NRNP 6635 Assignment: Legal and Ethical Issues Related to Psychiatric Emergencies
Psychiatric emergencies entail severe disturbances in mood, thought, behavior and social interactions among individuals suffering from or suspected of having mental health issues and require immediate interventions. These interventions may entail holding of the suspected patients in emergency rooms or departments to offer the much-needed mental health interventions based on federal and state laws (Hui et al., 2020). The purpose of this paper is to discuss the legal provisions for involuntary psychiatric holds in Maryland and the differences in inpatient and outpatient commitments. The paper also differentiates capacity and competency and holds a discussion on the differences between suicide and violence risk assessment tools.
Involuntary Psychiatric Holds Laws in Maryland
Psychiatric emergency holds laws in many states, including Maryland, allow involuntary admissions of individuals to health care facilities when they have acute mental illness under certain situations. Wh
ile state laws for involuntary hold of mental cases vary across stats, the core criterion to justify the holds is mental situations may pose a danger to the individual and other (Kim et al., 2022). In Maryland, the law allows one to be admitted involuntarily if they have a mental disorder and require inpatient treatment, presents a danger to their life and safety as well as of other and is not able or unwilling to get admitted voluntarily (Carroll, 2021). The law asserts that once certified in EH for involuntary hospital admission, the individual can only be kept in the emergency facility for not more than 30 hours. The state Department of Mental Hygiene offers admission within six hours after notification.
The law also requires that an individual who gets admitted involuntarily gets a hearing with an administrative law
judge (ALJ) within ten days of admission to determine if they still meet the criteria for involuntary admission. The individual also has a right to alter the status to a voluntary admission before the hearing session, if the psychiatrist finds that they understand and agree to the treatment (Carroll, 2021). The hearing decision by the judge can be attended by the parents, guardians of next of kin for the individual. The implication is that once released, the individual is received by the next of kin or parents or guardians. The law provides that if one meets the criteria for involuntary admission, they may be held for up to six months.
Emergency Hospitalization for Evaluation/Psychiatric Hold, Inpatient Commitment and Outpatient Commitment
Emergency hospitalization entails involuntary commitment of an individual with a mental illness which is considered as a threat to them or others to a facility based on the laws of involuntary psychiatric hold. In Maryland, this can be up to 30 hours during which the hospital should evaluate and provide therapeutic interventions. Mental health patients considered a threat to themselves or others are sent against their will to inpatient facilities. Maryland law states that the individual should be assessed as competent by two psychiatrists and cleared by a competent judge to determine their discharge status (Carroll, 2021). Outpatient commitment entails involuntary commitment to an outpatient program for individuals considered a threat to themselves and others because of their mental health status. While the person is not held in a mental health facility, he or she is obligated to receive outpatient therapy and comply with their treatment plans.
Difference Between Capacity and Competency in Mental Health Contexts
Capacity and competency are critical aspects in mental health provision for individuals and even providers. Capacity is the ability to understand, appreciate and apply the nature and implications of one’s situation and the decisions and actions needed to attain quality outcomes. A person has capacity if he or she understands the nature and effects of their decisions and actions and make logical choices about their moves and the situation. competency is the legal ability of an individual to make better decisions concerning their welfare (Kim et al., 2022). A person is considered competent when they understand the nature and consequences of their actions and decide the course of actions in their best interests in regard to the mental health interventions recommended or suggested. The implication is that competency and capacity impact the overall ability of one to make better choices.
Legal and Ethical Issues Related to Autonomy in Psychiatric Emergencies
A legal issue concerning patient autonomy in psychiatric emergencies which is applicable in the context of psychiatric emergencies in involuntary commitment of the person as a threat to self and others because of their mental heal. Involuntary commitment of the person in such facilities is a violation of the autonomy as they are deprived of their right to make decisions concerning their welfare and treatment. They are forced against their will to enter in facilities and regarded as lacking competency to make better decisions (Kim et al., 2020). An ethical issue affecting patient autonomy in this situation is the forced treatment of the person who is considered as lethal to self and others because of their mental health status. The forced treatment deprives one their right to autonomy, independence and self-determination.
