Legal and Ethical Issues Related to Psychiatric Emergencies
The diagnosis of psychiatric emergencies can include a wide range of problems—from serious drug reactions to abuse and suicidal ideation/behaviors. Regardless of care setting, the PMHNP must know how to address emergencies, coordinate care with other members of the health care team and law enforcement officials (when indicated), and effectively communicate with family members who are often overwhelmed in emergency situations. In their role, PMHNPs can ensure a smooth transition from emergency mental health care to follow-up care, and also bridge the physical–mental health divide in healthcare.
In this week’s Assignment, you explore legal and ethical issues surrounding psychiatric emergencies, and identify evidence-based suicide and violence risk assessments.
To Prepare
- Review this week’s Learning Resources and consider the insights they provide about psychiatric emergencies and the ethical and legal issues surrounding these events.
The Assignment
In 2–3 pages, address the following:
- Explain your state laws for involuntary psychiatric holds for child and adult psychiatric emergencies. Include who can hold a patient and for how long, who can release the emergency hold, and who can pick up the patient after a hold is released.
- Explain the differences among emergency hospitalization for evaluation/psychiatric hold, inpatient commitment, and outpatient commitment in your state.
- Explain the difference between capacity and competency in mental health contexts.
- Select one of the following topics, and explain one legal issue and one ethical issue related to this topic that may apply within the context of treating psychiatric emergencies: patient autonomy, EMTALA, confidentiality, HIPAA privacy rule, HIPAA security rule, protected information, legal gun ownership, career obstacles (security clearances/background checks), and payer source.
- Identify one evidence-based suicide risk assessment that you could use to screen patients.
- Identify one evidence-based violence risk assessment that you could use to screen patients.
Rubric Detail
| Excellent
90%–100% |
Good
80%–89% |
|||||
| In 2–3 pages, address the following:
• Explain your state laws for involuntary psychiatric holds for child and adult psychiatric emergencies. Include who can hold a patient and for how long, who can release the emergency hold, and who can pick up the patient after a hold is released. |
14 (14%) – 15 (15%)
The response includes a thorough and well-organized explanation of student’s state laws for involuntary psychiatric holds for child and adult emergencies. |
12 (12%) – 13 (13%)
The response includes an accurate explanation of student’s state laws for involuntary psychiatric holds for child and adult emergencies. |
||||
| • Explain the differences among emergency hospitalization for evaluation/psychiatric hold, inpatient commitment, and outpatient commitment in your state. | 14 (14%) – 15 (15%)
The response includes an accurate and concise explanation of the differences among emergency hospitalization for evaluation/psychiatric hold, inpatient commitment, and outpatient commitment in your state. |
12 (12%) – 13 (13%)
The response includes a well-organized explanation of the differences among emergency hospitalization for evaluation/psychiatric hold, inpatient commitment, and outpatient commitment in your state. |
||||
| • Explain the difference between capacity and competency in mental health contexts. | 9 (9%) – 10 (10%)
The response includes an accurate and concise explanation of the difference between capacity and competency in mental health contexts. |
8 (8%) – 8 (8%)
The response includes an accurate explanation of the difference between capacity and competency in mental health contexts. |
||||
| • Select one of the following topics and explain one legal issue and one ethical issue related to this topic that may apply within the context of treating psychiatric emergencies: patient autonomy, EMTALA, confidentiality, HIPAA privacy rule, HIPAA security rule, protected information, legal gun ownership, career obstacles (security clearances/background checks), and payer source. | 14 (14%) – 15 (15%)
The response accurately and concisely explains one legal and one ethical issue related to the selected topic, within the context of treating psychiatric emergencies. |
12 (12%) – 13 (13%)
The response accurately explains one legal and one ethical issue related to the selected topic, within the context of treating psychiatric emergencies. |
||||
| •Identify one evidence-based suicide risk assessment that you could use to screen patients. Attach a copy or a link to the assessment you identified. | 14 (14%) – 15 (15%)
The response identifies and explains an appropriate, evidence-based suicide risk assessment that could be used to screen patients. A copy of or a link to the assessment is included. |
12 (12%) – 13 (13%)
The response identifies an appropriate, evidence-based suicide risk assessment that could be used to screen patients. A copy of or a link to the assessment is included. |
||||
| • Identify one evidence-based violence risk assessment that you could use to screen patients. Attach a copy or a link to the assessment you identified. | 14 (14%) – 15 (15%)
