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Emergency Behavioral Emergencies

Background

  • The Lanterman-Petris (LPS) Act governs involuntary psychiatric holds in California.

    • These holds are designed for the detention, evaluation, and treatment of individuals with mental health disorders who meet specific legal criteria.

Core Legal Criteria

  • For placement on psychiatric holds, an individual must meet at least one of the following three criteria:

    • Danger to Self: Risk of self-harm (e.g., suicidal ideation or actions).

    • Danger to Others: Poses a threat to the safety of others.

    • Gravely Disabled: Unable to provide for basic needs such as food, clothing, or shelter.

    • Note: Starting in 2024, some counties will include individuals unable to provide for their personal safety or medical care due to severe substance use disorders in this definition.

Psychiatric Holds Overview

  • California utilizes specific sections of the Welfare and Institutions Code (WIC) to outline the duration and purpose of psychiatric holds.

Types of Psychiatric Holds

WIC 1799 (Emergency 24-hour hold)

  • Description: Short-term detention in general acute care hospitals for up to 24 hours when no authorized person is available to write a 5150 hold.

  • Authorized Personnel:

    • Emergency Department Physicians

    • Nurse Practitioners

    • Physician Assistants

WIC 5150 (Emergency 72-hour hold)

  • Description: Common initial hold allowing for 72-hour detention for evaluation and treatment.

  • Requirement: Written by a County Mental Health Professional; county mental health must be notified of all 1799 holds and potential qualifying patients.

WIC 5585 (Minor 72-hour hold)

  • Description: Similar to the 5150 hold but specifically for minors under 18 years of age.

  • Qualifying Criteria: Danger to self, danger to others, gravely disabled.

  • Distinction for Minors: Gravely disabled defined as unable to utilize essential elements of life even if provided by others.

  • Additional Considerations:

    • Parental Rights: Considers rights and responsibilities of parents/legal guardians.

    • Juvenile Care: Assessment and treatment protocols tailored for children and teenagers.

    • Designation: Professionals may need specific county certification to write 5585 holds, which may differ from 5150 certification.

    • Madera County Mental Health must evaluate and write 5585.

WIC 5250 (14-day extended hold)

  • Description: Utilized when a person still meets criteria after the 72-hour initial hold.

  • Legal Requirements:

    • Requires a “Certification Review Hearing” within the first 4 days to determine probable cause for continued detention.

    • Conducted by a neutral hearing officer or court-appointed commissioner/referee.

    • Participants: Attorney, psychiatrist, psychologist or licensed clinician, or non-lawyers with at least five years of mental health experience.

WIC 5260 (Additional 14-day hold for suicidal persons)

  • Description: Second 14-day hold for individuals who remain a danger to themselves after 5250 hold expiration.

  • Qualifying Criteria:

    • Must present an imminent threat of suicide.

    • Must have prior involuntary treatment (both 5150 and 5250).

    • Must have been advised of the need for voluntary treatment without acceptance.

    • Professional evaluation must confirm that the patient meets criteria for continued detention.

    • Facility must be designated by the county and equipped to admit the patient.

WIC 5270 (30-Day Extended Hold)

  • Description: Provides an additional 30-day intensive treatment for individuals classified as “gravely disabled” after a 5250 hold.

  • Gravely disabled refers to inability to provide for basic needs (food, clothing, shelter) due to mental health disorder or chronic substance abuse conditions.

WIC 5300 (180-Day Post-Certification Hold for Dangerousness)

  • Description: Long-term hold lasting up to 180 days for individuals who have made credible threats to harm others and continue to demonstrate dangerousness.

LPS Conservatorship (T-Con)

  • Description: A temporary 30-day conservatorship for those remaining gravely disabled requiring long-term assistance.

  • Grounds and Criteria:

    • Grave Disability: Inability to provide for basic needs due to mental disorder.

    • Specific Mental Disorders: Must be a mental illness listed in the DSM-5 (e.g., Schizophrenia, Bipolar Disorder).

    • Voluntary Treatment Unsuitable: Inability or unwillingness to accept treatment voluntarily.

    • Chronic Alcoholism: May be included if gravely disabled due to chronic alcoholism.

    • Exclusions: LPS conservatorships are not applicable to individuals whose primary condition is developmental disability, dementia, brain trauma, or drug addiction alone.

Evaluating Hold Status in Medical Settings

When arriving at Madera Community Hospital for evaluation/clearance:

  1. Verify the Legal Status: Confirm type of hold (5150, emergency detention, involuntary commitment).

    • Check start and expiration times since many holds are time-limited.

    • Ensure the hold was properly initiated by an authorized professional.

    • Check for documented legal criteria (danger to self, danger to others, grave disability).

    • Confirm the hold applies to the specific patient (correct identifiers).

  2. Review Documentation Carefully:

    • Locate original hold paperwork in the patient chart.

    • Ensure all required fields (date, time, signature, credentials) are complete.

    • Look for supporting clinical justification beyond checkboxes.

    • Check for whether the hold has been rescinded, expired, or superseded.

    • Review prior notes regarding psychiatric re-evaluations.

  3. Perform and Document Your Own Assessment:

    • Conduct and document a current suicide/homicide risk assessment.

    • Evaluate decision-making capacity regarding the hold status.

    • Assess for grave disability (ability to provide for basic needs).

    • Document any observed changes in mental status since the hold was enacted.

    • Note protective factors alongside risk factors.

  4. Confirm with Appropriate Parties:

    • Contact the ordering provider or psychiatric team if status is unclear.

    • Verify with behavioral health intake or social work.

    • Check with hospital legal/risk management if documentation is questionable.

    • Communicate with law enforcement only if they initiated the hold and if clarification is required.

  5. Follow Hospital Policy:

    • Utilize facility’s psychiatric hold verification workflow.

    • Ensure required re-evaluation timeframes are adhered to.

    • Confirm that medical clearance requirements have been fulfilled.

    • Verify appropriate observation orders (Constant Observer or Security).

  6. Watch for Common Red Flags of an Invalid Hold:

    • Missing or incomplete paperwork.

    • Hold time window has expired.

    • Absence of documented legal criteria.

    • Initiated by an unauthorized individual under state law.

    • Patient has clinically improved and no longer meets hold criteria.

    • Presence of duplicate or conflicting orders.

    • Hold applied solely for medical or social reasons.

  7. Document Thoroughly:

    • Record all reviewed and verified materials.

    • Note conversations with psychiatric or legal teams.

    • Clearly indicate whether the patient currently meets hold criteria.

    • Document clinical reasoning for assessments and decisions made regarding hold status.