Emergency Medicine Reports March 17, 1997

Civil Commitment: Medical, Legal, and Ethical Considerations

Author: Stephen A. Colucciello, MD, FACEP, Clinical Services Director, Trauma Coordinator, Department of Emergency Medicine, Carolinas Medical Center; Assistant Clinical Professor of Emergency Medicine, University of North Carolina Medical School, Chapel Hill, NC.

Peer Reviewers: Ron Rae, MD, FACEP, Medical Director, San Diego County Psychiatric Hospital, San Diego, CA.

Jonathan Lawrence, MD, JD, FACEP, Emergency Physician and Medical-Legal Consultant, San Juan Capistrano, CA.

The most difficult decisions regarding civil commitment fall squarely upon the shoulders of the emergency physician. A desperate family faced with a psychotic relative, police struggling with a febrile, raving prisoner, and paramedics coping with a dazed and babbling patient all turn to the ED for help.

Commitment decisions are difficult for a variety of reasons, including complex or ambiguous statutes, the presence of occult medical illness, and lack of clear guidelines that define dangerousness. While commitment may be life-saving to the suicidal, it is a death sentence for someone with meningitis who presents with acute confusion. "Medical clearance" of the psychiatric patient is a dangerous morass. The emergency physician must not succumb to the temptation of an expedient transfer to psychiatry in lieu of careful patient evaluation. Legal pitfalls abound, and the emergency physician can be accused of failure to diagnose medical illness, improper restraint, violation of civil rights, or negligent failure to protect a third party. For these reasons, an understanding of the perils and pitfalls of civil commitment is essential to our practice.

—The Editor

Legal Principles

Physicians in all 50 states have the power to commit patients who are mentally ill and dangerous to themselves or others; though emergency physicians are not always so empowered. While laws regarding civil commitment vary from state to state, several themes apply.1 The concept of "dangerousness," either to self or others, is central to commitment law. In addition, most states require that the person also have a mental disorder or mental retardation to be committed. Chronic mental illness alone is not grounds for civil commitment. Patients with chronic psychosis tend to frequent urban EDs and often exhibit unusual or nuisance behavior. Such patients do not meet the criteria for involuntary commitment unless the physician documents dangerousness or makes a compelling argument for potential dangerousness. Some states have a "gravely disabled" criteria that allows a physician to commit a psychiatric patient who is unable to care for himself in the most rudimentary fashion. Such profound helplessness may represent a particular subset of danger to self.

Common law provides the legal premise for civil commitment. "Police power" allows the state to ensure the safety of its citizenry. Under this doctrine, the state may protect those who would be endangered by a violent, mentally ill person. In addition, the separate doctrine of "parens patriae" holds that under certain circumstances an incompetent person may be cared for by the state—even if the treatment is against their will. In cases where life or limb is at risk, the mentally ill patient is considered a child whose decisions are made by the state or its agent.2,3

Characteristics of Committed Patients

Although there are certain characteristics common to patients who are committed, these qualities vary between countries. For example, the criteria in England and Wales target older women; in the United States, younger men; and in Italy, a group balanced in age and sex.4 In the United States, the patient who is manic, has grave psychiatric disability, or is psychotic is most likely to be committed from a variety of medical and legal perspectives.5,6 Violent, young, male schizophrenics who do not own homes are particularly likely to be committed.7 Substance abuse also correlates with civil commitment, possibly due to unstable living conditions and organic mental illness.8 It is almost a truism that candidates for civil commitment usually present after midnight.9

ED Management

It is important to determine dangerousness early in the ED encounter to avoid harm to patients, staff, and visitors. Quickly evaluate patients brought in by police for altered mental status or bizarre behavior. Patients who make suicidal statements to the triage nurse, are actively hallucinating, or are severely agitated should be escorted by security personnel to the treatment area immediately. ED protocols for management of the suicidal or violent patient help standardize care and avoid legal pitfalls.

