Psychiatric Emergency Essay

Psychiatric Emergency Essay

 

Michigan: Psychiatric Emergency

Psychiatric emergencies pose safety risks to the patient and sometimes to the health care provider. Admission of patients is majorly done on a voluntary and involuntary basis. For voluntary admission, the patients present themselves willingly with the knowledge of their condition. In cases of involuntary admission, the patient is brought in by relatives or under court order. Under these circumstances, the patient has no right to refuse treatment. However, these individuals must meet the Michigan Mental health code definition of a patient requiring treatment (Charlevoix County, n.d.). The use of physical or chemical restraints or holds is part of the treatment the patient receives to prevent harm to self or other people. In cases where the patient is at risk of harming themselves or the care providers, they may be put on psychiatric hold (Saya et al., 2019). The state of Michigan, department of health and human services abides by the mental health code that determines how these patients are teetered. The purpose of this paper is to define the laws defining involuntary use of psychiatric holds in Michigan related to ethical and legal issues.

Michigan Laws on Psychiatric Hold

The Michigan mental health code defines a person requiring treatment as a person or individual with mental illness with expected risk of harm to self and others in the future or who has made significant threats of harm to self or others (Michigan Legislature, 2019). Additionally, these individuals may not be able to meet their basics needs due to their mental illness or they have impaired judgment as a result of their mental illness. The psychiatric hold in Michigan follows an involuntary admission to the emergency unit, a psychiatric unit, or a hospital. The hold lasts for 72 hours, only inducing working days. During this time, the patient must be evaluated by a psychiatrist but a physician or psychologist when a psychiatrist is unavailable in the first 24 hours. The facility then petitions for mental health treatment to the court after which the order to supplementation to provide treatment will be granted. The person no longer requires the hold released by the hospital, sometimes to receive outpatient care if need be. The psychiatrist upon evolution of the patient releases the patient to the family or patient’s home. These holds apply for child and adult psychiatric emergencies such as acute psychotic episodes among adults and those condition with risk of self-harm among children. Suicidal attempts or violence explained by alternation in mental capacity warrants the provision of the psychiatric holds in the hospital or psychiatric units. Withdrawal form psychoactive substance among adults and children, depressive and manic episodes among adults and children, suicidal behavior, and aggressive psychomotor agitation among other emergencies warrant the use of psychiatric holds. However, the psychiatrist’s evaluation within the first 24 hours will confirm the need for this hold.  

Emergency Hospitalizations and Commitment

Emergency hospitalization is made in crisis centers, psychiatric units, or hospitals. Involuntary commitment is a legal process that involves the confinement of patients to a psychiatric unit for mental health evaluation and treatment against their wishes (Fariba & Gupta, 2021). Emergency admission n for psychiatric hold is mainly done by the police in Michigan (Michigan Department of Health and Human Services, n.d.). The individuals’ immediate relatives, friends, or concerned person establish their risk of harm and contact the emergency police line. Emergency admission for inpatient commitment is decided by the facility where the psychiatrists upon evaluation establish the risk and plans for care with court orders and permission. When these individuals do not require inpatient hospitalization, the facility director and the psychiatrists decide to direct further commitment to outpatient care settings (Charlevoix County, n.d.). Patients can also opt for assisted outpatient treatment for acid deterioration in their mental health.

Capacity and Competency in Mental Health Contexts

People with mental health illnesses are said to be limited in capacity and competence in decision-making. Capacity refers to their ability to make these decisions. Mental competency explains their ability to translate these decisions into actions and effects. Competency determines their ability to participate in the legal proceeding (Libby et al., 2021). Therefore, these are two related concepts in mental health that have major significance in legal and ethical aspects of mental health care.

