Risk Management Considerations When Treating Violent Patients

Kristen Lambert
Psychiatric News
Originally posted September 4, 2018

Here is an excerpt:

When a patient has a history of expressing homicidal ideation or has been violent previously, you should document, in every subsequent session, whether the patient admits or denies homicidal ideation. When the patient expresses homicidal ideation, document what he/she expressed and the steps you did or did not take in response and why. Should an incident occur, your documentation will play an important role in defending your actions.

Despite taking precautions, your patient may still commit a violent act. The following are some strategies that may minimize your risk.

• Conduct complete timely/thorough risk assessments.

• Document, including the reasons for taking and not taking certain actions.

• Understand your state’s law on duty to warn. Be aware of the language in the law on whether you have a mandatory, permissive, or no duty to warn/protect.

• Understand your state’s laws regarding civil commitment.

• Understand your state’s laws regarding disclosure of confidential information and when you can do so.

• Understand your state’s laws regarding discussing firearms ownership and/or possession with patients.

• If you have questions, consult an attorney or risk management professional.

The info is here.

Nonvoluntary Psychiatric Treatment Is Distinct From Involuntary Psychiatric Treatment

Dominic A. Sisti
JAMA. Published online August 24, 2017

Some of the most ethically challenging cases in mental health care involve providing treatment to individuals who refuse that treatment. Sometimes when persons with mental illness become unsafe to themselves or others, they must be taken, despite their outward and often vigorous refusal, to an emergency department or psychiatric hospital to receive treatment, such as stabilizing psychotropic medication. On occasion, to provide medical care over objection, a patient must be physically restrained.

The modifier “involuntary” is generally used to describe these cases. For example, it is said that a patient has been involuntarily hospitalized or is receiving involuntary medication ostensibly because the patient did not consent and was forced or strongly coerced into treatment. Importantly, a person may be involuntarily hospitalized but retain the right to refuse treatment. “Involuntary” is also used to describe instances when an individual is committed to outpatient treatment by a court. The fact that a person is being treated involuntarily raises numerous challenges; it raises concerns about protecting individual liberty, respect for patient autonomy, and the specter of past abuses of patients in psychiatric institutions.

Although it has become both a clinical colloquialism and legal touchstone, the concept of involuntary treatment is used imprecisely to describe all instances in which a patient has refused the treatment he or she subsequently receives. In some cases, a patient outwardly refuses treatment but may have previously expressed a desire to be treated in crisis or, according to a reasonable evaluator, he or she would have agreed to accept stabilizing treatment, such as antipsychotic medication. A similar scenario occurs in the treatment of individuals who experience a first episode of psychosis and who outwardly refuse treatment. With no prior experience of what it is like to have psychosis, these patients are unable to develop informed preferences about treatment in advance of their first crisis. In these cases, some believe it is reasonable to provide treatment despite the opposition of the patient, although this could be debated.

The article is here.

Feds probing psychiatric hospitals for locking in patients to boost profits

Beth Mole
Ars Technica
Originally published May 24, 2017

At least three US federal agencies are now investigating Universal Health Services over allegations that its psychiatric hospitals keep patients longer than needed in order to milk insurance companies, Buzzfeed News reports.

According to several sources, the UHS' chain of psychiatric facilities—the largest in the country—will delay patients' discharge dates until the day insurance coverage runs out, regardless of the need of the patient. Because the hospitals are reimbursed per day, the practice extracts the maximum amount of money from insurance companies. It also can be devastating to patients, who are needlessly kept from returning to their jobs and families. To cover up the scheme, medical notes are sometimes altered and doctors come up with excuses, such as medication changes, sources allege. Employees say they repeatedly hear the phrase: “don’t leave days on the table.”

The Department of Health and Human Services has been investigating UHS for several years, as Buzzfeed has previously reported. UHS, a $12 billion company, gets a third of its revenue from government insurance providers. In 2013, HHS issued subpoenas to 10 UHS psychiatric hospitals.

But now it seems the Department of Defense and the FBI have also gotten involved.

The article is here.

Ethics of Coercive Treatment and Misuse of Psychiatry

Tilman Steinert
Psychiatric Services
http://dx.doi.org/10.1176/appi.ps.201600066

Abstract

The author discusses a pragmatic approach to decisions about coercive treatment that is based on four principles from principle-based ethics: respect for autonomy, nonmaleficence, beneficence, and justice. This approach can reconcile psychiatry’s perspective with the U.N. Convention on the Rights of Persons With Disabilities. Coercive treatment can be justified only when a patient’s capacity to consent is substantially impaired and severe danger to health or life cannot be prevented by less intrusive means. In this case, withholding treatment can violate the principle of justice. In the case of danger to others, social exclusion and loss of freedom can be seen as harming psychosocial health, which can justify coercive treatment. Considerable efforts are required to support patients’ informed decisions and avoid allowing others to make substitute decisions. Mental disorder alone without impaired capacity does not justify involuntary treatment, which can be considered a misuse of psychiatry. Involuntary detention without treatment can be justified for short periods for assessment and to offer treatment options.