Patient Searches. The ED staff is at high risk for assault, and up to 30% of violent encounters in the ED involve weapons.10 If the physician determines that a patient is suicidal or potentially violent, security officers should search the patient and remove all dangerous objects. All committed patients should be searched, because it is difficult to predict who may be carrying a weapon.11 It has been estimated that at least 4-5% of psychiatric ED patients are armed.11-13 The use of a hand-held metal detector may reveal lethal devices disguised as harmless objects, such as a stiletto pen or belt-buckle knife. A search protocol may include confiscation of shoelaces and belts that patients could use to hang themselves. Placing the patient in a hospital gown is one good solution to the problem of hidden weapons. Keep pill bottles, syringes, and laceration trays away from the suicidal or violent patient. Experienced emergency physicians can attest to the fact that patients who have attempted suicide in the ED invariably have the overdose medication placed within their reach by well-intentioned nurses, medics, or family members. Studies show that anywhere from 5-40 patients per 100,000 commit suicide while in the hospital.14

Patient Restraint. The Supreme Court decision of Youngberg v. Romeo provided legal precedent for a physician to legally order restraints during the exercise of "professional judgment."15 To protect the patient as well as staff and visitors, security personnel should restrain the dangerous patient or designate an officer to be a "sitter." A locked room or leather restraints are most effective. Having determined the potential for danger, the emergency physician who does not act to prevent elopement may be liable if the patient escapes and either hurts someone or commits suicide.16 For this reason, involuntarily committed patients should be treated in a locked unit.17 Some state laws do, however, provide limited immunity in cases of escape. Patients who have recently committed assault or battery and those brought in by police are especially likely to require physical restraints.18

Since many states have strict requirements regarding charting, frequency of vital signs, and opportunity for exercise for physically restrained patients, it is important for the emergency physician to be aware of local requirements.

Chemical Restraints. The Court ruled in Riese v. St. Mary’s Hospital that, absent a judicial determination of incompetence, antipsychotic drugs cannot be administered to involuntarily committed mental patients in nonemergency situations without their informed consent.19 This right of refusal does not extend to the emergency situation where life or limb may be threatened by failure to sedate. ED patients who are acutely psychotic and uncontrollable cannot refuse tranquilizing medication. If the emergency physician clearly documents the need for chemical restraints, the medicine can be safely given from a legal perspective. Furthermore, patients who wildly tug against physical restraints may suffer muscle breakdown and dangerous rhabdomyolysis unless sedated. High-potency parenteral neuroleptics, such as haloperidol or droperidol, are the drugs of choice to sedate the agitated patient.20,21 (See Table 1.) This procedure, known as rapid tranquilization or "neuroleptization," allows the physician to prevent harm to the patient and staff. It provides the opportunity to perform essential examination and diagnostic testing that may otherwise be impossible. While rare reactions such as neuroleptic malignant syndrome and torsades de pointes occur, haloperidol is a safe drug. It can be safely given to critically ill patients in high intravenous doses.21-26 While up to 600 mg of haloperidol via continuous intravenous drip may be given with no complications, 5-10 mg IM or IV, repeated as needed for several doses, is a more standard approach.27 Haloperidol has not been approved by the Food and Drug Administration (FDA) for intravenous use, but numerous investigators have proven both its safety and efficacy by this route. Droperidol, another butyrophenone, is also valuable to control agitation and is FDA-approved for intravenous use. In equal IM doses (5 mg), droperidol results in more rapid control of agitated patients than haloperidol without any increase in undesirable side effects.28 There is less need for repeat dosing when using droperidol compared to haloperidol.29 Benzodiazapines are especially useful in patients with drug or alcohol withdrawal and in cases of sympathomimetic abuse such as cocaine or amphetamine intoxication. The combination of haloperidol and lorazepam is particularly effective in the disruptive patient.24,25,30,31 When using benzodiazepines, especially with inebriated patients, carefully monitor the patient for respiratory depression.

Decision Making

The decision to commit an individual patient is not always simple. The physician must weigh multiple factors and consider the danger to self and others, history of psychiatric illness, degree of disability, and impulsiveness.2,3 Consider the resources (or lack of resources) available to the patient should they be discharged.