Patient Autonomy

Patient autonomy relies on their mental capacity and competency in mental health. Their abilities to make a decision independently and act on them make them autonomous. However, in some mental illnesses, these abilities are limited. In psychiatric emergencies when the risk of harm to harm to self or others exceeds the benefits of lack of treatment, the patient autonomy may be overruled (Saya et al., 2019). In these cases, the patients have no right to refuse treatment or make a decision regarding how they want to be treated. Longer stays in the hospital under psychiatric holds and commitment also have associated morbidities such as depression. In this situation, a dilemma arises whether to uphold patient beneficence at the expense of autonomy. The risk of self-harm includes suicide and injuries from the restraints or self-harm.

Suicide Risk Assessment

Various tools have been used to assess suicide risk in mental health patients. The Columbia-Suicide Severity Rating Scale (C-SSRS) is one such tool that has been widely used to screen patients for risk of suicide. This tool can be used among children, adolescents, and adults safely (Rural Health Information Hub, n.d.). In identifying actual lifetime suicide risk, this tool has validation in emergency, inpatient and outpatient settings (Salvi, 2019). However, there have been recent concerns over its liability in capturing newer aspects of suicidal behavior and ideations. Other tools also exist for use in screening for suicide risks among patients both in acute and long-term care settings.

Violence Risk Assessment

Violence from psychiatric patients towards their fellow patients and health care providers is not a new concept in mental health practice. Anticipating and preparedness for this violence can be achieved by various evidence-based tools. The Violence Risk Screening-10 tool has been shown to prove excellent violence risk assessment, especially in acute settings (Anderson & Jenson, 2019). This screening prices evidence abs basis for early intervention to prevent violence. According to Anderson & Jenson (2019), most of the violence from the patient is direct toward nurses. Other tools such as the violence risk appraisal guide (VRAG) assess the risk of further violence in those patients who had shown violence before. More often, it is used in criminal violence settings.

Conclusion

The point of psychiatric patient admission is mainly voluntary and involuntary in Michigan. The state laws provide well laid out procedures and legislation on the process of providing voluntary care to patients on a voluntary and involuntary basis. The use of psychiatric holds, involuntary commencement, and outpatient commitments follow specific steps that involve a legal process. The maximum duration of holding a patient in the unit is 72 hours after which an extension may be requested from the court. Patients with mental illness may have limited mental capacity and competency to make independent decisions and translate these decisions into actions such as following the legal proceeding. In these situations, their patient autonomy rights can be overridden by involuntary commitment. During this treatment time, evidence-based tools such as the Columbia-Suicide Severity Rating Scale (C-SSRS) and Violence Risk Screening-10 can be used to assess their risk of suicide and violence respectively.

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References

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

Charlevoix County. (n.d.). Petition for Mental Health Treatment. Charlevoixcounty.Org. Retrieved April 5, 2022, from https://www.charlevoixcounty.org/the_7th_probate_court/mental_health_proceedings.php

Fariba, K. A., & Gupta, V. (2021). Involuntary Commitment. In StatPearls [Internet]. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK557377/

Libby, C., Wojahn, A., Nicolini, J. R., & Gillette, G. (2021). Competency and Capacity. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK532862/

Michigan Department of Health and Human Services. (n.d.). MDHHS – mental health. Michigan.Gov. Retrieved April 5, 2022, from https://www.michigan.gov/mdhhs/0,5885,7-339-71550_2941_4868—,00.html

Michigan Legislature. (2019). Michigan Mental Health Code 2019 (N. Krechet, Ed.). Independently Published.

