title42-section1395dd&num=0&edition=1994

 

[splik]

false imprisonment suits are rarely successful (even when they are legit) so there really isn't much liability for them not following the laws here. Which is probably why the hospital legal/risk management folks is totally disinterested. But these patients shouldn't be accepted in the ER in the first place and should be brought to a more appropriate facility for evaluation. That would be the most appropriate solution.

 

[TheRightMedication]

The mistake here is that the psychiatrists are allowing themselves to become involved at all.

 

[DocArmy]

To clarify, are they being admitted to treat their psychiatric issue or a non-psychiatric one? For example, if the person is delirious from pneumonia (but also making homicidal statements) then admitting them to a medical ward without a psychiatric hold might be appropriate if they lack decision making capacity.

No.
Purely psychiatric issues admitted “for placement.” Because the ER can’t get them out and they bully medicine into admitting.

 

[DocArmy]

false imprisonment suits are rarely successful (even when they are legit) so there really isn't much liability for them not following the laws here. Which is probably why the hospital legal/risk management folks is totally disinterested. But these patients shouldn't be accepted in the ER in the first place and should be brought to a more appropriate facility for evaluation. That would be the most appropriate solution.

I suspect this is the reason I’m the lone person fighting on this hill.

 

[DocArmy]

The mistake here is that the psychiatrists are allowing themselves to become involved at all.

Yeah. True enough.

But because they write what they write, less informed medicine teams will hold people for days, even weeks, waiting for a bed somewhere, getting no treatment and have police restrain them over and over.

But you’re right. They should never come through the doors anyway.

And that is a reasonable angle for me to approach other departments with.

 

[Celexa]

Yeah. True enough.

But because they write what they write, less informed medicine teams will hold people for days, even weeks, waiting for a bed somewhere, getting no treatment and have police restrain them over and over.

But you’re right. They should never come through the doors anyway.

And that is a reasonable angle for me to approach other departments with.

Whoever handles inpatient psychiatric consults for the hospital should be seeing these patients at least multiple times a week. As a consultation-liaison psychiatrist providing basic inpatient psychiatric care, including medication recs, is part of the responsibility. Patients may refuse at first, but they should still be offered and if the choice is take meds or don't leave many will come around. I work in an area where wait times for inpatient psych beds are long; I can get many people better and discharged from medicine before a bed opens up on psych.

You'll probably have more success with this argument (if the hospital actually treated these patients while they wait on medicine, they would leave sooner, and free up beds), than the argument about violating their rights, no matter how valid the latter.

 

[aim-agm]

First - thank you for caring about patient's psychiatric care and their civil rights.

To answer your question: Yes, you are witnessing wrongdoing. Indeed, you appear to be witnessing felonies.

There is a long list of criteria that all must be met in order to involuntarily retain a patient. Although many of these vary by state, no matter which state you are in, merely lacking capacity to leave AMA does not privilege retention of the patient. While it is common practice to prevent these patients from leaving, that doesn't make it not criminal. There are numerous more ways that this situation might be problematic that depend on state law - e.g. your state may forbid inpatient psychiatric treatment except on licensed/certified units.

 

[aim-agm]

And, of course, any informed consent (for admission) that the patient would sign would involve the implicit assumption that they have the 'capacity' to sign themselves into the hospital under a voluntary admission.

I don't see how one can both 'lack capacity' but be able to be admitted under a formal voluntary (which requires them to sign informed consent documentation).

Like everything else, this depends on state law. In my state, you are forbidden by explicit statute from requiring capacity for voluntary admission. To be suitable for voluntary admission, the person just has to be capable of understanding that they are asking to be admitted to a psychiatric hospital and their rights regarding voluntary admission (e.g. process of discharge). Interestingly, the law (and case law) also forbid involuntary admission if the person has capacity regarding the decision for hospitalization.

 

[comp1]

Definitely concur that this is an administrative and ultimately not a clinical issue. I also concur that if you are admitting patients without acute medical concerns to your medical service, that is much more of an ED issue than a psych issue. These patients need to be referred out to actual community psychiatric hospitals and remain in the ED until that is accomplished, potentially for days or weeks given our severe bed shortage in the country. I wouldn't be as concerned with legal liability as I would be with the patient actually getting the right care in the right setting. The federal government provides an immense amount of liability protection and it sounds like very few of these patients would have the resources to go up against the federal tort claims act regardless. Now if you are just admitting medically ill patients without capacity to your medical floor, that should be an every day sort of thing that shouldn't even involve psych. Capacity determination is everyone's responsibility.