Evidence-based Suicide and Violence Risk Assessment Tools to Screen Patients
Evidence based suicide and violence assessment tools allow psychiatric mental health nurses (PMHNPs) to screen patients and attain effective diagnosis to prevent suicide ideation and possible commission of violence. The Columbian Suicide Severity Rating Scale (C-SSRS) is a valid and reliable assessment tool that evaluate the present and prior suicidal ideation, attempts and preparatory behaviors as well as non-suicidal self-injury (NSSI) (Posner et al., 2018; Brodsky et al., 2018). NSSI entails a deliberate self-harm conduct an individual performs without any intention to cause death or suicide. The outcomes of the C-SSRS predicts future suicidal ideation and attempts for patients in psychiatric emergency situations.
The V-RISK-10 tool is an evidence-based violence risk assessment that can screen patients with the potential of committing violent actions while in healthcare facilities. The tool is used in triage to see if a patient requires more evaluation by other tools. The V-RISK-10 identifies the need for risk management to deflate immediate and potential risk for violence (Cox et al., 2018). This tool is very critical in psychiatric emergency departments to reduce and mitigate any possible violent confrontations between mental health patients and providers.
Conclusion
Psychiatric emergencies happen in all states and practitioners must know the legal frameworks of dealing with their different components. Understanding the existing hold laws, differences in commitments, capacity and competency is core to provision of best care possible. Providers must understand the ethical and legal aspects that may interfere with their overall abilities to offer quality patient care interventions.
References
Brodsky, B. S., Spruch-Feiner, A., & Stanley, B. (2018). The Zero Suicide Model: Applying
Evidence-Based Suicide Prevention Practices to Clinical Care. Frontiers in psychiatry, 9,
Carroll, H. (2021). Know the Laws in Your State. Treatment Advocacy
Center. www.treatmentadvocacycenter.org/component/content/article/183-in-a-crisis/1596- know the-laws-in-your-state.
Cox, J., Fairfax, C. J., DeMatteo, D., Vitacco, M. J., Kopkin, M. R., Parrott, C. T., & Bownes, E.
(2018). An update and expansion on the role of the Violence Risk Appraisal Guide and Historical Clinical Risk Management‐20 in United States case law. Behavioral Sciences & the Law, 36(5), 517-531. https://doi.org/10.1002/bsl.2376
Hui, K., Cooper, R. B., & Zaheer, J. (2020). Engaging Patients and Families in the Ethics of
Involuntary Psychiatric Care. American Journal of Bioethics, 20(6), 82-84. https://doi.org/10.1080/15265161.2020.1754511
Kim, A. K., Vakkalanka, J. P., Van Heukelom, P., Tate, J., & Lee, S. (2022). Emergency
psychiatric assessment, treatment, and healing (EmPATH) unit decreases hospital admission for patients presenting with suicidal ideation in rural America. Academic Emergency Medicine, 29(2), 142-149. https://doi.org/10.1111/acem.14374
Posner, K., Brown, G. K., Stanley, B., Brent, D. A., Yershova, K. V., Oquendo, M. A., Currier,
- W., Melvin, G. A., Greenhill, L., Shen, S., Mann, J. J., Nam, B., Wilcox, H. C., Hilimire, M., & DeVylder, J. E. (2018). Columbia-Suicide Severity Rating Scale. Journal of American College Health, 66(8), 713-719. https://cssrs.columbia.edu/wp-content/uploads/CSSRS_Supporting-Evidence_Book_2020-01-14.pdf
Saygili, E., & Ozturkoglu, Y. (2020). Patients’ rights and professional conduct issues in hospitals’
codes of ethics. International Journal of Human Rights in Healthcare, 13(3), 201-208. https://doi.org/10.1108/IJHRH-09-2019-0071
Psychiatric emergencies are severe mood, thought, behavioral and social disturbances that need immediate emergency interventions plan as defined by the family, patient and social care unit. These immediate interventions are critical in saving the patient and others from immediate harm to themselves and others. All states across the U.S. have laws and guidelines that offer directions on handling psychiatric emergencies and access to immediate interventions to deal with such cases. Three forms of involuntary treatment exist by civil commitment laws in 46 states and the District of Columbia. Therefore, one can only secure treatment during or following a psychiatric crisis when they understand the existing laws and standards in their states (Leo, 2019). The purpose of this paper is to explore the legal and ethical issues concerning psychiatric emergencies and identify evidence-based suicide and violence risk assessments in Illinois for patients with paraphilic disorders.