The response identifies and explains an appropriate, evidence-based violence risk assessment that could be used to screen patients. A copy of or a link to the assessment is included. |
12 (12%) – 13 (13%)
The response identifies an appropriate, evidence-based violence risk assessment that could be used to screen patients. A copy of or a link to the assessment is included. |
||||
| Written Expression and Formatting – Paragraph Development and Organization:
Paragraphs make clear points that support well-developed ideas, flow logically, and demonstrate continuity of ideas. Sentences are carefully focused—neither long and rambling nor short and lacking substance. A clear and comprehensive purpose statement and introduction are provided that delineate all required criteria. |
5 (5%) – 5 (5%)
Paragraphs and sentences follow writing standards for flow, continuity, and clarity. A clear and comprehensive purpose statement, introduction, and conclusion are provided that delineate all required criteria. |
4 (4%) – 4 (4%)
Paragraphs and sentences follow writing standards for flow, continuity, and clarity 80% of the time. Purpose, introduction, and conclusion of the assignment are stated, yet they are brief and not descriptive. |
||||
| Written Expression and Formatting – English writing standards:
Correct grammar, mechanics, and proper punctuation |
5 (5%) – 5 (5%)
Uses correct grammar, spelling, and punctuation with no errors |
4 (4%) – 4 (4%)
Contains 1-2 grammar, spelling, and punctuation errors |
||||
| Written Expression and Formatting – The paper follows correct APA format for title page, headings, font, spacing, margins, indentations, page numbers, parenthetical/in-text citations, and reference list. | 5 (5%) – 5 (5%)
Uses correct APA format with no errors |
4 (4%) – 4 (4%)
Contains 1-2 APA format errors |
||||
| Total Points: 100 | ||||||
| Fair
70%–79% |
Poor
0%–69% |
|
| 11 (11%) – 11 (11%)
The response includes a somewhat vague or inaccurate explanation of student’s state laws for involuntary psychiatric holds for child and adult emergencies. |
0 (0%) – 10 (10%)
The response includes a vague or inaccurate explanation of student’s state laws for involuntary psychiatric holds for child and adult emergencies. Or the response is missing. |
|
| 11 (11%) – 11 (11%)
The response includes a somewhat vague explanation of the differences among emergency hospitalization for evaluation/psychiatric hold, inpatient commitment, and outpatient commitment in your state. |
0 (0%) – 10 (10%)
The response includes a vague explanation of the differences among emergency hospitalization for evaluation/psychiatric hold, inpatient commitment, and outpatient commitment in your state. Or the response is missing. |
|
| 7 (7%) – 7 (7%)
The response includes a somewhat vague or incomplete explanation of the difference between capacity and competency in mental health contexts. |
0 (0%) – 6 (6%)
The response includes a vague or inaccurate explanation of the difference between capacity and competency in mental health contexts. Or the response is missing. |
|
| 11 (11%) – 11 (11%)
The response somewhat vaguely or innacurately explains one legal and one ethical issue related to the selected topic, within the context of treating psychiatric emergencies. |
0 (0%) – 10 (10%)
The response vaguely or innacurately explains one legal and one ethical issue related to the selected topic, within the context of treating psychiatric emergencies. Or, response is missing. |
|
| 11 (11%) – 11 (11%)
The risk assessment identified is somewhat inappropriate for the intended use or dated. A copy of or a link to the assessment may be missing. |
0 (0%) – 10 (10%)
The risk assessment identified is inappropriate for the intended use, not evidence based, or dated. Or, response is missing. |
|
| 11 (11%) – 11 (11%)
The risk assessment identified is somewhat inappropriate for the intended use or dated. A copy of or a link to the assessment may be missing. |
0 (0%) – 10 (10%)
The risk assessment identified is inappropriate for the intended use, not evidence based, or dated. Or, response is missing. |
|
| 3.5 (3.5%) – 3.5 (3.5%)
Paragraphs and sentences follow writing standards for flow, continuity, and clarity 60%–79% of the time. Purpose, introduction, and conclusion of the assignment are vague or off topic. |
0 (0%) – 3 (3%)
Paragraphs and sentences follow writing standards for flow, continuity, and clarity < 60% of the time. No purpose statement, introduction, or conclusion were provided. |
|
| 3.5 (3.5%) – 3.5 (3.5%)
Contains 3-4 grammar, spelling, and punctuation errors |
0 (0%) – 3 (3%)
Contains five or more grammar, spelling, and punctuation errors that interfere with the reader’s understanding |
|
| 3.5 (3.5%) – 3.5 (3.5%)
Contains 3-4 APA format errors |
0 (0%) – 3 (3%)
Contains five or more APA format errors |
|
Expert Answer and Explanation
Mental Health Laws in Texas
There are various guiding PMHNP when providing mental health services to patients. Mental health laws play a significant role in the integration of mental health in primary health care, community integration of people with mental health problems, and provision of high-quality care. In the US, states have different laws prescribing how their citizens should be handled when mental health emergency occurs.