Rural Health Information Hub. (n.d.). Screening for and addressing suicide risk in clinical settings – RHIhub toolkit. Ruralhealthinfo.Org. Retrieved April 5, 2022, from https://www.ruralhealthinfo.org/toolkits/suicide/2/screening-tools

Salvi, J. (2019). Calculated decisions: Columbia-Suicide Severity Rating Scale (C-SSRS). Emergency Medicine Practice, 21(5), CD3-4. https://www.ncbi.nlm.nih.gov/pubmed/31039299

Saya, A., Brugnoli, C., Piazzi, G., Liberato, D., Di Ciaccia, G., Niolu, C., & Siracusano, A. (2019). Criteria, procedures, and future prospects of involuntary treatment in psychiatry around the world: A narrative review. Frontiers in Psychiatry, 10, 271. https://doi.org/10.3389/fpsyt.2019.00271

Psychiatric Emergencies
A psychiatric emergency is a situation that if left untreated is likely to cause harm to oneself or others. These acute disturbances of behavior may manifest as suicidal ideation or attempts, violence, agitation, drug overdose, delirium, psychosis, mania, neuroleptic malignant syndrome, or serotonin syndrome. When psychiatric emergencies arise, they can present many challenges to the PMHNP. While many approaches to emergencies are similar when dealing with children and adolescents versus adults, significant differences also exist. This is particularly true with coordination of care, availability of resources, and legal implications of the psychiatric emergency.

This week, you examine psychiatric emergencies and explain the ethical and legal issues surrounding these events. You will also review evidence-based suicide and violence risk assessments that you may use to screen patients.
Learning Objectives
Students will:

Explain salient ethical and legal issues relevant to psychiatric emergencies in psychiatric-mental health practice
Select evidence-based risk assessments for psychiatric emergencies
Learning Resources
Required Readings (click to expand/reduce)

Buppert, C. (2021). Nurse practitioner\’s business practice and legal guide (7th ed.). Jones & Bartlett Learning.

Chapter 7, “Negligence and Malpractice”
Chapter 8, “Risk Management”
Chapter 16, “Resolving Ethical Dilemmas”
National Institute for Health and Care Excellence (2019). Brøset violence checklist. http://riskassessment.no/

Sadock, B. J., Sadock, V. A., & Ruiz, P. (2015). Kaplan & Sadock’s synopsis of psychiatry (11th ed.). Wolters Kluwer. (For review as needed)

Chapter 23, “Emergency Psychiatric Medicine”
Chapter 36.2, “Ethics in Psychiatry”
Thapar, A., Pine, D. S., Leckman, J. F., Scott, S., Snowling, M. J., & Taylor, E. A. (Eds.). (2015). Rutter’s child and adolescent psychiatry (6th ed.). Wiley Blackwell.

Chapter 19, “Legal Issues in the Care and Treatment of Children With Mental Health Problems”
Chapter 64, “Suicidal Behavior and Self-Harm”
U.S. Department of Veterans Affairs. (2019). VA/DoD clinical practice guidelines: Assessment and management of patients at risk for suicide (2019).

https://www.healthquality.va.gov/guidelines/MH/srb/

Zakhari, R. (2021). The psychiatric-mental health nurse practitioner certification review manual. Springer Publishing Company.

Chapter 15, “Violence and Abuse”
Medication Review
Review the FDA-approved use of the following medicines related to treating psychiatric emergencies:

Aggression Behavioral problems Cataplexy syndrome
clozapine
propranolol
zuclopenthixol aripiprazole
asenapine
chlorpromazine
haloperidol
iloperidone
lurasidone
olanzapine
paliperidone
quetiapine
risperidone
ziprasidone clomipramine
imipramine
sodium oxybate
Catatonia Extrapyramidal side effects Mania
alprazolam
chlordiazepoxide
clonazepam
clorazepate
diazepam
estazolam
flunitrazepam
flurazepam
loflazepate
lorazepam
midazolam
oxazepam
quazepam
temazepam
triazolam benztropine
diphenhydramine
trihexyphenidyl alprazolam (adjunct)
aripiprazole
asenapine
carbamazepine
chlorpromazine
clonazepam (adjunct)
iloperidone
lamotrigine
levetiracetam
lithium
lorazepam (adjunct)
lurasidone
olanzapine
quetiapine
risperidone
sertindole
valproate (divalproex)
ziprasidone
zotepine
Assignment: Legal and Ethical Issues Related to Psychiatric Emergencies

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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.