A suicidal patient, once in the ED, often decides he does not want to stay for further evaluation and demands to leave. Patients and medical staff can be harmed by allowing a suicidal patient to leave the ED, and it is the physician's task to attempt to short-circuit this unwise and usually poorly reasoned decision.
Some patients leave against medical advice because they simply don't want to wait. Others have inscrutable social or personal issues. Patients with suicidal thoughts or attempts pose unique challenges, and few universal standards of care exist for discharging potentially suicidal patients against medical advice.
Patients' Rights and Psychiatrists' Duties: Discharging Patients Against Medical Advice
Gerbasi JB, Simon RI
Harv Rev Psychiatry.
The problems with patients leaving AMA from an inpatient service are similar to those who leave AMA from the ED. Psychiatric inpatients are discharged AMA at a high rate compared with the general medical population: Almost 20 percent of psychiatric patients admitted voluntarily will leave AMA. (Mayo Clin Proc. 2009;84:255; https://bit.ly/3a3kmCd.)
Patients who leave AMA are more anxious, hostile, and aggressive than their counterparts who remain in the hospital until formally discharged. The most challenging patients are those involuntarily admitted because of the potential for self-harm or suicide. Some suicidal patients agree to hospitalization, but most are mandated to be hospitalized by court order for at least 72-120 hours in most states.
An insurance company will frequently deny coverage after a few days of hospitalization, deeming it no longer necessary for vague and confusing reasons. The patient, informed that he will be responsible for an outrageous hospital bill, demands to leave. Many still have unresolved suicidal issues, and the physician may not think the patient is ready or safe for discharge. It is, of course, almost impossible to address suicidal behavior, thoughts, or attempts in just a few days of hospitalization.
A number of issues must be addressed when a suicidal patient demands to leave the hospital AMA. There is often an insurmountable divergence between the patient's rights, autonomy, and safety and the physician's duty to treat. Admission may be voluntary at first or involuntary for a limited time, but it's difficult to keep patients in the hospital for prolonged periods if they are not seriously ill. Suicidal patients also require difficult-to-obtain outpatient follow-up. The length of stay supported by insurance companies usually does not include weeks of therapy, and suicidal patients in need of continued evaluation and care must often fend for themselves in a difficult outpatient environment.
The structured and controlled hospital environment is much more necessary for suicidal patients than for those with medical problems. Outpatient services and continued support for psychiatric patients can be abysmal, difficult to orchestrate in a timely way, and impossible to achieve if the patient is not motivated or cooperative. Outpatient psychiatric follow-up is often forgotten by everyone once the patient leaves the hospital. The patient's decision to leave can be impulsive, irrational, and made on the spur of the moment over minor issues, and there is little that clinicians can do about these precipitous decisions.
Voluntary admissions comprise approximately three-quarters of the 1.6 million admissions to psychiatric facilities in this country. Voluntary admission for psychiatric patients is preferred in most hospitals. Many practical and logistical external pressures are placed on psychiatric patients from family, police, lack of shelter or personal resources, and winter weather. An involuntary admission, even for suicidal patients, is often limited to three to five days. The patient has to meet specific requirements for the admission even to be initiated; he must be a danger to himself by voicing suicidal intent or demonstrating self-harm. Once admitted, these conditions must be clearly and repeatedly documented in the medical record. This is often a gray area, subject to physician, insurance company, and court interpretation, and it is certainly open to patient manipulation.
Even when involuntary commitment criteria are clear-cut, the incarceration is limited (72-120 hours), but can be extended by complicated and time-consuming judicial review. Few hospitals have the resources to routinely obtain or enforce prolonged involuntary admissions in a complex overburdened court system. Physicians' good intentions are often thwarted when a suicidal patient states he is no longer suicidal and demands to leave.
Simply stated, it's difficult to keep a suicidal patient in the hospital against his will. Even for an emergency physician to start the involuntary admission process is to respond to a higher calling that requires patience, understanding, the correct paperwork, and a lot of time and effort to jump through the hoops to obtain even temporary involuntary commitment. One's best efforts are easily thwarted by a savvy or manipulative patient or an impersonal legal system bent on preserving individual autonomy. Contrary to the public's naïve beliefs, drug and alcohol problems are not grounds for involuntary commitment.