The state that will be focused on in this assignment in Texas. The legislative body of Texas has enacted various guiding PMHNP on how to provide mental health services among various populations. It is the responsibility of PMHNP to understand these laws and follow them to avoid legal problems. This assignment has discussed legal and ethical principles regarding mental health emergencies in the state of Texas.
Texas Laws
The law guiding involuntary psychiatric holds for child and adult psychiatric emergencies is known as the Texas Health and Safety Code – HEALTH & SAFETY § 574.014 (FindLaw.com, 2021). The involuntary psychiatric holds can be initiated by an adult by applying detention, evaluation, and treatment of the individual with the county courts.
A law enforcement officer is also allowed to detain an individual they believe to be a threat due to substance abuse or mental disorders and transport the individual to a mental health facility for evaluation for admission under their police powers. Mental health facilities recognized by the Department of Mental Health can initiate the process of holding a patient if they believe that the individual has a serious mental health problem and needs emergency psychiatric treatment (FindLaw.com, 2021).
Mental health professionals allowed to begin an on-site civil involuntary detention for an individual in need of emergency mental health care include psychiatric residents, licensed physicians, psychiatrists, licensed professional counselors, a qualified addiction professional, and PMHNP. An individual should only be detained for 72 hours, excluding holidays and weekends (FindLaw.com, 2021).
However, if the psychiatrist still believes that the individual needs further treatment beyond 72 hours, they can begin a court hearing to get court permission to continue holding the patient. The mental health professional can release the emergency hold if they believe that the individual does not need emergency care (FindLaw.com, 2021). The emergency hold can be picked by their family members or people they chose.
Differences
Emergency hospitalization for psychiatric hold or evaluation can be initiated by an adult, a police officer, or a health professional qualified to handle mental health services. This process does not need a court order (FindLaw.com, 2021). However, for a person to be committed to receiving mental health services as an inpatient or outpatient, a court order must be sought.
The guardian or applicant must go to court and seek a court order. The individual patient must also be given a chance to explain themselves (FindLaw.com, 2021). Therefore, the difference is emergency hospitalization for evaluation/psychiatric hold does not need a court order while inpatient and outpatient commitment need a court order.
Capacity and Competency
In the mental health context, capacity is a clinical determination and functional assessment of a specific decision that can be made by a health professional who has interacted with the patient’s case (Keene et al., 2019). However, competency is a legal determination and global assessment made in court by a judge. In other words, competency is determined by a judge while capacity by a health professional (Keene et al., 2019).
HIPAA Privacy Rule
HIPAA privacy rule requires that healthcare professionals protect patients’ information and prevent unauthorized persons from accessing them (Edens et al., 2018). The healthcare professionals are only allowed to share the information with the courts during hearing on whether the patients should receive involuntary inpatient or outpatient care. The healthcare professionals are only allowed to share the information with patient’s family member when the patient is incapacitated ad cannot make informed decisions (Edens et al., 2018).
