What if Psych Patient Attempts to Leave AMA?

Delays make it more likely

Margaret Bergin, an attorney with Palumbo Wolfe in Phoenix, AZ, and a former hospital risk manager, says the longer the psychiatric patient is allowed to remain in an ED without mental evaluation, the higher the possibility that the patient will leave against medical advice (AMA).

"In some rural facilities it can take up to two hours to have a Mental Health Provider respond to a call for evaluation," says Bergin. "During that time, the patient may try to leave AMA. This presents a sticky situation for the ED facility and staff."

One problem is that ED physicians may not feel qualified to determine if a patient is a danger to self or others, unless the patient admits this is the case. Also, if there is a delay in getting the Mental Health Provider to the ED, the ability to hold a patient becomes more difficult.  This can lead to violations of the Emergency Medical Treatment and Labor Act.

"A medical screening exam is not complete until a Mental Health Provider has evaluated the patient," warns Bergin.

If a psychiatric patient, deemed to be dangerous to self or others, elopes from the ED, all efforts must be made to find and return the patient to the ED for a complete evaluation, says Andrew Garlisi, MD, MPH, MBA, VAQSF, medical director for Geauga County EMS and codirector of University Hospitals Geauga Medical Center's Chest Pain Center in Chardon, OH.

"This includes notification of law enforcement officers," says Garlisi. "The ED is liable for consequences if the patient injures him or herself or others during the elopement time frame."

Can Patient Legally Be Held?

If ED physicians and staff aren't clear on when they can hold a psychiatric patient against their will and for how long, this poses legal risks.

"Many times, the ED staff has not witnessed the behavior that led to ED visit," says Bergin. "The patient won't talk, thereby requiring the ED staff to rely on third-party accounts from friends or family of what occurred."  

The ED is then required to weigh the accounts and determine whether to hold or release the patient.  "If the patient is released and is then successful at suicide or harming others, the facility and provider can be held liable for improper release," says Bergin.

Thus, it is important for the ED staff to be trained and educated regarding when, and for how long, a patient can be held against his will.  ED staff should also document all efforts made to evaluate and treat the patient. 

"Should a lawsuit ever arise, the records will be the best evidence to show that the treatment provided was reasonable under the circumstances," says Bergin.

To justify forced detention and psychiatric evaluation of the potentially suicidal patient, Garlisi says that the ED physician "must track down witnesses, relatives, police officers, or others to supply information."

In addition, the ED physician should be made aware of the arrival of a psychiatric patient right away. Failure to document the statements of witnesses as to the reason for forced detention could create legal complications for the ED if the patient sues for false imprisonment, explains Garlisi.

"Speak with the paramedics and police officers when they arrive with the patient, in order to establish the need for forced detention sooner rather than later," says Garlisi.

Have you heard statements made by police officers, emergency medical services personnel, witnesses, friends, and family members regarding the circumstances that resulted in the patient's ED visit? Carefully document these in the patient's medical record. "These statements by reliable witnesses can justify the physician's forced detention of a patient," Garlisi says.