The article is here.

Restrict the Recruitment of Involuntarily Committed Patients for Psychiatric Research

Carl Elliott and Matt Lamkin
JAMA Psychiatry
Published online February 10, 2016. doi:10.1001/jamapsychiatry.2015.3117

Can an involuntarily committed psychiatric patient give truly voluntary consent for medical research? This question has been fiercely debated in Minnesota since 2008, when the St Paul Pioneer Press reported the death of Dan Markingson, a mentally ill young man who had been recruited into an antipsychotic study at the University of Minnesota while under a civil commitment order. Along with many others, we have argued that the circumstances of Markingson’s commitment order compromised the voluntariness of his consent to the study. Although federal guidelines are silent on the issue, we believe the Markingson case serves as a powerful argument for serious restrictions on the recruitment of involuntarily committed patients into psychiatric research studies.

The article is here.

Assisted Outpatient Treatment: APA’s Position Statement

Renée Binder
Psychiatric News
Originally posted February 29, 2016

Here is an excerpt:

• Is AOT ethical? Some opponents of AOT feel that it is unethical to force patients into treatment except for emergency treatment, that is, when a patient is a danger to self, a danger to others, or unable to care for basic needs. They argue that AOT goes against the principles of autonomy and right to self-determination.

Opponents contend that even if someone has a chronic mental illness and has a history of hospitalization or incarceration, they still have the right to decide if they want to comply with treatment, barring an emergency. AOT supporters argue that AOT is consistent with the principle of beneficence and tries to intervene before someone meets the criteria for involuntary hospitalization to prevent deterioration based on past history. After reviewing the arguments on both sides, the APA position statement supports the use of AOT and opines that it is ethical when used appropriately.

The article is here.

Advocates Seek Mental Health Changes, Including Power to Detain

By BRANDI GRISSOM
The Texas Tribune/The New York Times
Published: February 23, 2013

Here are some excerpts:

Mr. Thomas, who confessed to the murders of his wife, their son and her daughter by another man, was convicted in 2005 and sentenced to death at age 21. While awaiting trial in 2004, he gouged out one of his eyes, and in 2008 on death row, he removed the other and ate it.

At least twice in the three weeks before the crime, Mr. Thomas had sought mental health treatment, babbling illogically and threatening to commit suicide. On two occasions, staff members at the medical facilities were so worried that his psychosis made him a threat to himself or others that they sought emergency detention warrants for him.

Despite talk of suicide and bizarre biblical delusions, he was not detained for treatment. Mr. Thomas later told the police that he was convinced that Ms. Boren was the wicked Jezebel from the Bible, that his own son was the Antichrist and that Leyha was involved in an evil conspiracy with them.

He was on a mission from God, he said, to free their hearts of demons.

Hospitals do not have legal authority to detain people who voluntarily enter their facilities in search of mental health care but then decide to leave. It is one of many holes in the state’s nearly 30-year-old mental health code that advocates, police officers and judges say lawmakers need to fix. In a report last year, Texas Appleseed, a nonprofit advocacy organization, called on lawmakers to replace the existing code with one that reflects contemporary mental health needs.

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Hospital officials say they face a Catch-22 under current law: if they detain a mentally ill person against his or her will, they face liability because they have no legal authority to do so. If they allow the person to leave and something tragic happens, they risk a lawsuit like the one the Boren family filed.

The entire story is here.

Loughner forced medication OKd by judge

From the San Francisco Chronicle

A judge ruled Wednesday that prison officials can forcibly give the man accused of the Tucson shooting rampage antipsychotic drugs in a bid to make him mentally fit for trial.

U.S. District Judge Larry Burns' decision came after Jared Lee Loughner's attorneys filed an emergency request last week to prevent any forced medication of their client without approval from a judge. The judge said he did not want to second guess doctors at the federal prison in Springfield, Mo., who determined that Loughner was a danger.

"I have no reason to disagree with the doctors here," Burns said. "They labor in this vineyard every day."

Loughner, who was not at the hearing in San Diego, has been at the Missouri facility since May 28 after the judge concluded he was mentally unfit to stand trial and help in his legal defense.

Mental health experts had determined the 22-year-old college dropout suffers from schizophrenia and will try to make him psychologically fit to stand trial. He will spend up to four months at the facility.

Prosecutors have argued that Loughner should be given antipsychotic drugs because he has been diagnosed as schizophrenic and poses a danger to others.

"This is a person who is a ticking time bomb," prosecutor Wallace Kleindienst said Wednesday.

In a filing Tuesday, prosecutors cited an April 4 incident where Loughner spit on his own attorney, lunged at her and had to be restrained by prison staff. They also cited an outburst during a March 28 interview with a mental health expert in which Loughner became enraged, cursed at her and threw a plastic chair at her twice.

Loughner has pleaded not guilty to 49 charges stemming from the Jan. 8 shooting that injured Rep. Gabrielle Giffords and 12 others and killed six people, including John Roll, the chief federal judge for Arizona.

If Loughner is later determined to be competent enough to understand the case against him and assist his lawyers, the court proceedings will resume.