Finally, I would say be nice to involuntary patients. They are some of our sickest and most dangerous patients and will likely benefit from remaining in our care. They may make us angry, and they may be a lot of work, but these patients need us. Like all human beings, those in need of emergency care may well appreciate small acts of kindness.
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ACEP Now: Vol 36 – No 07 – July 2017As difficult as involuntary care may be, the truth is that it’s better to have a traumatized patient than a dead patient. Still, there are times when involuntary treatment could be avoided or when the trauma could be mitigated. It’s effort worth making.
Dr. Miller is an instructor of psychiatry at Johns Hopkins School of Medicine and has a private psychiatry practice in Baltimore. She is coauthor of Committed: The Battle Over Involuntary Psychiatric Care and Shrink Rap: Three Psychiatrists Explain Their Work.
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5 Responses to “Is Involuntary Hold for Psychiatric Patients the Only Answer?”
July 16, 2017
Gary ZimmerWhile this is a thoughtful and compelling article, I find it important to note that it is a patient-centric piece without the balance of the health system/physician/staff/society perspective. In short, people present in crisis and the emergency department is often the only place to go. There are vanishingly few psychiatric emergency departments and, in my experience (multiple east coast states), voluntary services have limited availability during business hours and none for new patients off hours. Therapists and psychiatrists aren’t available (generally) to discuss their patients so emergency physicians are left in our usual predicament: limited information, questionable followup and pressure to keep the department moving. Let a patient walk out and they commit suicide — good luck defending that decision.
Imagine a better world: crisis workers who had the time to talk to patients, functional secure assessment areas that could accommodate patients safely for extended observation, and hospitals that acknowledged the importance of mental health patients and could provide resources to accomplish this. Oh, while I’m on my soap box – insurance companies actually paying reasonable rates to make this all work and not denying visits after the fact based on the outcome rather than the presentation…
July 16, 2017
Gary GechlikFocusing on affect and not the standard of care is a psychiatric land mine.
The psychiatrist could come immediately to the emergency department like a surgeon, evaluate the patient, and dictate a note like the emergency physician.
Once stabilized a psychiatric patient on a hold needs admission or transfer.
This is a national standard of care. The safety of the patient and staff come before our feelings.
July 16, 2017
WILLIAM KENTI totally agree with Dr. Miller that kindness and offering comfort and even food to our psych pts in the ER forms a
bond of confidence to help in the healing process before the mental health team sees the patient.
July 24, 2017
BruceAnother article that talks about general concepts without addressing the very difficult reality surrounding these patients. I agree these patients have difficult and sometimes traumatizing emergency department experiences. I agree that we should be nice to them and try and deescalate circumstances were possible. The reality however is that frequently we cannot deescalate and the patient is already out of control. The disconnect between reality and concept is starkly apparent in Dr. Miller statement about not using force to adhere to policy. Specifically she mentions admission lab work. Anyone who has experience in emergency department is aware of the duck,bob and weave mentality that exists. Any excuse to delay specialty consultation and evaluation. In many cases the very specialist this patient most needs, mental health, refuses to evaluate the patient until a urine drug screen and alcohol level is available. In order to achieve expedited and critically needed care, sometimes force is necessary to “adhere to policy”. These patients are a victim of limited resources, limited time, and no one taking ownership of their issues. Unfortunately until needed dollars are committed to mental health, they will continue to languish for days in the emergency department “awaiting crisis disposition”.
August 13, 2017
Mike BarnumIn my area (Las Vegas) a “voluntary hold” is not an option. There are no psychiatrists available to the ERs. Patients placed on a hold will be visited in the subsequent 72 hours by a social worker sent by the agency contracted with the patient’s insurance plan or the county mental health organization if the patient is unfunded. These social workers then arrange for the patient to be held in the ED longer, sent to a psychiatric facility or they compel the EP to discharge them. The psychiatric social workers will not see a patient who is not on a legal hold. They will not see a “voluntary” patient. They are our only resource. Less severe patients must frequently choose if they wish to be placed on a hold or attempt to navigate the outpatient mental health maze on their own. I have no other options to give them.