 

[nexus73]

I think there may be some nuance to consider here.

I've always viewed the psychiatric hold laws as something that MAY be pursued if the person has a psychiatric issue leading to a concern for safety and the hold forces them to stay in the hospital. I believe that if forcing them onto a psychiatric unit then you would be required to use a psychiatric hold. However, I'm not sure if a psych hold is something that MUST be used if it is someone forced to stay in an ED or medical floor.

If the hospital is not going to admit to the psych unit due to civilian status or no beds, patient either ends up boarding in the ED or I've seen a similar setup where the IM hospitalists will admit patients to keep the ED clear. What I'm not certain of is whether a psychiatric hold MUST be used in these scenarios.

It will vary by state I'm sure, but for dementia or delirium patients for example, my state has no formal hold process (i.e., there are no medical holds). It becomes an issue of decisional capacity and either a proxy decision maker consents to them being kept in the hospital against their wishes, or if no proxy is available, it ends up falling to the attending physician to decide. And in these scenarios we certainly have people who don't demand to leave but are in no way able to consent to being in the hospital, just because they don't comprehend the scenario at all. I don't see why this wouldn't be similar for a patient with an acute psych issue and lacking decisional capacity. But if you are going to make them go onto a psych unit, I always thought this was a higher stakes situation and would force the use of a psych hold and not this other "lacks capacity so you just can't leave" approach.

 

[aim-agm]

I've always viewed the psychiatric hold laws as something that MAY be pursued if the person has a psychiatric issue leading to a concern for safety and the hold forces them to stay in the hospital. I believe that if forcing them onto a psychiatric unit then you would be required to use a psychiatric hold. However, I'm not sure if a psych hold is something that MUST be used if it is someone forced to stay in an ED or medical floor.

Any infringement of liberty must be privileged by explicit statute.* There are rare exceptions,* but generally in medical situations the ONLY statute that exists that you can apply are psychiatric civil commitment statutes. So effectively, you MUST use a psychiatric hold law if you are medically holding someone.

*: technically there are common law holds, which you can use "at your own peril" in very limited circumstances (e.g. the person is partway out a window and is in the midst of attempting to jump out of it to their death)
**: this depends on state law. For example, in my state, the one exception would be someone who is (a) incapacitated to make a decision to leave the hospital, and (b) they have already been adjudicated incompetent or there has been a court hearing where a judge granted a request to override patient's request to leave the hospital.

 

[TheRightMedication]

Yeah. True enough.

But because they write what they write, less informed medicine teams will hold people for days, even weeks, waiting for a bed somewhere, getting no treatment and have police restrain them over and over.

But you’re right. They should never come through the doors anyway.

And that is a reasonable angle for me to approach other departments with.

Amen. Good boundaries are known by the wailing and gnashing of teeth.

Saying no doesn't solve the problem, of course, but at least it prevents bad solutions to the problem.

 

[nexus73]

Any infringement of liberty must be privileged by explicit statute.* There are rare exceptions,* but generally in medical situations the ONLY statute that exists that you can apply are psychiatric civil commitment statutes. So effectively, you MUST use a psychiatric hold law if you are medically holding someone.

*: technically there are common law holds, which you can use "at your own peril" in very limited circumstances (e.g. the person is partway out a window and is in the midst of attempting to jump out of it to their death)
**: this depends on state law. For example, in my state, the one exception would be someone who is (a) incapacitated to make a decision to leave the hospital, and (b) they have already been adjudicated incompetent or there has been a court hearing where a judge granted a request to override patient's request to leave the hospital.

The physician as proxy decision maker for patients lacking decisional capacity is in statute (my state statute anyways) and doesn’t require a judges order on incompetence.

 

[whopper]

I assume you're in a VA? IF you suspect wrong-doing you can contact the head of the psych and IM department, the patient's rights advocate and the hospital lawyer.

I've been in institutions where something seemed foul. On average I'd see something at least once a year. Just did a legal case where some other doctors messed up and the patient (another physician) is suing them.

 

[Stagg737]

However, I'm not sure if a psych hold is something that MUST be used if it is someone forced to stay in an ED or medical floor.

This may depend on state law, but in the states I've practiced you are required to go through the formal involuntary process if holding a patient for psychiatric reasons regardless of setting. That means if they're sitting in the ER for 3 weeks you have to go through all the court hearings while the patient stays there.

 

[aim-agm]

The physician as proxy decision maker for patients lacking decisional capacity is in statute (my state statute anyways) and doesn’t require a judges order on incompetence.

