Psychiatric ‘holds’ for nonpsychiatric patients

Dear Dr. Mossman,

At the general hospital where I work, doctors and nurses sometimes ask me to fill out psychiatric “hold” documents to keep seriously ill medical or surgical patients from leaving the hospital. Last week, they asked me to stop Mr. J, a man with diabetes and a gangrenous lower leg, from leaving against medical advice (AMA). If he left, he would die. But if I filled out the psychiatric “hold,” I’d be saying the man needed civil commitment for a mental illness, which wasn’t true. If this happens again, what should I do?
Submitted by “Dr. Q”

“It is tempting, if the only tool you have is a hammer, to treat everything as if it were a nail,” wrote Abraham Maslow.¹ The situation Dr. Q describes is one that psychiatrists frequently encounter because in some situations, a psychiatric “hold” can seem like the only way to stop a physically ill patient from leaving the hospital AMA. But pounding on this problem with a civil commitment hammer is the wrong response.

What’s wrong with using psychiatric holds in these situations? Do doctors have any other equipment in their medical toolbox for stopping an improvident AMA departure? To find out, we’ll look at:

• what a psychiatric hold does
• why holds don’t apply to medical-surgical treatment
• alternative responses to patients who lack capacity to refuse care.

Psychiatric holds

All states have laws that permit involuntary psychiatric hospitalization. The wording and procedural details in these laws vary across jurisdictions, but all states allow civil (ie, noncriminal) commitment of mentally ill persons who have gross impairments of judgment, behavior, reality-testing, or everyday functioning if their recent behavior show that they pose a danger because of their mental illness.² Table 1³ lists examples of the types of dangers that are potential reasons for civil commitment.

Table 1

Types of risks covered in civil commitment statutes

State laws also allow certain individuals (eg, police) to apprehend and transport mentally ill persons to facilities for psychiatric evaluation. Doctors may hold these persons temporarily until a court decides whether a longer involuntary hospitalization is justified. The documents used to initiate psychiatric holds have various informal names—”5150” (California), “pink slip” (Ohio), “pink paper” (Massachusetts), “Baker Act Form” (Florida)—but their function is the same: permitting lawful restraint of patients whose dangerousness results from their mental illness.

Urgent medical and surgical care

What about medical or surgical patients who refuse care despite being told they’ll die without it? Might involuntary psychiatric hospitalization procedures be a convenient way to keep them from coming to harm?

The answer: probably not, for 4 reasons:

1. Once a psychiatric hold has been executed, the person who is subject to detention must be transferred to an appropriate facility within a specified period (usually 24 hours) for further evaluation and care.^4,5 In this context, “appropriate facility” means a state-approved psychiatric treatment setting. A hospital’s medical or surgical unit usually would not qualify.
2. The lawful use of a psychiatric hold is to declare that someone needs involuntary psychiatric examination for dangerousness arising “as a result of mental illness”—not for danger from a nonpsychiatric medical problem.⁶ Some civil commitment statutes specify that persons who have serious nonpsychiatric illness but no mental health problems that satisfy civil commitment criteria are to be offered voluntary treatment only.⁷
3. A psychiatric hold only authorizes short-term detention. It does not allow forcing what patients such as Mr. J need: medical or surgical treatment. A psychiatric hold would not solve the problem that Mr. J’s doctors are facing.
4. Doctors who execute psychiatric holds in good faith—sincerely believing a patient meets the legal criteria—enjoy statutory immunity from later accusations of malpractice or false imprisonment.⁸ Using civil commitment mechanisms when one does not actually believe those mechanisms apply might void this immunity.

Nonconsent: 2 varieties

For present purposes, let’s think of nonconsenting medical-surgical patients as coming in 2 varieties:

Variety 1: patients with compromised mental status. Often, medical-surgical patients cannot express objections to treatment because they are unconscious, delirious, or incoherent. Nurses and doctors assume such patients would want proper care and proceed with what they believe is in the patients’ best interest, often with input from family members.