Illinois State Laws for Involuntary Psychiatric Holds
Psychiatric emergency hold laws allow individuals with mental health disorders like paraphilic disorders to get involuntary admissions to health facilities to get immediate interventions to reduce potential harm to themselves and others. The state of Illinois is among 17 states that offer access to treatment on a needs-basis with a consideration of possible risk or danger (Kenneally, 2022). The implication is that laws in the state allow individuals to get admitted to mental health facilities against their consent or wishes under the involuntary civil commitment. There are two ways individuals with mental illness can involuntarily be admitted to a mental health facility (Posner et al., 2019). These include by a court order where a state judge forces one to be admitted to a facility, and emergency admission by certification where due to the nature of one’s mental health, and posing immediate harm himself or other. The second scenario means that one does not require a court order as long as local authorities are aware of the immediate danger, they can take the individuals to a mental health facility to get treatment.
Proof of mental illness alone is not sufficient to admit an individual; either a minor or an adult, into a mental health facility. The issuance of a mental health warrant means that a sheriff’s office can detain a patient and transport them to a health facility for evaluation and subsequent treatment. A psychiatrist must provide a medical certificate to court upon assessment. The certificate is a proof that the individual may potentially harm themselves and even other. The court then issues an order of protective custody (OPC) where the individual is held for at most 72 hours before a judge holds a probable cause hearing to determine if the facility can hold or release the patient (Kenneally, 2022). The court is then mandated to hold a mental health hearing within 14 days.
For minors, the Illinois law mandates parents, managing conservator, or guardian to request for their admission to inpatient health facility. They can do this by filing a request with the administrator of the facility. A psychiatrist can only discharge such patient upon the determination that they do not pose any harm to themselves or others. Minors can only be released to parents, guardians and the managing conservator.
Psychiatric Hold, Inpatient Commitment & Outpatient Commitment in Illinois
Patients on psychiatric hold are confined in psychiatric facilities against their will for a maximum of 72 hours. Illinois laws require the individual to either be a danger to themselves or others, suffer from severe distress, and experiencing significant deterioration as well as lacking the ability to make rational and informed decisions to submit to treatment (Santillanes et al., 2018). Inpatient commitment occurs when a judge orders an individual to get hospital treatment when they meet the state’s criteria for civic commitment after being in psychiatric hold. On its part, outpatient commitment is a treatment intervention or alternative where a judge orders a qualifying individuals with mental illness symptoms to comply with a prescribed mental health plan while they live in the community.
Capacity and Competence in Mental Health Contexts
Capacity entails the evaluation of a person’s functional abilities to make rational choices and decision. Physicians conduct assessments to determine if one lacks the capacity to make reasoned medical decision. Under such situations, they grant others or surrogates to make decisions on their behalf. On its part, competency is assessment and legal determination by a court on one’s ability to rationally execute legally recognized acts and situation (Bipeta, 2019). The court determines the level of one’s incompetence where those deemed incompetent get assigned persons to make decisions on their behalf.
HIPAA: Legal and Ethical Issues in Psychiatric Emergencies
Caring for individuals with mental health issues, especially psychiatric emergencies needs a multidisciplinary team and families as well as friends. The implication is that these entities must share information about the care for effective care coordination to yield better outcomes. However, sharing of the information requires all involved to adhere to the provisions of the Health Insurance Portability and Accountability Act (HIPAA). This federal law protects the privacy of individual health information (Theodos & Sittig, 2020). The law is essential as it assists in protection of confidential mental health records for individuals with the problem. Ineffective communication hinders care process and HIPAA understands that individuals with mental illness may lack the competency and even capacity to make decisions. The law allows representatives of such individuals to request and obtain complete medical records for effective decision making.
