Hospitals continue to see a surge of psychiatric patients coming to their EDs. Some end up admitted involuntarily — and not always appropriately.
The underlying ethical issue is that mental healthcare is “terribly under-resourced. We have not valued or prioritized that type of care,” says Mark McClelland, DNP, RN, CPHQ, project manager of international operations at Cleveland Clinic Health System.
Lack of resources for mental healthcare results in multiple ethical concerns. “Most of the problems associated with the care of mental health patients are systemic and knowable,” McClelland observes.
Many patients need intensive outpatient therapy. However, for whatever reason, they cannot access it. “This may lead some clinicians to admit a patient, due more to a lack of service availability than a patient’s clinical needs,” McClelland explains.
Michael Allen, MD, sees certain patterns involving involuntary commitment of people with psychiatric complaints as ethically troubling:
• Health plan authorization requirements are interfering with medical decision-making. To secure inpatient psychiatric treatment approval, some insurers require the patient to be committed involuntarily. “Civil commitment has come to be used as a proxy for insurance company medical necessity,” explains Allen, professor of psychiatry at the University of Colorado Anschutz Medical Campus.
The reasoning is that if the patient truly is dangerous, the evidence would be civil commitment. If not, then the patient must not be dangerous from an insurer’s point of view.
“Of course, this is completely false,” Allen says. “Dangerous people can and should be encouraged to seek voluntary treatment. The misapplication of involuntary procedures may discourage that.”
• Individuals who evaluate patients with psychiatric complaints often lack expertise. “Given the shortage of qualified individuals and the fact that assessments of this type occur around the clock, the minimum qualifications have slipped,” Allen laments.
Individuals responsible for making this determination may have no more than a bachelor’s degree, or may have only a medical background with no mental health training.
Lack of competent assessors means poor and even unsafe decisions. “There is a tendency for anyone who says they are suicidal to get admitted, while more disturbed but not overtly dangerous people who should qualify for involuntary admission are neglected,” Allen says.
• Patients are undergoing screening and diagnostic tests they do not really need. Once the decision to involuntarily commit is made, the receiving facility typically requires a long list of diagnostic tests before agreeing to accept the patient. For example, medical screening is required for anyone suicidal, usually including a urine drug screen, blood tests, and a head CT.
“None of this is usually medically necessary, and can be quite traumatic,” Allen says. For instance, if a patient is combative or uncooperative, a catheter might be necessary to obtain a urine sample.
• Some patients present voluntarily with a psychiatric complaint, but decide at some point to leave without being seen. Often, it takes many hours for a psychiatric evaluation to occur. If someone wants to leave the ED before it happens, it is highly possible they will be prevented from doing so.
“Some places will hold the patient against their will for the purpose of assessment, even though the yield on this is low and may actually discourage help-seeking,” Allen says.