Once a suicidal patient is in the hospital, he may readily appear to have seen the error of his ways and no longer be overtly suicidal. Because extended involuntary commitment requires a physician to provide formal and detailed documentation supporting continued involuntary commitment and almost always a cumbersome court appearance, it's easy to rationalize an AMA discharge and move on to another case.
The neophyte physician might assume there is a legal consensus that a suicidal patient cannot give informed consent simply because he is suicidal, but the law considers patients competent until proven otherwise, even for suicidal individuals. Patients admitted against their will retain their autonomy to consent to treatment. The only medications that can be administered without their consent are those necessary for stabilization during a crisis. If daily medications are deemed necessary to treat underlying psychiatric disorders, clinicians will need to obtain a court order if the patient refuses medications or interventions.
Many suicidal patients have an underlying psychiatric disorder. Once in the system, a suicidal patient often quickly learns tactics and behavior to appear competent enough to leave. Someone who voluntarily seeks admission is usually assumed to possess the mental capacity to understand the nature and implications of that decision and therefore would be capable of leaving at will with an understanding of possible risks. Essentially, a voluntarily admitted patient must be mentally competent, or he would not have opted for admission in the first place.
Even if a patient meets involuntary hospitalization criteria, many physicians prefer to make the admission voluntary because it involves fewer stigmas to the patient and certainly less paperwork and personnel effort. A voluntary psychiatric admission is less coercive, often avoids an adversarial relationship between the doctor and the patient, allows the patient to acknowledge a desire for help, and increases patient involvement and personal responsibility. Essentially, the patient has bought into the treatment plan.
A voluntary admission respects individual autonomy, and it is clearly the best scenario. Current law has great concern for protecting patient rights, and suicidal patients are included in this mandate. When one tries to balance mental health laws with clinical care, the physician's intentions often compete with the patient's right to refuse such care. One wonders if most suicidal patients are informed of their right to refuse medications or other interventions.
It seems counterintuitive, but low-risk patients can be discharged from the ED or hospital utilizing standard AMA practices. This concept is difficult to understand or rationalize if there are any suggestions or issues of suicide. Nonetheless, it is not that uncommon, though it was common in the past for patients to agree that they would not harm themselves if discharged, the so-called contract for safety. This concept is no longer supported, and was never proven helpful.
A request for discharge from psychiatric patients boils down to two options: release him voluntarily using a carefully orchestrated AMA process or initiate involuntary commitment procedures. The concept behind involuntary hospitalization is that the patient is a danger to himself, which seems obvious if he is suicidal or has stated or attempted self-harm. Often a physician's decision has to be made with minimal data, in a hostile milieu, and with limited time. Clinicians who initiate the involuntary commitment process have immunity from civil and criminal liability. Of course, this requires a properly documented evaluation that concludes that the patient is a potential danger to himself. These authors said it is best to assume that the risk for the physician being sued for false imprisonment does not exist if the procedure is done correctly. There is, however, a risk of litigation if the discharged patient harms himself or completes suicide. Malpractice suits that allege negligence because a patient is prematurely released and subsequently harms himself are not common. Families and the general public simply do not understand why the clinician cannot cure the patient's desire to kill himself or simply keep him in the hospital until able to do so.
To proceed with involuntary commitment, it must be documented that the person demonstrated suicidal intent or planning, has done self-harm, or has attempted either of these within the previous 30 days. A suicide note is considered an overt act for suicide. “I want to kill myself” as the chief complaint is usually all that is required for involuntary admission.
Involuntarily admitted patients have the right to refuse medications and treatment even when those are clearly in their best interest. The only medications that can be administered without their consent are those necessary for stabilization of a behavioral crisis. Most involuntary commitment laws expire in 72-120 hours unless extended in court. Allegations of negligence against physicians can be failure to prevent suicidal patients from leaving the hospital AMA or failure to invoke involuntary commitment.
Most people do not understand mental health laws, and expect the hospital to do the right thing and keep the potentially suicidal patient safe for his own good. In low-risk patients, allowing the patient to leave AMA is not unusual, but it is risky, in my opinion. I believe it is best to avoid the issue of AMA discharge from the ED for suicidal patients. Simply admit them involuntarily, and allow the inpatient team to deal with issues as they arise.
Conforming to the nuances and vagaries of a highly detailed AMA discharge may confer some legal protection for the physician, but it is not a free pass to legal immunity if there is a bad outcome. Court rulings generally hinge on whether the doctor had a duty to admit the patient forcibly or to release him AMA. If the discharging physician can show in the medical record that the patient's ability to make an informed decision was done competently (just try to prove that mandate), a properly completed AMA discharge is generally protective for malpractice claims.