An ethical issue also arises from the HIPAA law as it is more synonymous with privacy measure imploring providers to only make disclosures based on consent. Despite its good intention, many question its ethical viability as it obstructs or interferes with effective care coordination. Many assert that the law restricts providers from effective care delivery based on fast-changing technology (Theodos & Sittig, 2020). Consumers want seamless communication and believe that such should also happen in healthcare settings. For instance, patients feel comfortable texting their physicians directly or emailing their care team and getting what they want without using the patient portals. The implication is that these regulations raise ethical issues with providers being keen on offering better interventions by information sharing.
Suicide Risk Assessment Tool
The Columbia-Suicide Severity Rating Scale (C-SSRS) is an evidence-based suicide risk assessment tool that can be used in different care setting for psychiatric assessment. These include schools, campuses, fire departments and even the military. Multiple institutions and organizations developed the tool. These include Columbia University, National Institute of Mental Health and National Institute of Health as well as Substance Abuse and Mental Health Service Administration (SAMHSA) (Posner et al., 2019). The tool has a rating scale where individuals with suspected mental health issues are rated on their level of suicide ideation. The scale identifies specific behaviors and at least one must be among those identified by the scale to more likely lead to complete suicide.
Violence Risk Assessment Tool
Violence towards healthcare workers, especially in emergency rooms, continues to be a concern in healthcare and affects the quality of care that they can offer. Structured clinical tools can help healthcare providers to identify patients and their family members that can be potentially violent or aggressive. The Broset Violence Checklist (BVC) is a six-item instrument which evaluates the presence or absence of three aspects of patients that include confusion, irritability and boisterousness. The tool also measures patient behaviors like verbal threats, physical threats and attacking of objects which are indications of possible violence (Sarver et al., 2019). Individuals displaying any two or more of these aspects are likely to become violent with a 24-hour duration if no immediate interventions are put in place. The tool is effective in enhancing adherence to treatment interventions to reduce the possibility of violence.
Conclusion
Illinois state has laws that mandate involuntary admission of individuals into psychiatric facilities against their will if they pose danger to themselves and others. Those seeking such interventions must use the state’s legal system. Courts determine mental competency and but physicians determine mental capacity for individuals. The HIPAA regulations help protect patient privacy and health information. Ethical and legal concerns also arise from the use of HIPAA as it hinders effective care provision. The use of suicide risk assessment tools and violence risk tools is essential in offering better interventions to patients with mental health issues.
References
Bipeta, R. (2019). Legal and Ethical Aspects of Mental Health Care. Indian Journal of
Psychological Medicine, 41(2): 108-112. DOI: 10.4103/IJPSYM.IJPSYM_59_19
Kenneally, P. D. (2022). Mental Health Involuntary Commitment.
https://www.mchenrycountyil.gov/county-government/departments-j-z/state-s-attorney-s-office/divisions/civil-division/mental-health-involuntary-commitment
Leo R. J. (2019). Competency and the capacity to make treatment decisions: A primer for
primary care physicians. Journal of clinical psychiatry, 1(5), 251–256.
DOI: 10.4088/pcc.v01n0501.
Posner et al. (2019). The Columbia–Suicide Severity Rating Scale: Initial validity and internal
consistency. American Journal of Psychiatry, 168: 126 6 –1277.
DOI: 10.1176/appi.ajp.2011.10111704.
Santillanes, G., Kearl, Y. L., Lam, C. N., & Claudius, I. A. (2017). Involuntary psychiatric holds
in preadolescent children. Western Journal of Emergency Medicine, 18(6), 1159. DOI: 10.5811/westjem.2017.8.35114
Sarver, W., L., Radziewicz, R., Coyne, G., Colon, K., Mantz, L. (2019). Implementation of the
Brøset Violence Checklist on an Acute Psychiatric Unit. Journal of American Psychiatric Nurses Association, 25(6):476-486. DOI: 10.1177/1078390318820668.
Theodos, K., & Sittig, S. (2020). Health information privacy laws in the digital age. Perspectives
in health information management, 18(2), 15-21.