WEEK 8: LEGAL AND ETHICAL ISSUES RELATED TO PSYCHIATRIC EMERGENCIES.

Egemonu Ndidi Joan

College of Nursing-PMHNP, Walden University

NRNP 6675: PMHNP Care Across the Lifespan II

Faculty Name: Dr. M. Reyes

Assignment Due Date: 01/23/23

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In 2–3 pages, address the following:

Florida 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.

There are two ways a person can be held involuntarily in Florida when safety is compromised.

The Baker Act (BA) is a short-term involuntary placement of a person with questionable

cognition who appears to be a danger to self and others in a designated psychiatric facility until

the need for extended hospitalization is determined. It should be at most 72 hours. The second is

the Marchman Act (MA) which is meant to assist those struggling with substance abuse and

should not exceed 72 hours. During the 72-hour psych hold for BA or MA, a specific set of

guidelines is geared towards stabilizing the individual and validating the case to determine if

there is a need for a more extended stay in the facility. In Florida, if a competent court

adjudicates a person incapacitated under part V of chapter 744 of the Mental Health Act, a

guardian is appointed to make health decisions on behalf of the individual. A child’s biological

parents or court-appointed legal guardians should make decisions for the minor. Due to the

significance of involuntarily placing a person in a treatment facility, specific measures must be

met by the individual to qualify. These measures include the person’s inability to make a rational

decision about self. If the person declines examination, the person is at risk of harming himself

or manifesting adverse effects from self-neglect, and the person poses a risk of harming others. It

also includes when the person is using substances that could cause harm to him or others and

cannot decide on his own to seek help for addiction. Those authorized to file and place a hold on

a patient include a doctor, law enforcement officer, spouse, parents, or a close relative of the

person involved. In some extreme conditions, a non-relative, such as a roommate, can get a

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patient involuntarily admitted to a drug rehabilitation facility if two other witnesses can confirm

the risk to self or others’ claim. Physical examination on arrival rules out a person’s immediate

physical distress and must be done within minutes of arrival but not exceeding 24 hours. It

includes drug tests and other assessments to validate possible reasons for a patient’s escalated

behavior. A confidential psychological examination is also carried out within 72 hours of the

person’s hold. The information gathered will help the facility make a professional

recommendation to the court regarding whether to continue an extended hold on the person.

Most individuals calm down within 72 hours of stabilization, can make a more definitive

decision, and are allowed to seek voluntary treatment, which changes their status.

Explain the differences between emergency hospitalization for evaluation/psychiatric hold,

inpatient, and outpatient commitment in your state

Under the Florida Mental Health Act, which is also known as the Baker Act and Marchman Act

(MA) sections 394-451, addressed as legislative intent, the Department of Children and

Families (DCF) is the parastatal designated with the permission to evaluate, research, plan, and

recommend to the governor and the legislature programs designed to reduce the incidence,

severity, duration and disabling aspects of mental, emotional and behavioral health issues. Severe

mental health can affect a person’s ability to make sound or reasonable decisions. In Florida,

involuntary outpatient commitments are court orders mandating persons with severe mental

illness and repeated hospitalization to adhere to community-based treatment. To take a patient

involuntarily, all available less restrictive treatment alternatives which would offer an

opportunity to improve the patient’s condition would have been judged appropriately. There

should be sworn statements of experts testifying in involuntary inpatient placement hearings

about the availability and appropriateness of less restrictive community alternatives (394.467(b),

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FS). The person must meet the statutory criteria for admission to a state treatment facility. The

Baker Act also specifies in s.394.461(2), FS, that it governs the designation of receiving and

treatment facilities that a civil patient shall not be admitted to a state treatment facility without

undergoing a transfer evaluation. A mandatory form CF-MH 3089, "Transfer Evaluation," as

referenced in subsection 65E-5.1301(1), FAC, the process for conducting such transfer

evaluations shall be developed by the community mental health center or clinic and approved by

the district or regional office of the department where the center or clinic is located shall be

completed.

Explain the difference between capacity and competency in mental health contexts.