Voluntary vs. Involuntary Commitment. Some patients may agree to voluntary psychiatric admission—an offer gratefully seized by the busy emergency physician as less paperwork is involved. Because it avoids involvement of the police, notaries, and courts, voluntary admission has a seductive appeal, and the emergency physician may attempt to convince the patient to "sign in". Unfortunately, there are numerous legal pitfalls associated with voluntary admissions. Of greatest concern is the suicidal patient who initially agrees to a voluntary admission but subsequently changes his or her mind upon leaving the ED. If a patient is truly suicidal or homicidal, this window for escape may prove fatal. The emergency physician should consider involuntary commitment in patients with a high "danger potential" (whether suicidal or homicidal) despite the patient’s willingness to be admitted. Another pitfall of voluntary admission regards the issues of consent and competence. Only a competent patient may give consent for voluntary admission. In one case, the Court ruled that a mentally ill man was unable to give informed consent and could sue state officials who committed him to a state hospital using voluntary commitment procedures.32 The Supreme Court’s Zinermon v. Burch decision could result in the informal voluntary admission process being transformed into a formal one resembling current practices for involuntary hospitalization.33

Suicidal Ideation. The most frequent decision regarding civil commitment regards the patient who has attempted or is considering suicide. Because suicide is the eighth leading cause of death in the United States, the emergency physician must carefully consider the risk factors for completed suicide. (See Table 2.) Directly ask the patient if he intends to kill himself and evaluate such factors as the lethality of the attempt, concomitant psychosis, degree of social supports, and the presence of a gun in the home.

Scoring Systems. Experts have devised a number of scoring systems to predict the risk of suicide,34,35 but prospective studies demonstrate that they have limited utility.34,36 It is frustrating, but probably true, that predicting suicide in a given individual is impossible.37,38 Despite these caveats, one of the most useful scoring systems for the emergency physician is the Modified Sad Persons’ score. (See Table 3.) It helps predict need for hospitalization or consultation in the non-intoxicated patient at risk for suicide. In one prospective study, no patient sent home committed suicide at 6-12 months.39 Nevertheless, a low Sad Persons score should not obviate civil commitment if the clinician still believes the patient to be at high risk.

Not all patients who make suicidal gestures receive civil commitment. While some physicians commit a patient based upon a realistic appraisal of the suicidal risk, other physicians may commit based upon the perceived legal risk to themselves if they discharge the patient (i.e., overpredicting dangerousness).40 After the physician performs a careful evaluation and arranges follow-up, it may be safe to discharge certain low-risk patients. However, recognize that a significant portion of patients discharged from the ED after a suicide attempt never comply with the follow-up plan.41

The law does not demand that physicians always be correct in their decision to commit or discharge. The law insists that the physician demonstrate "professional judgment" and "reasonable care" in patient evaluation. Carefully document the decision-making process to avoid legal repercussions. The primary deterrent to a judgment against the physician in such cases is the well-documented ED record.42 Despite this importance, the emergency physician is frequently remiss when it comes to recording suicidal risk.43,44

Studies demonstrate that patients who are involuntarily committed have a high suicide rate, but whether hospitalization has any impact on long-term survival is unknown.45 Civil commitment has never been proven to prevent suicide in the long term. In fact, some authorities believe that commitment may further injure the patient’s psyche by promoting hopelessness, dependency, or rebellion.40 Nonetheless, civil commitment is the accepted standard of care for the truly suicidal patient.

During recent years, some emergency physicians have had suicidal patients sign a "no harm" contract, stating that the patient agrees not to harm himself if discharged from the ED. While the value of such a contract is debatable, the contract is not legally binding and grants no protection from a malpractice suit.46

Dangerousness to Others. There is scant literature regarding the emergency physician’s ability to predict dangerousness to others. Danger to others is more likely to be associated with major mental illness, particularly psychosis, than danger to self.2,3,47 Patients with paranoid schizophrenia or manic-depressive illness are particularly likely to be assaultive or homicidal.48 A growing number of violent patients are characterized as "dual diagnosis," with a psychiatric diagnosis in combination with a diagnosis of substance abuse.49 Despite the supportive value of a complete psychiatric and drug-use history, the single best predictor of impending violence is a history of prior violence.50 Some psychotic patients, especially those with paranoia, may not be acutely combative but have the potential for assaultive behavior as they deteriorate mentally. The "predictive deterioration" standard may be constitutional, and such patients can be committed even if they are not currently dangerous but are predicted to become dangerous in the near future.

Obtain a history of prior violent behavior and determine if there has been any recent aggression. Patients who are violent in the two weeks prior to commitment are likely to be violent in the first 72 hours of hospitalization.51,52 Directly question the patient about arrest for violent crimes (assault, rape, murder, armed robbery, etc.). A history of weapons possession by paranoid schizophrenics is also predictive of violence.53 Patients brought to the hospital by police are also likely to be aggressive, particularly if intoxicated.63,27 Persons restrained by police prior to hospital arrival will probably require restraints in the ED.56 Directly question patients regarding auditory hallucinations. Command hallucinations are especially dangerous if they instruct the patient to injure himself or others. Increased motor activity, such as pacing, twitching, and clenching fists, often immediately precede violent acts.

