Frantic calls for hospital security through overhead pages can be a knee-jerk reaction to patients who are becoming loud, threatening, or aggressive. For Scott Zeller, MD, that is an ethical concern: “The tendency is to look at it as a criminal matter, and that this is a bad person. But they are probably just a regular person who is demonstrating symptoms of a disease state.”
Some hospitals have put in place progressive policies to ethically manage agitated patients. “But my guess is that far too many still have a default plan, that it’s just an automatic call to security, and that’s the way to deal with it,” says Zeller, vice president of acute psychiatric medicine at Vituity in Emeryville, CA.
This underscores how those with psychiatric symptoms are, in many ways, treated differently than other hospital patients. “From an ethical standpoint, that is the one thing that always stands out to me. We don’t get angry at a person for having shortness of breath. We don’t yell at them for having chest pain,” Zeller observes.
Police officers are not mental healthcare professionals, but often are the ones called to help a person in crisis, even if that person is in the hospital at the time. Instead, police should be teamed with a mental health professional to help de-escalate volatile situations, says Dominic A. Sisti, PhD, director of the Scattergood Program for the Applied Ethics of Behavioral Health Care. Co-responder programs exist in several cities and counties across the United States. The programs are helping prevent harm to mentally ill individuals.1
“There’s an important role for medical ethicists — to first observe how these programs function, and then identify common ethical challenges,” says Sisti, assistant professor of medical ethics and health policy at the University of Pennsylvania. The next step is for ethicists to develop policies and procedures that ensure ethical care for individuals with serious mental illness.
The patient/physician relationship is based on trust, confidentiality, protection of patient autonomy, and the belief that clinicians will act in the best interest of their patients, notes Keren Ladin, PhD, MSc, director of the for Research on Ethics, Aging, and Community Health (REACH) Lab at Tufts University in Medford, MA. “When law enforcement is called in, it can undermine these tenets of the clinician-patient relationship,” Ladin explains.
The same is true if clinicians are constantly calling hospital security on patients. It raises concerns about whether providers are really acting in the best interest of patients. “Clinicians face additional obligations in their capacity as leaders on the healthcare team,” Ladin notes.
There is an ethical obligation to consider the safety of staff and other patients if a patient is behaving in a threatening manner. “Use of security in these circumstances should be guided by the principle of reducing harm to the extent possible for both patients and bystanders,” Ladin says. She recommends these approaches:
- Understand the underlying reason for violence. For example, if agitation is a symptom of illness, treating the cause can prevent a call to security.
- Develop clear policies on how to manage agitated individuals, with input from ethicists and the hospital’s legal and risk management departments.
- Analyze the number of calls to security or law enforcement by race, ethnicity, gender, age, and diagnosis. Bias of some kind may be playing a role in decisions to call security on certain patients. “Clinicians ought to be cognizant of their biases and aware that people may express agitation differently without being dangerous,” Ladin says.
- Use a multidisciplinary team approach, with ethicists, mental health professionals, social workers, community advocates, and patient services teams. “This can help reduce conflict and ensure that patients’ rights are protected while ensuring safety for all,” Ladin offers.
Differences in communication preferences, high levels of untreated pain, alcohol withdrawal, or poorly treated psychiatric conditions all are possible reasons for agitation. “Often, these are best approached with care and compassion, not with law enforcement or hospital security,” Ladin stresses.
Notably, not all hospital personnel have undergone the right training in de-escalation. This is especially important for staff who come into contact with the public and/or see new patients regularly. “That is first and foremost,” Zeller underscores.
Some training focuses mainly on self-defense techniques or how to subdue an attacker. Instead, Zeller says the priority should be on how to calm people. That is something that, at first glance, seems counterintuitive. Staff usually argue that calling security whenever they feel threatened is necessary to protect everyone — until they see the results of de-escalation. “It’s actually just the opposite. The more you reduce security getting involved, you actually have assaults and injuries go way down,” Zeller reports.
Zeller has seen this firsthand as chief of psychiatric emergency services at John George Psychiatric Hospital in San Leandro, CA. Between 1,500 and 1,800 patients on involuntary holds presented each month, brought in by either police or ambulance. By the time they arrived at the hospital, most were angry, paranoid, and anxious — all of the preconditions that put them at risk for becoming violent.
Staff were dedicated to noncoercive interventions, and developed great expertise in these skills. As a result, less than 1% of the highly agitated patients required physical restraints. “And that’s in the highest acuity psychiatric environment that you can imagine,” Zeller adds.
If an agitated person sees someone in a police uniform coming toward them with a badge and handcuffs, he or she is likely to think the only way to respond is violently, Zeller suggests. He recommends staff take the complete opposite approach by giving the person plenty of space and making statements such as “We’re here to help you,” “What do you need?” or “Tell me what we can do for you.”
Zeller says a change in mindset is needed to provide ethical care. Cases should be viewed as behavioral health emergencies. Just as clinicians call a code for heart attack and stroke patients, some hospitals use a “code agitation” team. These teams consist of a group of well-trained volunteers who agree to immediately respond to calls about an agitated individual anywhere in the hospital.
“They are the ones who ‘run the code’ if you will, and follow the prescribed methods of de-agitation and calming,” Zeller explains.
The problem is hospitals often come to this conclusion too late, only after a terrible outcome happens and people are hurt. Administrators may be reluctant to make a financial investment in training proactively. Ethicists can help clinicians make the case that it is a small investment for what could be enormous preventive savings.
“It takes only one incident to get the hospital in all kinds of legal trouble, and ruin the hospital’s reputation,” Zeller adds.
- Wood JD, Watson AC. Improving police interventions during mental health-related encounters: Past, present and future. Policing Soc 2017;27:289-299.