Yup, so much of this comes down to state law. To clarify, my state has statute for capacity and proxy decision making but it also has a section that says if the patient objects to the proxy's decision (or to the determination that they are incapacitated) then you need a court hearing or a prior adjudication of incompetence in order to override the objection. Other fun things with my state's capacity laws include the fact that they don't apply outside of hospitals, so with ED patients we have technically have to admit them first (because EDs are technically outpatient facilities) before we can do the capacity rigamarole.

Even with these laws, there can be a lot of difficulty applying them in cases of retention over objection because of the constitutional issues of liberty and due process protections. For example, if the patient is incapacitated but it wouldn't be dangerous for them to leave, then holding them may be unconstitutional. Unfortunately there isn't a lot of case law (at least in my state) examining the issue.

 

[comp1]

I'm not assuming VA, I'm assuming DoD based on the OP's description, but more details sure would be interesting.

 

[Celexa]

I suspect this is the reason I’m the lone person fighting on this hill.

To contextualize the lack of concern over false imprisonment in psychiatry even further, in training when on call I was required only to discuss patients I wanted to discharge with my attending. If I decided to keep them involuntarily as a brand new pgy2? Could do that all on my lonesome.

I ain't saying it's right, but that's how it is.

That was in emergency settings in which they were 100% of the time either going to be transferred to a definitive level of care or remain under observation where a psychiatrist was always present. Involuntarily holding people without any treatment is dicier, albeit still very low liability, unfortunately for the patients.

 

[whopper]

I saw someone, a physician, who was misdiagnosed by 3 other doctors as having dementia. As a result this guy lost his license. The guy does not have dementia and making the issue significantly worse and inexcusable it's pretty clear he had delirium. He recently had a surgery, had osteomyelitis, and several other causes for delirium. Add to this those 3 same doctors zonked the guy out on Olanzapine while he was evaluated for "dementia" and did not factor this in, and paid no attention to considering he might've had delirium.

So as a forensic evaluator, I looked into the case. The guy was clear, coherent, oriented, showed no signs of any cognitive disorder for over 90 minutes. It's pretty much in your face the guy likely had delirium, and yet these 3 docs wrote "dementia." Let's just say that the misdiagnosed doctor is suing and that's why I was involved.

This type of cutting corners medicine is unfortunately a significant minority. No it's not a 1% or less. It's more like double digits. For this reason I wouldn't be surprised at all if the OP's criticisms are true (although I do not know for fact if they are true, just not surprised).

 

[DocArmy]

I really appreciate all of your advice and observations.

I raised the issue today and got significantly more buy in from medicine than previously. And I’ve filed a patient safety report to get the issue to ED leadership.

But thanks all. This was a really good discussion for me as a hospitalist.

 

[Fan_of_Meehl]

I really appreciate all of your advice and observations.

I raised the issue today and got significantly more buy in from medicine than previously. And I’ve filed a patient safety report to get the issue to ED leadership.

But thanks all. This was a really good discussion for me as a hospitalist.

Thanks for being an ethical doc!

 

[SmallBird]

You should show your administration some of the responses on this thread! I used a thread a few years back to get paid more for overnight call

 

[Bartelby]

There is a long list of criteria that all must be met in order to involuntarily retain a patient. Although many of these vary by state, no matter which state you are in, merely lacking capacity to leave AMA does not privilege retention of the patient. While it is common practice to prevent these patients from leaving, that doesn't make it not criminal.

This point has always fascinated me. Many states don't appear to have any clear pathway to a "medical hold," or necessarily allow one in states of emergency. Thus, violation of a person's "rights" happens routinely.

Following this line of thought, if an incoherent delirious 88 year-old screams that they are leaving and gets up, we should have no legal ability to stop them. If they stumble down, break their hip, and wail on the floor then legally I guess we should just stand there and wait until they eventually lose consciousness and then are no longer objecting. And if they regain consciousness and start trying to get up for round two, we should stand back and watch.

I agree that I don't know of any basis for non-psychiatric "holds" of patients who outright lack decision making capacity. To fully follow the (lack of) law on this point, though, would require a large number of absolutely ghoulish episodes like the above. It amazes me how people are routinely held for delirium etc. without a clear legal basis for doing so (in other words, the doctor is expected to perform a criminal act) and from a regulatory perspective society just seems to to shrug and say "that's fine."

 

[Stagg737]

Following this line of thought, if an incoherent delirious 88 year-old screams that they are leaving and gets up, we should have no legal ability to stop them. If they stumble down, break their hip, and wail on the floor then legally I guess we should just stand there and wait until they eventually lose consciousness and then are no longer objecting. And if they regain consciousness and start trying to get up for round two, we should stand back and watch.

