Legal and Ethical Issues Related to Psychiatric Emergencies
Legal and Ethical Issues Related to Psychiatric Emergencies
Psychiatric emergencies are common in mental health care, and psychiatric mental health nurse practitioners (PMHNP) should understand how to administer emergency care and the laws guiding the practice. Due to the complexity of emergencies, PMHNPs should coordinate care effectively, involve law enforcement agencies appropriately, and ensure that family members and other support systems know the process and patient needs. The importance of follow-up care is critical for comprehensive healing. The purpose of this paper is to explore legal and ethical issues surrounding psychiatric emergencies and outline risk assessment tools for suicide and violence.
State Laws for Involuntary Psychiatric Holds
Children and adults can be confined in a psychiatric setting against their wishes. New Jersey permits court-ordered treatment for mental disorders if, upon personal observation, a law enforcement officer is convinced that a person requires involuntary treatment. The other instance is when a mental health practitioner screens the person and establishes the need for involuntary commitment to treatment (Treatment Advocacy Center, 2018). The psychiatric facility can hold up a person for up to 72 hours. During this time, the facility initiates court proceedings and receives a temporary court order for the commitment (Treatment Advocacy Center, 2018). The medical providers can release the patient or request the court to allow further treatment if the patient poses a danger to self or others. Family members, friends, or caregivers can pick up the patient after the hold is released.
Evaluation/Psychiatric Hold, Inpatient Commitment, and Outpatient Commitment
The terms differ in purpose for treatment. An emergency hospitalization for evaluation/psychiatric hold is a crisis response where the patient is admitted to a psychiatric facility for mental evaluation for a short period. Inpatient commitment applies when the patient is mentally ill and poses a risk for self, others, and property (New Jersey Courts, 2023). Outpatient commitment happens when the court establishes that the patient requires continued involuntary commitment.
Capacity and Competency in Mental Health Contexts
Patients should make informed decisions to enhance recovery and not pose any risk to others. According to Libby et al. (2018), capacity represents the functional determination that a patient can or cannot make decisions. The implication is that a capacitated patient can make effective decisions. Competence is primarily about the ability to perform actions to actualize decisions. As a result, capacity precedes competence.
Legal and Ethical Issues Related to Patient Autonomy
Regardless of the setting, health care providers should ensure and empower patients to make correct decisions. Patient autonomy is crucial when treating psychiatric emergencies. Zhang et al. (2021) described autonomy as the patient’s ability to make independent decisions. Ethically, informed consent promotes patient autonomy since it empowers patients to understand and freely agrees to the medication process and alternatives. Legally, patient autonomy is violated when a health care practitioner acts exclusively on behalf of patients or pressurizes them to act in a particular way.
Suicide Risk Assessment
The risk of suicide is high among patients requiring emergency holds. The Columbia Protocol is an effective suicide risk assessment that can be applied across settings for different patients. Also called the Columbia-Suicide Severity Rating Scale (C-SSRR), this assessment helps practitioners to analyze the risk of suicide and its severity to determine the support level that a patient needs (Ryan & Oquendo, 2020). Assessment areas include ideation, actions that demonstrate preparation for suicide, and suicide attempts. C-SSRR is simple to administer and uses plain-language questions to assess a patient.
Violence Risk Assessment
Violence assessment can be conducted through the Historical Clinical Risk Management- 20 (HCR-20) tool. As the name suggests, mental health practitioners focus on history, clinical items such as ideation and symptoms of major mental disorders, and risk management. Focus areas include formulating previous violence, estimating risk, and hypothesizing future scenarios (Ramesh et al., 2018; Silva, 2020). The screening outcomes help mental health providers to determine the most appropriate intervention depending on symptoms and severity of risks.
Conclusion
Psychiatric emergencies can be complex to handle, depending on their severity. PMHNPs should understand the ethical and legal implications of every process and ensure it is implemented according to standard guidelines. Family and caregivers should be integrated into the plan as PMHNPs ensure coordination and patient-centeredness as much as possible. For a comprehensive assessment, C-SSRR and HCR-20 can be used to assess suicide and violence risk respectively.
References
Libby, C., Wojahn, A., Nicolini, J. R., & Gillette, G. (2018). Competency and capacity. StatPearls Publishing.
New Jersey Courts. (2023). RULE 4:74-7 – Civil Commitment – Adults. https://www.njcourts.gov/attorneys/rules-of-court/civil-commitment-adults#:~:text=The%20court%20shall%20enter%20an,patient%20to%20be%20dangerous%20to
Ramesh, T., Igoumenou, A., Vazquez Montes, M., & Fazel, S. (2018). Use of risk assessment instruments to predict violence in forensic psychiatric hospitals: a systematic review and meta-analysis. European Psychiatry: the Journal of the Association of European Psychiatrists, 52, 47–53. https://doi.org/10.1016/j.eurpsy.2018.02.007
Ryan, E. P., & Oquendo, M. A. (2020). Suicide risk assessment and prevention: Challenges and opportunities. Focus, 18(2), 88-99. https://doi.org/10.1176/appi.focus.20200011
Silva, E. (2020). The HCR-20 and violence risk assessment – will a peak of inflated expectations turn to a trough of disillusionment?. BJPsych Bulletin, 44(6), 269–271. https://doi.org/10.1192/bjb.2020.14
Treatment Advocacy Center. (2018). Emergency hospitalization for evaluation. https://www.treatmentadvocacycenter.org/component/content/article/180-fixing-the-system/2275-emergency-hospitalization-for-evaluation
Zhang, H., Zhang, H., Zhang, Z., & Wang, Y. (2021). Patient privacy and autonomy: a comparative analysis of cases of ethical dilemmas in China and the United States. BMC Medical Ethics, 22(1), 1-8. https://doi.org/10.1186/s12910-021-00579-6