Assignment: Legal and Ethical Issues Related to Psychiatric Emergencies

Week 8: Psychiatric Emergencies

College of Nursing-PMHNP, Walden University

NRNP 6675: PMHNP Care Across the Lifespan II

Psychiatric Emergencies

Psychiatric emergency is an acute disturbance in the patient's behavior, thought, or emotion that could result in damage to the patient or others in the immediate environment if it goes untreated. Because the threat to society is considered in the definition of a psychiatric emergency, the term is distinct from other medical emergencies in this regard. The severity of a patient's incapacity can be defined as either significant or minor, depending on whether the patient's life is in risk. 90-94% of people who die by suicide have been diagnosed with some form of mental illness at the time of their death. A meta-analysis of 249 suicide studies conducted between 1966 and 1993 found that, except for mental retardation and dementia, almost all mental diseases are associated with an increased risk of suicide. Suicide is most likely for those suffering from a major mental illness, while the risk is lowest for those suffering from an organic illness, with substance use disorders in the middle.

The purpose of this paper is to explain California state laws regarding involuntary psychiatric holds for child and adult psychiatric emergencies, the distinctions between emergency hospitalization for evaluation/psychiatric hold, inpatient commitment, and outpatient commitment in the state, and the distinction between capacity and competency in mental health contexts. Suicide risk assessment and violence risk assessment that might be used to screen patients, as well as legal and ethical concern related to the HIPAA privacy rule.

California State Laws for Involuntary Psychiatric Holds

The number of patients of any age who are placed on involuntary psychiatric detention in the United States each year is not reliably reported (Hedman, Petrila, Fisher, et al. 2016). Putting a person on a 72-hour hold, often known as a "5150," is only authorized by designated professionals in the state of California. They can be police officers, members of a "mobile crisis team," or other mental health experts who have been approved by the individual county where this this incident is taking place. (namisantaclara.org). For an individual to be placed on a 72-hour hold, one of three conditions must be met. The designated personnel believe there is a good chance that the individual being placed on hold meet the following criteria: the individual must be a danger to themselves, they must be a danger to others, and they must be Gravely disabled, which means they are unable to meet their fundamental and personal necessities such as cloths, food, and shelter (namisantaclara.org).

In addition, the 72-hour hold individual must be advised of his or her legal rights. As a first step, authorities and facilities must compile a file outlining how and why a person's condition was brought to their attention; what probable cause there is to believe the person is a danger to others, a danger to themselves, or gravely handicapped as result of mental illness; and the facts on which this probable cause is founded. Conclusions without supporting evidence are insufficient (namisantaclara.org).

It is important to keep in mind that when an individual is placed on a 72 hour hold which is usually called a 5150, the holding facility has a responsibility over this patient, they are required by law to re-evaluate that individual taking into consideration the following aspects into consideration, the patient’s legal, financial, psychological, educational, and medical situation. We should also keep in mind that the individual does not also have to be kept for full 72 hours if the person in charge deems necessary that the person is no longer a danger to themselves or others and Gravely Disabled. One of the following must occur by the conclusion of the 72-hour period: The individual may be freed; the individual may sign in as a voluntary patient; or the individual may be placed on a 14-day "5250" involuntary hold (a "certification for intense treatment").

Psychiatric Hold, Inpatient Commitment, and Outpatient Commitment

When a patient is placed on a 5150, which is a 72-hour psychiatric hold in California, the patient may be placed in a confined location, generally a psychiatric institution, against their will for 72 hours. A 72-hour hold can only be issued if one of the following conditions is met: Is likely to have a mental illness, according to those who have been delegated to investigate a hazard to oneself or to others; or gravely incapacitated (namisantaclara.org). In the case of an inpatient commitment, after the psychiatric hold has expired and the judge may decide to order hospitalization for a patient and this patient must meet the state’s civil commitment criteria. On the other hand, when it comes to outpatient commitment, the judge may order a patient suffering from mental health issues to receive treatment while living in the community, but this individual must deem qualified by the ordering judge (Swartz, Robertson, & Swanson, 2017).

Capacity and Competency in Mental Health

A judge's decision of competency is based on a global evaluation and legal determination. It refers to a person's ability to rationally carry out a legally authorized conduct. (Leo, 2019). It should be noted that it the court that has the authority to determine a patient’s incompetency. When the court determine that you are incompetent, you are assigned a public guardian who become your decision maker. Capacity, on the other hand, is an evaluation of a person's functional skills to make reasonable judgments (Leo, 2019). During the evaluation, a doctor will determine whether the person being evaluated can make rational medical decisions. If this is the case, another person may be designated to make such decisions on their behalf.