A clinician or hospitalist familiar with a patient can make a specific decision based on a

functional assessment of the patient to assist with clinical determination. Capacity is usually

defined by state law and varies by jurisdiction. It is evident when a patient’s functional

assessment is questionable, and the hospitalist has to decide independently of a consultant. Four

cardinal components are assessed in evaluating functional capacity assessment: communicating a

choice, understanding, appreciation, and rationalization/reasoning. Capacity is variable, on hand,

and not static. A clinician who has earned rapport with the patient and is familiar with the case

details can make the determination. In contrast, competency in mental health is a global

assessment and legal determination made by a judge in court. The MacArthur Competence

Assessment Tools for Treatment (MacCAT-T) serves as a yardstick to measure capacity

assessment aid.

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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.

The vulnerability of patients living with mental health poses a lot of legal and ethical issues.

Providers and clinicians must apply ethical reasoning when faced with clinical challenges to

improve patient outcomes. In psychiatric emergencies, when a patient requires involuntary

placement, his autonomy and ability to make a sound decision are queried and removed. It is

legally binding under the emergency to assess the decision-making capacity of the patient using

the four criteria communication, understanding, appreciation, and reasoning. The goal of placing

a patient involuntarily is to protect him from harm, not to expose him to where he is capable of

autonomous decision-making, not dangerous, or not impaired by their psychiatric illness using

the least restrictive means possible. It is, therefore, ethically and legally required to re-assess the

patient after the acute phase to determine his mental status and possible removal of his

involuntary status.

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

The Columbia-Suicide Severity Rating Scale (C-SSRS) is one evidence-based suicide risk

assessment tool used to assess suicidal behaviors. It uses questions to detect patients at risk for

suicide through the intensity of the suicide ideation, potentially self-injurious act committed with

at least some wish to die due to the act and thought of as a method to kill oneself. It is important

to note that the intent does not have to be 100%; instead, the intent/desire to die associated with

the act can be considered an actual suicide attempt. Potential for injury or damage without any

actual injury or damage is considered a suicidal attempt, for example, a headshot or jumping

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from the window of a high floor/story. A highly destructive act is not an accident but is

considered intent for suicide, and the same applies to when one denies intent to die but thinks

that what he did could be lethal; intent may be inferred.

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.

The violence risk assessment screening tool is used to identify patients prone to violent attacks

on caregivers and providers, thereby creating avenues for prompt interventions. According to

research, about 90% of doctors, nurses, and patient caregivers encounter violent attacks from

their patients. The V-RISK-10 checklist uses the rater to collect information about the potential

violent intentions of the patient expressed in a yes or no response. It is from the responses that

the severity of the intent to inflict injury will be rated in degree terms as severe, low, or no risk.

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References:

King, C. A., Horwitz, A., Czyz, E., & Lindsay, R. (2017). Suicide Risk Screening in Healthcare

Settings: Identifying Males and Females at Risk. Journal of clinical psychology in medical

settings, 24(1), 8. https://doi.org/10.1007/s10880-017-9486y

Anderson, K. K., & Jenson, C. E. (2019). Violence risk-assessment screening tools for acute care

mental health settings: A literature review. Archives of psychiatric nursing, 33(1), 112–119.

https://doi.org/10.1016/j.apnu.2018.08.012

Doyle M, Dolan M: Predicting community violence from patients discharged from mental

health services. Br J Psychiatry. 2006, 189: 520-526. 10.1192/bjp.bp.105.021204.

Sjöstrand, M., Sandman, L., Karlsson, P., Helgesson, G., Eriksson, S., & Juth, N. (2015). Ethical

deliberations about involuntary treatment: interviews with Swedish psychiatrists. BMC medical

ethics, 16, 37. https://doi.org/10.1186/s12910-015-0029-5

Link– https://pubmed.ncbi.nlm.nih.gov/30663614/

Link – [HTML] Patient health questionnaire depression scale as a suicide screening instrument

in depressed primary care patients: a cross-sectional study source: Ganzini L, Volicer L, Nelson

WA, Fox E, Derse AR. Ten myths about decision-making capacity. J Am Med Dir Assoc.

2004;5(4):263-267.

https://app.grammarly.com/ddocs/1903514634

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