Suicide Risk Assessment
The suicide risk assessment tool I could use to screen patients is the Columbia-suicide severity rating scale. This tool is validated to be used in adults, adolescents, and children (Matarazzo et al., 2019). The authors argue that it assesses both active and passive suicidal ideation, plan, method, suicidal behavior, and intent to act on the plan.
Violence Risk Assessment
The violence risk assessment I would use is the historical, clinical, and risk management-20 (HCR-20) tool. The tool is used to assess violence by health professionals across the globe. Ramesh et al. (2018) found that the tool accurately identifies patients with violent behaviors. They also noted that the tool is valid and reliable.
Conclusion
In Texas, individuals in need of mental healthcare emergencies can be detained at a mental health hospital for 72 hours by a police officer, an adult, or a healthcare provider. Competency is determined by a judge while capacity by a health professional. Healthcare professionals are legally and ethically needed to respect patients’ autonomy. However, during mental health emergencies, the professionals can detain the patient for 72 hours if they believe that the patient is a threat.
References
Edens, J. F., Petrila, J., & Kelley, S. E. (2018). Legal and ethical issues in the assessment and treatment of psychopathy. In C. J. Patrick (Ed.), Handbook of psychopathy (pp. 732–751). The Guilford Press.
FindLaw.com. (2021). Texas Health and Safety Code – HEALTH & SAFETY § 574.014. Compilation of mental health commitment records. https://codes.findlaw.com/tx/health-and-safety-code/health-safety-sect-574-014/
Keene, A. R., Kane, N. B., Kim, S. Y., & Owen, G. S. (2019). Taking capacity seriously? Ten years of mental capacity disputes before England’s Court of Protection. International Journal Of Law And Psychiatry, 62, 56-76. https://doi.org/10.1016/j.ijlp.2018.11.005
Matarazzo, B. B., Brown, G. K., Stanley, B., Forster, J. E., Billera, M., Currier, G. W., & Brenner, L. A. (2019). Predictive validity of the Columbia‐Suicide Severity Rating Scale among a cohort of at‐risk Veterans. Suicide and Life‐Threatening Behavior, 49(5), 1255-1265. https://doi.org/10.1111/sltb.12515
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
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Who Can Authorize an Involuntary 72-Hour Hold: Understanding the Process
As a society, we have a responsibility to care for those who are in need of mental health services. One way that we do this is through the use of involuntary 72-hour holds. These holds allow for individuals who are in crisis to receive the care that they need, even if they do not want it. However, many people are unsure of who has the authority to initiate an involuntary 72-hour hold. In this article, we will explore the process of involuntary holds and the individuals who can authorize them.
Understanding Involuntary Holds
Before we dive into who can authorize an involuntary 72-hour hold, it is important to understand what these holds are and why they are necessary. Involuntary holds, also known as involuntary psychiatric holds or 5150 holds, are legal mechanisms used to detain individuals who are deemed to be a danger to themselves or others due to their mental health condition.
The purpose of involuntary holds is to provide immediate care to individuals who may be a danger to themselves or others. These holds allow medical professionals to assess the individual’s mental state, provide treatment if necessary, and determine if further care is needed. In most cases, an involuntary hold lasts for 72 hours, but this can vary depending on the individual’s circumstances and the state in which they reside.
Who Can Authorize an Involuntary 72-Hour Hold?
Now that we understand what involuntary holds are and why they are necessary, let’s explore who has the authority to initiate these holds. The process for initiating an involuntary hold varies by state, but in general, the following individuals can authorize an involuntary 72-hour hold:
1. Licensed Mental Health Professionals
In most states, licensed mental health professionals, such as psychiatrists, psychologists, and licensed clinical social workers, can initiate an involuntary hold. These professionals are trained to evaluate an individual’s mental health and determine if an involuntary hold is necessary.
2. Law Enforcement Officers
Law enforcement officers can also initiate an involuntary hold if they believe that an individual is a danger to themselves or others. However, in most cases, law enforcement officers will only initiate a hold if they are unable to contact a mental health professional or if the situation is deemed to be an emergency.
