BH E3- Legal Issues

What is a standard of care?

Level of medical care or treatment which is expected from a provider on average

What are the 4 elements of malpractice?

Professional duty owed tot he patient, breach of duty, causation, damages

Who should obtain informed consent (IC)?

Medical provider who is prescribing or performing the treatment

*NOT ancillary or nursing staff

What are the 5 areas of information for informed consent?

Diagnosis, purpose of treatment, consequences and benefits, alternatives, & prognosis with and without treatment

What is considered extraordinary treatments?

Sterilization, abortion, psychosurgery, ECT, removal of maintenance of nutrition or hydration for an incapacitated person, and antipsychotics

Competency or capacity?

• global / legal assessment or determination

Competency

Competency or capacity?

• limited assessment regarding a particular health decision

• any medical provider should be able to assess

• ex- can a patient consent to this treatment?

Capacity

What are the 4 elements of capacity?

Understanding, appreciation, reasoning, expression of choice

What should be obtained each time a new behavioral health drug is introduced?

Informed consent

The following are examples of what?

• exceeding recommended dosages

• failing to adjust therapeutic levels (lithium)

• unreasonable mixing of drugs (SSRI & MAOI)

• prescribing meds not indicated

• prescribing too many drugs at once

• failing to disclose meds effects and interactions

Negligent prescription practices

What is a well established premise of medical ethics that binds providers to hold secret all information given by patients, to the extent of the law?

Confidentiality

What are the exceptions to confidentiality?

*Five “C”s

Consent, court order, continued treatment (minimum necessary rule, rule disclosure for transfer), comply with law (mandatory reporting- abuse), communicate a threat (duty to protect)

What forces a provider to give relevant documents or records and requires provider to appear as a witness in court, issued by a judge or requested by attorney?

Subpoena

What statute allows judges, law enforcement officers, physicians, PAs, or mental health professionals to involuntary admit a patient to prevent harm to self or others?

Baker act (Florida mental health act of 1971)

What must there be evidence of before a baker act is placed?

Behavioral health diagnosis, harm to self or others or is self neglectful

How long does a baker act last?

Pt can be held involuntarily, for pending psych evaluation, for up to 72 hours after a person is deemed medically stable but suicidal

*can be shorter, longer, or end in voluntary or involuntary inpatient or outpatient commitment

What are the guidelines for an involuntary (temporary) admission?

Baker acted for 72 hours → reviewed by in house psychiatrist to confirm need for admission → can’t be hospitalized for >15 days against will → Pt has right to legal counsel and judge any time → can’t be hospitalized > 60 days without periodic review by mental health board

What are the guidelines for voluntary admission?

Pt applies for admission to hospital & agrees with provider to go to hospital, pt is free to leave at any time if not at risk of harm

What are indications for seclusion (with or without restraints)?

Prevent harm to patient or others, prevent significant disruption to treatment program, decrease sensory overstimulation, & assist in treatment as part of ongoing behavioral therapy

What are CIs to seclusion?

Unstable medical or psychiatric conditions, overtly suicidal patients, or for “punishment” or convenience of staff

What are the requirements for seclusion with restraints to be placed?

Pt creates risk of harm to self or others, has to be a written order from an appropriate medical official, written orders are confined to a specific time limited period, pt condition must be regularly reviewed and documented, & extension of original order must be reviewed and reauthorized

Can PAs write for restraints?

Yes

What are “chronic suicides"?”

Death by alcohol or drugs

What is the MC mental health emergency in the US?

Suicide

What are most suicides due to?

Firearms

90% of those who attempt/ commit suicide have _______

Mental illness diagnosis (MC depression), usually amenable to treatment

What are RF for suicide?

Prior attempt (greatest RF), veterans, rural residents, American Indian, Alaska natives, & caucasians, protestants & jewish, divorce, widows, higher social status, fall in social status, recession, illness, mental illness, BPD, isolation

In order, what are the highest risk occupations more likely to commit suicide?

Medical doctors or psychiatrists, dentists, police & firefighters, etc

What gender is more likely to overdose & more likely to attempt suicide (not successful)?

Women

What gender is more likely to commit suicide by firearms, jumping, hanging, MVA and is more likely to be successful?

Men

In order, what ages are more likely to commit suicide?

Males > 65, males 45-54, females 45-54, females 55-64

What is Maslow’s hierarchy of needs?

Physical needs → safety needs → social needs → self esteem needs → self actualization needs

What sociological factors contribute to suicide?