When I was previously an EMT in IL, I remember being told during training in that if someone needs medical care (like your example) but is refusing that we should just stay there and wait until they pass out and then take them to the hospital. I always thought it was messed up, but more than a few of the guys I worked with did exactly that. I honestly don't know the legal statutes at the time there, but wouldn't surprise me if this was following them.

 

[whopper]

On the flip side you get a lot of doctors not doing enough in addition to overstepping. Some common problems I see are doctors transferring a patient who has a guardian to another hospital without the guardian's consent. This is technically illegal. ERs especially ERs in hospital without psych units are all to eager to get rid of a patient that needs to be in psych and overstepping.

Another often times seen problem is the patient is on a hold and they want to send to a hospital across state lines. Once that patient crosses state lines that hold is now illegal. That doctor's 72 hold is only good within the state it's written in.

I had one ER doctor who tried to send me a patient with severe intellectual disability who had a guardian and this would be across state lines. I said no. The ER doc started screaming at me. I told her that she could scream at me all she wants, it won't change the guardianship issue and how it needs to be reported to the guardian and I need to hear from the guardian.

 

[Stagg737]

Another often times seen problem is the patient is on a hold and they want to send to a hospital across state lines. Once that patient crosses state lines that hold is now illegal. That doctor's 72 hold is only good within the state it's written in.

Yep, see this all the time too, but it's 96 hours in your state

 

[G Sheb]

Your persistence on pursuing this should be commended.
Most people would have given up or found another job.
Let us know how this pans out and if administration will seriously respond to your concerns.

 

[aim-agm]

This point has always fascinated me. Many states don't appear to have any clear pathway to a "medical hold," or necessarily allow one in states of emergency. Thus, violation of a person's "rights" happens routinely.

Following this line of thought, if an incoherent delirious 88 year-old screams that they are leaving and gets up, we should have no legal ability to stop them. If they stumble down, break their hip, and wail on the floor then legally I guess we should just stand there and wait until they eventually lose consciousness and then are no longer objecting. And if they regain consciousness and start trying to get up for round two, we should stand back and watch.

I agree that I don't know of any basis for non-psychiatric "holds" of patients who outright lack decision making capacity. To fully follow the (lack of) law on this point, though, would require a large number of absolutely ghoulish episodes like the above. It amazes me how people are routinely held for delirium etc. without a clear legal basis for doing so (in other words, the doctor is expected to perform a criminal act) and from a regulatory perspective society just seems to to shrug and say "that's fine."

I'm actually not aware of any states that have a clear "medical hold" statute/pathway (although I haven't looked at all 50), but it would frequently be unconscionable not to hold these patients. The good news is that, unless there is malfeasance, criminal charges I think are unheard; civil suit seems to be quite rare (whether this is good or bad is a matter of perspective), but I came across a case in my state where a judge reversed a jury decision in a false imprisonment case (involving a typical "medical hold" situation) and found the hospital liable for false imprisonment. This is honestly something the AMA should be working on - lobbying in state governments and developing legislation to cover these situations where patients are incapacitated and dangerous but not mentally ill.

While the patient is in the hospital, you might be able to ensure that they are able to safely leave (e.g. walk alongside them to catch them if they fall) because you still have responsibility for their well-being while they are in the building.

 

[aim-agm]

When I was previously an EMT in IL, I remember being told during training in that if someone needs medical care (like your example) but is refusing that we should just stay there and wait until they pass out and then take them to the hospital. I always thought it was messed up, but more than a few of the guys I worked with did exactly that. I honestly don't know the legal statutes at the time there, but wouldn't surprise me if this was following them.

I wouldn't be surprised either, although technically they might have to go a step further in their weirdness: "Of course I wasn't waiting for them to lose consciousness and become non-objecting so I could override their objection; that would be a callous disregard for their rights. I was just staying on-hand in case their decision changed. Obviously, their objection was just to receiving care for the relatively minor condition of [broken hip/exsanguination/disembowlment/etc.], but I had no grounds to believe that he would object to care for the more serious condition of being unconsciousness plus [above condition]."

 

[Geraltofrivia]

" Here’s my problem: the psychiatry department will evaluate these patients and write in their chart that they “lack capacity.” And are “admitted voluntarily,” while also writing that, because they lack capacity, the cannot leave AMA and should be physically restrained if they try. This often results in multi day admissions to a medical ward without psychiatric treatment. "

Zinermon v. Burch?