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Involuntary commitment and medical patients.

Involuntary civil commitment to a psychiatric unit or hospital is a well-established legal principle. But what should happen when a medical patient wants to leave the hospital against medical advice but might be harmed by doing so? Consultant psychiatrists are often called on in these cases to make a determination about whether the patient has the capacity to make a stable, informed medical decision.

Last year, Dr. Debra A. Pinals and two of her colleagues, Dr. Nancy Byatt and Dr. Rasim Arikan, examined the issue in a paper that won an award from the American Association for Emergency Psychiatry and spawned a session on the subject at this year's American Psychiatric Association annual meeting in San Diego.

The paper (Psychosomatics 2006;47:443-8) called involuntary hospitalization of medical patients an "unresolved issue."

This month, CLINICAL PSYCHIATRY NEWS talks with Dr. Pinals about the issues involved in involuntary commitment of medical patients and what consultant psychiatrists need to do in such cases.

Dr. Pinals, whose expertise includes treatment of violence in the mentally ill, and the interface of mental illness and the justice system, is codirector of the Law and Psychiatry Program and associate professor of psychiatry at the University of Massachusetts, Worcester.

CLINICAL PSYCHIATRY NEWS: The paper written by you and your colleagues described a situation in which an HIV-positive patient with a history of psychiatric illness, presumed HIV-related dementia, and an intracranial hemorrhage, wanted to leave the hospital, and your institution was not prepared to deal with it.

Campus police had to be called but refused to help without any commitment documents. Why hasn't involuntary commitment of medical patients been adequately discussed before?

Dr. Pinals: The clinical issues certainly have come up before. And civil commitment laws for psychiatric patients have been written about before. But sometimes you have a medical patient who has a clinical picture that doesn't fall under the psychiatric commitment law. And that was the case here: The patient clearly lacked decisional capacity, was delirious, and had what constituted organic brain damage--which the state does not allow as a reason for psychiatric commitment.

The medical team can restrain people if they need to for medical healing purposes, but people are confused about that issue. In this case, the issue of civil commitment probably would not have come up except that the patient had a psychiatric history, and that made matters confusing about how to hold the patient and whether civil commitment should be initiated to allow her to be held. At times in these cases when a delirious medical patient refuses treatment, a psychiatrist would not even be contacted.

CPN: Is this an issue that is coming up more often because of the prevalence of HIV, including the HIV-related mental symptoms?

Dr. Pinals: This issue is not unique to HIV. This can arise for any patients with medical illness that compromises their capacity to make decisions for themselves, including those with substance abuse problems that cloud judgment.

CPN: It is estimated that perhaps 1% to 5% of hospital discharges are done against medical advice, and that some hospitals take the position that it is easier to discharge patients who want to leave, as long as they are willing to sign out against medical advice. Is that approach common?

Dr. Pinals: If competent medically hospitalized patients want to leave, they are allowed to leave. Sometimes patients make health care decisions that we as doctors may not agree with, but if they are competent individuals and have capacity, they have the right to make the decisions they want to make. But if you have a question about somebody's competence--a question about whether they are delirious or confused or psychotic--or if you think they may lack decisional capacity, then often a psychiatric consult will be requested. Then the psychiatrist makes an assessment of the patient's capacity and competence to make medical decisions, and then that sets a course of action--for us and for them.

CPN: What is that course?

Dr. Pinals: In our paper, we noted that patients who appear to meet criteria for civil commitment because they present a risk of harm to themselves or others may not lack the capacity to make medical judgments, and, likewise, that the lack of decisional capability is not equivalent to the need to be committed to a psychiatric unit. And so we developed an algorithm for what steps one could take when faced with a patient who does not appear to have a serious mental illness but lacks the capacity to make medical decisions because of an underlying medical condition and wants to leave the hospital.

The first step is for the psychiatrist to assess and document whether the patient has the capacity to make medical decisions ... If the patient does not have that capacity, then the least restrictive method of keeping the patient in the hospital needs to be used. Sometimes that is just talking with the patient. Some hospitals use sitters who remain in the patient's room.

CPN: What would be the role of the medical team at this point?

Dr. Pinals: At this time, the medical team needs to try to contact the next of kin or the patient's health care proxy to obtain guidance about how to proceed. If that fails, the hospital may need to pursue temporary guardianship of the patient. While the guardianship is proceeding, only emergent-based treatment can be given. The situation is not simple.