A Stacked Deck
The system's failure to make things easy is frustrating to the clinician dealing with suicidal patients. The next time you are having a bad day dealing with a drug abuser in the ED, have some empathy for your psychiatric colleagues dealing with an involuntarily admitted suicidal patient. Most of us merely complete the involuntary commitment form, institute one-on-one supervision in the ED by taking a much-needed tech out of circulation, and let the psychiatrist deal with the other issues. In psychiatry, the hard work begins after the ED visit. When patients' right to autonomy, such as their right to refuse medications, comes into direct conflict with the legitimate need for psychiatric treatment, it can be a no-win situation. Always looming is potential litigation for a premature discharge with a bad outcome. The deck is clearly stacked. It's not easy to prove incompetence on the medical record or to complete all the necessary steps to support continued involuntary commitment.
On the floor, the involuntarily admitted patient can be restrained and secluded, and medications to treat agitation or violence can be administered at the physician's discretion, but the patient maintains the right to refuse all other medications or interventions. Want to spend all day in mental health court, only to have the case continued? There is no easy answer.
It is clear that suicidal patients are prime candidates for bad outcomes if they are discharged AMA. They know the system and can be hostile. It should be the rare case where an AMA discharge of a bona fide suicidal patient is orchestrated by the EP. There is no magical way for anyone to predict who will complete suicide, and any patient who wants to kill himself may do so at some point.
Read an excellent discussion of the medicolegal consequences of an AMA discharge at https://bit.ly/33DHSV8. (Psychiatr Serv. 2000;51:899.)
Initiating Involuntary Commitment of a Suicidal Patient from the ED
Involuntary commitmentis an application for emergency in-hospital evaluation and treatment of a person who is a danger to himself, including suicide potential.
- To be involuntarily admitted, the person must be unable to satisfy his need for safety unless admitted to the hospital.
- The person has voiced suicide intent or desire, attempted suicide or self-harm, made threats to die by suicide, or written a suicide note.
- The person has harmed himself or has threatened to harm himself.
- Because the commitment is involuntary, it may require the assistance of family, crisis professionals, police, ambulance personnel, and any other person knowledgeable of the situation. The petitioner is required to sign the request, possibly appear at a hearing, have firsthand knowledge of the dangerous conduct or threat, and be willing to sign the commitment form.
- The petitioner may also be required to testify at a hearing about the dangerous conduct or statements that he witnessed.
- A physician has the authority to initiate involuntary commitment without prior authorization.
- An emergency physician evaluation is started to determine if the patient should be admitted for involuntary psychiatric treatment. If admitted, the patient may be kept no longer than three to five days unless a petition for extended emergency involuntary treatment is filed.
- The physician filing for involuntary commitment has immunity from civil and criminal liability.
Unsolved Dilemmas in Treating Psychiatric Patients with Suicidal Thoughts or Intent
- Involuntarily committed patients have the right to refuse medication, treatment, or physician intervention in the hospital, even when the actions are clearly in their best interest.
- Medications to control acute agitation or violence can be given without patient consent, but other medications or interventions can be refused.
- A psychiatric diagnosis does not automatically make a patient incompetent or incapable of refusing medical care.
- Competence, not incompetence, is assumed unless proven otherwise.
- The criteria for involuntary commitment are limited to a clear danger, desire, or action to self-harm or complete suicide.
- Drug abuse or alcohol dependence does not provide the criterion for involuntary commitment.
- Involuntary commitment laws expire in 72-120 hours unless pursued in court.
- Most common allegations of negligence against physicians are a bad outcome due to failure to invoke involuntary commitment.
- Patient confidentiality issues should not keep the physician from discussing with or informing family, other physicians, and other pertinent parties.
- Low-risk patients can be discharged AMA, but that does not always protect the physician from liability for a bad outcome.
Note: Most families do not understand mental health laws, and expect that the hospital will do the right thing and keep the obviously distressed patient safe for his own good.
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Dr. Robertsis a professor of emergency medicine and toxicology at the Drexel University College of Medicine in Philadelphia. Read the Procedural Pause, a blog by Dr. Roberts and his daughter, Martha Roberts, ACNP, PNP, at http://bit.ly/EMN-ProceduralPause, and read his past columns athttp://bit.ly/EMN-InFocus.