Friday, January 09, 2009

You Need to Be in the Hospital

I'm learning the ropes in psychiatry, and one issue that comes up is "commitment". Why is it that you can "commit" a patient to the hospital for their schizophrenia, but not for their myocardial infarction? What is the difference? How are the procedures different for each? What if the patient wants to leave AMA? I think there's a lot of fear and misinformation surrounding this topic, so I'd like to delve briefly into how a medical hospital stay is similar to and different from a psychiatric hospital stay.

If Mr. X walks into the emergency room with chief complaint of "chest pain", he gets triaged to the medical ER. Likely within a few minutes he'll have an EKG and cardiac enzymes done. If the EKG shows massive ST elevation and the troponin is elevated, the doctor will say "Mr. X, you are having a heart attack. You need to come stay in the hospital to have treatment."

Mr. X has two options at that point: say "sure doc" or "no way". If he says yes, he signs the consent form and is off to the cath lab. If he says "no way", it's a little more complicated. Is he delirious? Is he drunk? In other words, is he in his right mind and able to make this decision? Is he unconscious without family around--if so, you treat emergently and let the consent work itself out later. If he is not delirious, you assess him for capacity to refuse treatment: does he know what a heart attack is, does he know what the treatment is, does he know he could die without treatment, does he know he could live with the treatment? If he meets capacity and says "doc, I know I could die if I leave, but I do not want treatment" then he signs a paper stating that he is leaving Against Medical Advice (AMA) and walks out the door. The procedure is the same if he's already on the floor and decides to leave.

What if Mr. X is delirious? What if his brain is deoxygenated and he's agitated and trying to leave, but only yesterday he told his wife "absolutely treat me if I have a heart attack?" In this situation, you can obtain consent from his wife (or next of kin) for treatment and pursue treatment. If you document that the patient does not have the capacity to refuse, and you feel that the benefits of treatment likely outweigh the risks, and that they are "not themselves" (disoriented, delirious, etc), then you now have the ability to use restraints against this patient if you need to do so. Ever see the patients tied down in the ICU so they won't pull out the vent tube? A patient who is septic, hypotensive, and delirious may try to pull out a tube--they're uncomfortable--and clearly doesn't know that what they're doing can kill them. That patient is at that moment being held and treated against their will, so this is not something you take lightly. Restraints usually have to be assessed every few hours by a doctor, and patients may need to be sedated so they don't a) have discomfort that led them to try to pull the tube out in the first place and b) fight against the restraints so hard they have rhabdomyolysis.

Therefore, not everyone in the medical hospital is there with their consent. An adult with capacity may consent to or refuse treatment and this should be honored. An adult without capacity to consent to or refuse life-saving treatment may be restrained in certain situations. The family may provide consent for treatment if the patient is incapacitated (which is how we end up with so many demented patients in the ICU--another issue altogether).

So how is it different in psychiatry?

If Mr. Y walks into the same emergency room with chief complaint of "I want to kill myself", he gets triaged to the psychiatric ER. Shortly thereafter a doctor or "mental health professional" (maybe social worker or PA) will assess the patient and perform a mental status exam. If the patient is very depressed, still says he will kill himself, and states that he keeps a loaded gun at home just for this purpose, the doctor will say "Mr. Y, I'm concerned for your safety. You need to come stay in the hospital to have treatment."

Mr. Y has two options at that point: say "sure doc" or "no way". If he says "sure doc" then he signs a consent for mental health treatment and is admitted to the psych unit (after some basic labs to be sure there's nothing major medically wrong at that moment). If he says "no way", then it gets tougher. If his risk of committing suicide seems very high, as in he is an elderly Caucasian male, feels hopeless, has no family, lives alone, has a firm plan for death, is in dire financial straits, and it's the anniversary of his wife's death, then you may make the argument that he is in imminent danger of harming himself and should be admitted to the hospital. (If his risk is low, he's a "frequent flyer" in the ER who uses this line to get a warm bed because the shelter was full and his check is spent, etc, then "Sayonara!") You may also argue that the patient's severe depression is preventing him from making rational decisions or having full capacity to refuse treatment.