3. Medical Professionals
Medical professionals, such as emergency room physicians, can also initiate an involuntary hold if they believe that an individual is a danger to themselves or others. However, in most cases, medical professionals will only initiate a hold if they are unable to contact a mental health professional or if the situation is deemed to be an emergency.
4. Family Members or Friends
In some states, family members or friends can initiate an involuntary hold if they believe that an individual is a danger to themselves or others. However, in most cases, these individuals will need to go through a licensed mental health professional, law enforcement officer, or medical professional to initiate the hold.
The Process for Initiating an Involuntary Hold
The process for initiating an involuntary hold varies by state, but in general, the following steps are taken:
1. Evaluation by a Mental Health Professional
The individual is evaluated by a licensed mental health professional to determine if an involuntary hold is necessary.
2. Petition for an Involuntary Hold
If the mental health professional determines that an involuntary hold is necessary, they will file a petition with the court.
3. Court Hearing
A court hearing will be scheduled to determine if an involuntary hold is necessary. At this hearing, the individual will have the opportunity to present their case and challenge the hold.
4. Treatment
Once the court has determined that an involuntary hold is necessary, the individual will be transported to a hospital or psychiatric facility for treatment. During the 72-hour hold, the individual will receive care from licensed mental health professionals. The purpose of this treatment is to stabilize the individual’s mental health and determine if further care is necessary.
During the hold, the individual may receive medication, therapy, and other treatments to address their mental health condition. If the mental health professionals determine that the individual is no longer a danger to themselves or others, the hold will be lifted and the individual will be released. However, if further care is deemed necessary, the individual may be subject to a longer involuntary hold or voluntary commitment.
It is important to note that involuntary holds are not intended to punish individuals for their mental health condition. Instead, they are a mechanism to provide care to individuals who are in crisis and may harm themselves or others if left untreated.
Conclusion
Involuntary 72-hour holds are an important tool in providing care to individuals who are in crisis due to their mental health condition. While the process for initiating a hold varies by state, licensed mental health professionals, law enforcement officers, medical professionals, and family members or friends may have the authority to initiate a hold. If you or a loved one is in need of mental health services, it is important to seek help as soon as possible.
FAQs
- Can an individual refuse an involuntary 72-hour hold?
In most cases, individuals cannot refuse an involuntary hold. However, they do have the right to challenge the hold at a court hearing.
- How long does an involuntary hold last?
In most cases, an involuntary hold lasts for 72 hours. However, this can vary depending on the individual’s circumstances and the state in which they reside.
- Can family members or friends initiate an involuntary hold?
In some states, family members or friends can initiate an involuntary hold if they believe that an individual is a danger to themselves or others. However, in most cases, these individuals will need to go through a licensed mental health professional, law enforcement officer, or medical professional to initiate the hold.
- Can an individual be forced to take medication during an involuntary hold?
In most cases, individuals can be forced to take medication if it is deemed necessary by licensed mental health professionals.
- What happens after an involuntary hold is lifted?
After an involuntary hold is lifted, the individual may be released or subject to voluntary commitment if further care is deemed necessary.
What is Psychiatric Hold?
Psychiatric hold refers to the involuntary hospitalization of an individual in a psychiatric facility for assessment and treatment of mental illness or substance abuse. The procedure allows healthcare providers to take immediate action when an individual poses a danger to themselves or others, or when they are unable to make rational decisions regarding their health.
Types of Psychiatric Holds
There are different types of psychiatric holds, including emergency, temporary, and long-term holds.
Emergency Hold
An emergency hold, also known as a 5150 hold, is a type of psychiatric hold that allows healthcare providers to involuntarily admit individuals to a psychiatric facility for up to 72 hours for evaluation and treatment. The hold is usually initiated when an individual poses an immediate threat to themselves or others, such as when they exhibit suicidal or homicidal tendencies.
Temporary Hold
A temporary hold, also known as a 5250 hold, is a type of psychiatric hold that allows healthcare providers to extend an emergency hold for an additional 14 days if the individual continues to meet the criteria for involuntary commitment.
Long-Term Hold
A long-term hold, also known as a 5260 hold, is a type of psychiatric hold that allows healthcare providers to extend a temporary hold for an additional 180 days if the individual continues to meet the criteria for involuntary commitment.