CPN: What does the psychiatrist need to understand about his role, and what does he need to do?

Dr. Pinals: The psychiatrist has to be clear about what information has been told to the patient, about what the patient's diagnosis is, what treatment is recommended and what the course of that treatment might be, and what the side effects and risks might be.

Specifically, the psychiatrist needs to be sure that the patient has been told about the risks of no treatment, and the risks of leaving the hospital. Next, the psychiatrist will assess the patient's capacity to make medical decisions. That would include first an evaluation of the patient's understanding of the information about the treatment.

Second, the psychiatrist would need to assess the patient's appreciation of the clinical situation. Third, the assessment would include an evaluation of the patient's ability to rationally think through the information and the implications for any medical decisions that the patient might make. In addition, the psychiatrist would be assessing the patient's capacity to express a choice related to the treatment and sustain the choice long enough to allow the clinicians to implement it.

These are generally considered the four factors that the psychiatrist needs to think about when assessing capacity to make medical decisions.

CPN: Is sometimes just talking to the patient enough to change her decision?

Dr. Pinals: There are lots of reasons why people want to leave medical treatment. Often, it is not based on acute psychiatric issues. It may be fear, misinformation, or misunderstanding. Or maybe the patient has just not had his or her voice heard or been told adequately about the proposed treatment. So yes, sometimes it's just a matter of sitting down--and I mean sitting down--just to talk with the patient and listening to the patient's concerns.

CPN: Do you think that the stigma issue might come into play when a psychiatrist is called in?

Dr. Pinals: In some cases, medical patients are reluctant to speak with a psychiatrist consultant. That likely has to do with stigma. The psychiatrist should explain to the patient why he was called. He might explain that the treating doctor is concerned that her decision to leave the hospital could put her at risk and that psychiatrists are often called in to assess such situations, and help assess the patient's understanding of the medical issues and related decision-making. The psychiatrist might explain that he is also assessing whether any emotional issues need addressing related to the medical situation. The psychiatrist should talk with the patient and address her concerns head-on.

Patients need to feel empowered, but when they lack capacity to make decisions for themselves, that autonomy may need to be challenged.

CPN: You have said that the legal profession and the medical profession speak different languages when it comes to involuntary hospitalization. In what way are those languages different?

Dr. Pinals: In Massachusetts, for example, the civil commitment paperwork rules out organic brain syndromes as a cause for involuntary psychiatric hospitalizations. But that bright-line rule is not so bright. It doesn't really help us know what to do when one has a patient who might have illnesses that are complex mental disorders, such as dementia with psychosis, or a mood disorder due to a traumatic brain injury.

The legal system often needs the doctor to translate a DSM diagnosis into a regulatory definition for the purposes of appropriate civil commitment.

CPN: At what point should hospitals begin the process of seeking guardianship?

Dr. Pinals: If you think that somebody is not capable of making decisions and the cause is not something that is resolvable, then a treatment team needs to use advance directors and/or consider guardianship. In emergency situations, it is possible to get medical guardianships fairly quickly. But that takes coordination with the legal team that works with the hospital.

CPN: It sounds like it might make sense for the hospital's ethics committee to get involved at this point. How important is the role of ethics committees in these kinds of cases?

Dr. Pinals: In some cases, it can be quite important. Ethics committees are not always involved, but are often called when there are disagreements between the patient and the treatment team or among treatment providers and family members about how to proceed with patient care. Ethics consultation may also be sought when there appears to be value judgments being made that could affect a patient's autonomy.

CPN: How has the profession responded to the issues raised in the article you wrote with your colleagues?

Dr. Pinals: It was interesting to hear people in our session at the APA realize that there is this disconnect between psychiatric commitment and how you manage a medically ill, decisionally impaired person who is refusing care. Participants generally found this a topic worthy of further exploration.

By Timothy F. Kirn, Sacramento Bureau. Send your thoughts and suggestions to
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Title Annotation:INPATIENT PRACTICE; Debra A. Pinals
Author:Kirn, Timothy F.
Publication:Clinical Psychiatry News
Article Type:Interview
Geographic Code:1USA
Date:Aug 1, 2007
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