HIPPA Privacy Rule - Legal Issue

In the United States, the Health Insurance Portability and Accountability Act safeguards patient privacy (HIPAA). With privacy safeguards enacted with the bill, it was originally designed to protect employees' rights to medical insurance when they were between jobs, but now it is more closely associated with individual's protected health information (Theodor & Sittig, 2020). Opponents say the law is unethical despite its noble intentions since it prevents coordinated clinical care. Some providers say that legislation hinders them from providing an experience that maintains pace with the rapid advancements in technological innovation. Communication with healthcare practitioners is expected to be smooth for consumers, who are used to this. Rather than logging into a portal, they'd rather send a text or email to their doctor or other members of their healthcare team.

Suicide Risk Assessment Tool

The Columbia-Suicide Severity Rating Scale (C-SSRS) is an evidence-based suicide risk assessment tool that has been successfully implemented in a variety of settings, including schools, the military, and fire departments (Posner et al., 2019). This tool was developed by several institutions, including Columbia University, with funding from the National Institute of Mental Health (NIMH), and it has been recommended by reputable organizations such as the National Center for Injury Prevention and Control, the Department of Defense, the National Institute of Health (NIH), and the Substance Abuse and Mental Health Service Administration (SAMHSA), to name a few. This assessment employs a scoring scale that ranges from "want to be dead" to "active suicide thoughts with a definite plan, intent, and activities." It can be administered in the form of an interview or as a self-report assessment. The scale detects behaviors that may indicate a person's intent to commit suicide. An individual who exhibits at least one of the scale's recognized behaviors is 8 to 10 times more likely to finish the scale.

Violence Risk Assessment Tool

Violence against healthcare workers has increased in recent years, particularly in sectors such as mental health. It is very evidence that violence can affect the quality of care provided by mental health professionals. As a result of violence in mental health patients there have been the development of structured clinical tools that have been developed which could help healthcare providers identify people who are at risk of becoming violent or hostile a good example of a tool of this nature is the Broset Violence Checklist (BVC). This is a six-item questionnaire designed to examine the presence or absence of three patient features which are boisterousness, irritability, and confusion. It also assesses three patient’s behaviors which are attacks on objects, physical threats, verbal threats, Sarver et al. (2019) suggest that an individual who exhibits two or more of these actions is more likely to turn violent during the next 24 hours.

Conclusion

To conclude this piece of work it is important to stress that is California a mental health patient could be treated in the hospital involuntarily or voluntarily. Voluntarily is when a patient goes into the hospital and seek treatment by his or herself without the legal system being involved, involuntarily when a patient is placed on a 5150 hold which is 72 hours hold which can progress to a 5250 which is a 14-day hold. It should also be noted that in California mental health patients could be treated as outpatient or inpatient. Without us laying too much emphasis the issue of patient’s information being protected is of prime importance which is why we have HIPAA which the Health Insurance Portability and Accountability Act. This is a Federal Law laid down to protect an individual’s health information. Given the sensitive nature of mental health and the treatment of substance use disorder, this regulation is critical since it protects these persons' confidential mental health data. It is also important to note that the Columbia-Suicide Severity Rating Scale (CSRS) is an evidence-based tool for measuring the risk of suicide. On the other hand, the Broset Violence Checklist is a six-item survey that examines whether a patient exhibits violent characteristics or behaviors.

References:

Hedman, L., C, Petrla, J. Fisher, W., H, et al. (2016). State laws on emergency holds for mental

health stabilization. Psychiatr Serv. 2016;67(5):529–35.

Leo R. J. (2019). Competency and the capacity make treatment decsions: A primer for

primary care physicians. Journal of clinical psychatry, 1(5), 251–256.

Posner et al. (2019). The Columbia–Suicde Severity Rating Scale: Initial valdity and internal

consistncy. Am J Psychiatry 2019; 168: 126 6 –1277)

Sarver, W., L., Radziewicz, R., Coyne, G., Colon, K., Mantz, L. (2019). Implementation of the

Brøset Volence Checklist on an Acute Psychatric Unit. J Am Pychiatr Nurses Assoc.

2019 Nov/Dec;25(6), 476-486.

State of California. (n.d.). Involuntary Treatment Information. Retrieved from

https://namsantaclara.org/wp-contnt/uploads/2015/05/Involuntary-Treatment-Page.pdf

Sudarsanan, S., Chaudhury, S., Pawar, A. A., Salujha, S. K., & Srivastava, K. (2004). Psychiatric

Emergencies. Med J. Armed Forces India. 30(1), 59-62. https://doi:10.1016/S0377-1237(04)80162-X

Swartz, D. S., Robertson, A. M., & Swanson, N. W. (2017). Involuntary outpatint commtment

and the elusive pursuit of volence prevention. Amrican journal of psychatry. 15(3),

181–187

Theodor, K., & Sittig, S. (2020). Health informtion privacy laws in the digital age. Perpectives

in health information managment, 18(2), 15-21