Legal Framework for Psychiatric Holds
Involuntary commitment is a legal procedure that involves the deprivation of an individual’s liberty. As such, it is subject to due process and the protection of the individual’s rights.
Criteria for Involuntary Commitment
The criteria for involuntary commitment vary by jurisdiction but generally require that the individual poses a danger to themselves or others or is unable to make rational decisions regarding their health due to mental illness or substance abuse. In most cases, a healthcare provider must provide evidence of the individual’s condition, and a judge must approve the commitment order.
Due Process
Due process requires that the individual be given notice of the commitment proceedings, the right to a hearing, the right to legal representation, and the right to appeal the decision.
Rights of Patients
Patients who are subject to involuntary commitment have the right to receive humane treatment, the right to refuse treatment, the right to communicate with family members and legal counsel, and the right to challenge the grounds for their commitment.
Medical Considerations for Psychiatric Holds
Medical considerations for psychiatric holds are an essential part of the involuntary commitment process. The purpose of psychiatric holds is to provide individuals with immediate assessment and treatment of their mental health conditions. Healthcare providers must consider several factors when determining the appropriate course of treatment during a psychiatric hold.
Psychiatric Evaluation
The first step in the psychiatric hold process is a psychiatric evaluation. Healthcare providers will assess the individual’s mental status, including their behavior, mood, and thought processes. The evaluation may include diagnostic tests and assessments to determine the individual’s mental health condition and any underlying medical conditions.
Treatment Options
Once the evaluation is complete, healthcare providers will develop a treatment plan that is tailored to the individual’s specific needs. Treatment may include medication, psychotherapy, or a combination of both. In some cases, electroconvulsive therapy (ECT) may be recommended.
Length of Stay
The length of stay for a psychiatric hold will depend on several factors, including the severity of the individual’s mental health condition, the effectiveness of treatment, and the risk of harm to themselves or others. Emergency holds typically last for 72 hours, while temporary and long-term holds may be extended if the individual continues to meet the criteria for involuntary commitment.
It is important to note that the goal of psychiatric holds is to stabilize the individual’s mental health condition and facilitate their return to the community. Healthcare providers will work with the individual and their family members to develop a plan for aftercare, which may include outpatient treatment, medication management, and therapy.
Situations that May Lead to Psychiatric Holds
Several situations may lead to the initiation of a psychiatric hold, including:
Mental Illness
Individuals with severe mental illness, such as schizophrenia or bipolar disorder, may require involuntary commitment if they pose a danger to themselves or others.
Substance Abuse
Individuals who abuse drugs or alcohol may require involuntary commitment if they pose a danger to themselves or others or are unable to make rational decisions regarding their health.
Self-Harm or Suicidal Ideation
Individuals who exhibit self-harming behavior or have suicidal ideation may require involuntary commitment to prevent them from causing harm to themselves.
Violence or Aggression
Individuals who exhibit violent or aggressive behavior may require involuntary commitment to prevent them from causing harm to others.
Alternatives to Psychiatric Holds
While psychiatric holds are an essential tool in the treatment of mental health conditions, there are alternative options that may be considered, including:
Voluntary Admission
Individuals who require psychiatric treatment but are not an immediate danger to themselves or others may choose to seek voluntary admission to a psychiatric facility.
Outpatient Treatment
Individuals who require ongoing psychiatric treatment but do not require hospitalization may receive treatment on an outpatient basis.
Crisis Intervention
Individuals who are experiencing a mental health crisis may receive crisis intervention services that are designed to stabilize their condition and prevent the need for hospitalization.
Conclusion
Psychiatric holds are a legal procedure that allows healthcare providers to involuntarily admit individuals to psychiatric facilities for assessment and treatment of mental illness or substance abuse. The procedure is subject to due process and the protection of individual rights. Medical considerations for psychiatric holds include psychiatric evaluation, treatment options, and the length of stay. Situations that may lead to psychiatric holds include mental illness, substance abuse, self-harm or suicidal ideation, and violence or aggression. Alternative options to psychiatric holds include voluntary admission, outpatient treatment, and crisis intervention.
