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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