For psychiatry, instead of having the family sign the patient in when they refuse but lack capacity, you file paperwork with the court--legal "commitment". This varies from state to state, but usually involves some manner of stating that the patient is in imminent danger of harming himself or others, lacks capacity to refuse due to mental illness, and will acutely decompensate and/or likely kill himself if allowed to leave without treatment. The patient will be brought to a locked psych unit and will remain until treatment is completed. Patients who are on "involuntary" status don't necessarily stay longer than "voluntary" patients; it simply means that they must stay until a physician releases them or the court determines that they may be released.

Now, if Mr. Y signs himself in voluntarily, but 4 hours later decides he wants to leave, what do you do? On the medical floor, the patient asks to sign out AMA. In the psych unit, they ask for essentially the same thing. Different states have a different procedure for doing this, but the patient must ask for a document stating that they want to leave (essentially AMA). A doctor must come examine them within a certain period of time to determine whether the patient has capacity to leave. Mr. Y in our example above told us 4 hours ago he wanted to kill himself and has a gun. If the doctor examines him and he says "doc, I want to leave so I can go kill myself", then the doctor is going to have to file paperwork to commit him to the hospital--after he's already there. If the patient is stable, and doesn't meet criteria for legal commitment, then you must let them leave AMA after they request it.

We often err on the side of having patients sign in voluntarily so that the patient isn't forced to be committed legally, but sometimes that leads to a double standard (in my opinion)--we're saying the patient has capacity to accept treatment (which we want), but not to refuse (which we don't want). I think one reason we do this is because we want to use the commitment process as infrequently as possible. Once a patient has been committed, this becomes a matter of public record with the court, where if they sign in voluntarily this is covered by HIPAA.

Legally, it's all very complicated. Due to some abuse of commitment in the past (in this country and others) a very complicated set of rules must be followed. The patient must meet criteria for admission (usually reserved for acutely suicidal, acutely psychotic, acutely manic, etc) and be either about to commit suicide, about to hurt someone, or be completely unable to take care of themselves (the manic patient wearing their undies in the snow to preach the gospel in the middle of the street, for example) to the point that they cannot practice basic safety. Once you file paperwork with the court stating that you've examined them and they should be committed, they'll be assigned a court date. After around 72 hours, a second exam must continue to document that patient still requires involuntary hospitalization. The case will go before a judge at some point who will either confirm the commitment until a doctor says they may be released or will deny the commitment and order the release of the patient.

You can also order emergency medication. After his heart attack, Mr. X became hypotensive and was acutely bleeding, and was unconscious so he couldn't sign the consent for blood products; he will still be transfused. After his admission, Mr. Y became acutely psychotic and agitated, tried to throw tables at the staff, tried to punch through a glass window, and refused to take his meds; if he refused to take an oral med, he would likely get a shot of something sedating (usually haldol 5 mg + Ativan 2 mg) to calm him down. If Mr. Y continues to refuse to take his meds, continues to be agitated and dangerous, you can petition the court to order medication.

Some people would argue that the two aren't the same at all. After all, the patient with the MI who is bleeding is going to die; as my med student put it yesterday "well, psych stuff isn't life-threatening." It depends. Even patients in locked psych units can commit suicide if they're determined enough; they can commit homicide, they can attack other patients or staff. A condition called "agitated delirium" or "excited delirium" can actually cause a patient who is so overstimulated by their psychosis (and often by drugs) to suddenly drop dead. Maybe it's not as clear cut as the MI situation, but psychiatric patients can die from their disorders or related complications. Speaking for myself and the people I work with, we wouldn't put someone in the hospital against their will and medicate them against their will if it didn't seem vitally important to that patient's ability to survive.

Legal commitment remains controversial; just look at the wikipedia page. Obviously, there is some overlap with this and medical treatment, but some striking differences as well. I think we should continue to work very hard only to use involuntary hospitalization and forced medication when absolutely necessary. Judicial oversight helps keep the process honest, but I'm sure mistakes are made. It does help to compare it to what happens in the regular hospital; if you're out of your right mind and lack capacity you're not leaving, whether it's post-MI or the aliens infiltrating the TV set. If you need emergency IV fluids or emergency sedation, it's an emergency, period. This is a rather awesome power doctors wield, and I'm kinda glad there's a judge looking over this process.