Egoistic (not strongly integrated into any social group) & altruistic (integration into a group that idolizes “suicide for a cause”)

What psychological factor is the single best indicator of long term suicidal risk?

Hopelessness

*other factors: isolation, depression or anxiety, & fantasias of the aftermath

What biological factors contribute to suicide?

Diminished 5HT levels & chronic pain which decreases 5HT

What genetic factors contribute to suicide?

Tends to run in families, higher risk with monozygotic twins

What should suicide evaluation include?

Inquiry about hopelessness, full psychiatric history, thorough examination of mental status, inquiry about depression, suicidal thoughts, intents, plans & attempts (PHQ-2)

What are the stages of change in motivational interviewing?

Precontemplation → contemplation → planning → action → maintenance → relapse

What is the following an example of?

• pt doesn’t know they have depression

• pt is sad & empty, thinks they might have depression, needs to make appointment

• pt goes to PCM, plants to control depression & keep journal

• initiates action to control depression - takes meds, keeps journal

• depression is controlled & pt continues activities that control it

• pt stops something & depression returns

Stages of change model

What suicide factors are associated with a poor prognosis?

Low levels of hope, lack of future plans, giving away personal property, making a will or getting affairs in order, & having recently experienced a loss

What does the treatment of depressed suicidal inpatients include?

Remove objects that can be used for suicide, observation, vigorous use of antidepressants, psychotherapy

The following criteria is for what condition?

• In the last year, ≥ 5 days of intentional self inflicted damage to own body with NO suicide intent (cutting, burning, etc)

• Self injury w/ ≥1 expectation:

  • relief from negative feelings or cognitive estate, resolve to interpersonal difficulty, or induce positive feeling

• Self injury associated with ≥1:

  • interpersonal difficulties, negative feelings or thoughts, preoccupation with behavior that is difficult to control

Nonsuicidal self-injury disorder

What population is nonsuicidal self injury MC?

F > M, patients in their 20s, BPD, can be single or married

What is the treatment for nonsuicidal self injury?

Consult psych for psychotherapy

What are the most common psychiatric diagnosis in the ED?

*40% require admission

Mood disorders & alcohol dependence

What should emergency evaluation of psychiatric patient in ED assess?

Is it safe for patient to be in emergency room, is patient psychotic, is patient suicidal or homicidal, & to what degree is patient capable of self care?

What should the ED provider do if the patient is deemed significantly at risk for violence?

Inform patient that violence is not acceptable, approach pt in non threatening manner, inform pt that restraints or seclusion will be used if necessary, have teams ready to restrain patient, & closely observe and frequently check vitals if pt is restrained

What medical conditions are common mimickers of psychiatric conditions?

DM, thyroid dz, acute intoxications, withdrawal states, AIDS, TBI, tumors, stroke

What are major indications for the use of drugs in a psychiatric patient in the emergency department?

Violent or assaultive behavior, massive anxiety or panic, EPS (dystonia and akathisia)

What medications do periodic outbursts or agitation due to psychiatric disorder typically respond to?

Haloperidol, atypical antipsychotics, BZDs

What sedatives or antipsychotics can be sued in violent, aggressive, or threatening patients?

Lorazepam (avoid w respiratory compromise), haloperidol, diazepam

*monitor vitals

What can be used when patients are dangerous to themselves or others & pose a severe threat that cannot be controlled in any other way?

Physical or chemical restraints

What patients should be screened for DV?

All patients ≥ 14 y/o

What should a provider do for a victim of DV?

Reassure patient they don’t deserve to be abused, they deserve help, DV is common and they are not alone, encourage patient to break cycle of abuse, & provide resources

What is the cycle of DV?

Honeymoon phase → tension building phase → explosion phase → repeat

*each phase may be followed by periods of calm, last different amounts of time, not every experience is the same

What should be assed in DV patients (lethality)?

Prior hx DV, estrangement or separation from partner, obsessive or possessive behavior of partner towards patient, suicidal patient, depressed, substance use, & 1st pregnancy

What patients are least likely to report DV?

Hispanic women, elderly, educated, wealthy, low income women, & males

How should DV be documented?

Objective, factual, as many quotes as possible, body charts, photos (full body, face, close up with date and time, use a rule), do NOT use terms battered women or wife syndrome

When should a DV patient with bruises follow up?

2-3 days

What is part of the safety plan for a DV patient?

Decided where to go, who can support patient/children, give a codeword to a trusted friend to call police, plans for kids, keep important papers, clothes, and money at friend’s home’s, & reassure that stuff is replaceable- protect life first