Medical Clearance

A major pitfall in civil commitment is sending a medically ill patient to a psychiatric facility. Unsuspected medical illness may account for 4-46% of apparent psychiatric disease.57,58 In one important study, the majority of alert, adult patients with new psychiatric symptoms had an organic etiology.57 Life-threatening medical illness may masquerade as new-onset psychosis. There is a frightening 10% mortality in committed patients within 19 months after hospitalization. Most deaths occur by suicide and in elderly demented patients with underlying medical disease.59 Yet emergency physicians mistakenly write "medically clear" on the charts of the vast majority of patients with an organic etiology for their apparent mental illness.60 Once a patient is committed, he or she may have little or no further medical evaluation. Because the majority of psychiatrists do not perform physical examinations, the emergency physician is responsible for the medically ill who presents in a psychiatric manner. Despite the importance of this evaluation, the physical examination performed for medical clearance is frequently superficial.61

Look for clues in the history, mental status and physical examination for evidence of organic disease. (See Table 4.) New-onset psychosis is almost always preceded by prior psychiatric history and rarely manifests as an acute event. It first presents between the ages of puberty and 40, and sudden appearance (especially in people over 40) may herald infection, toxic/metabolic derangement, mass lesion, or hypoxia. Perform a mental status exam to assess orientation, affect, cognition, appearance, hallucinations, delusions, and suicidal or homicidal ideation. Address abnormal vital signs, especially fever, in all candidates for civil commitment. Altered mental status in the presence of fever is a strong argument for lumbar puncture.57 Four screening criteria: disorientation, abnormal vital signs, clouded consciousness, and patients older than 40 years with no previous psychiatric history, will identify many patients with organic illness.62

The management of the geriatric patient presenting to the ED with an acute change in behavior is fraught with peril. The elderly are more likely than younger patients to have a serious underlying medical illness as basis for a psychiatric presentation.58,63 Medication side effects and alcohol or drug withdrawal must be considered in addition to physical illness.64 Almost 20% of elderly patients brought in for emergency psychiatric evaluation may be suffering from a drug reaction.65 It may be that most emergency physicians now recognize the association between advanced age and organic mental illness. Unfortunately, they frequently miss organicity in the young. In one ED study, "psychiatric" patients less than 55 years old had a four times greater chance of a missed medical diagnosis.60

Laboratory Evaluation. Not all patients who are civilly committed require laboratory evaluation. The necessity and scope of any laboratory evaluation is dependent upon the clinical presentation. A homicidal schizophrenic with a long psychiatric history who recently stopped his psychotropic medication and who has stable vital signs and a normal physical examination probably requires no laboratory testing. A patient with new-onset altered mental status, no prior psychiatric history, or who is febrile may require extensive diagnostic testing. Recommended evaluation may include an SMA-7, calcium, CPK (if there is possible rhabdomyolysis), alcohol and drug screens, computed tomography scan, and lumbar puncture in the appropriate clinical setting.66,67 A bedside measurement of glucose is the most important immediate test in a patient with new-onset abnormal behavior. Consider pulse oximetry in the confused elderly, those with clouded sensorium, and in patients with elevated respiratory rates.

Consultation Issues

Some fortunate emergency physicians may have a psychiatrist available to assist in commitment decisions. These on-call psychiatrists may come to the ED and assume management of the patient. In this situation, the majority of potential liability arising from commitment decisions will be transferred to the psychiatrist. However, more often than not, psychiatric back-up comes in the form of a psychiatric social worker or other paraprofessional. While these mental health paraprofessionals frequently provide valuable assistance, it is the emergency physician who is responsible for the patient’s disposition. If a patient commits suicide after being released by a psychiatric social worker, the emergency physician may well share liability with the other mental health professionals.40

Transfer. If the accepting psychiatric facility is in the same institution as the ED, federal transfer laws do not apply. However, if the psychiatric facility is located elsewhere, the emergency physician must comply with all governmental laws regarding transfer. The Health Care Financing Administration (HCFA) specifically states that any patient who presents to an ED due to a psychiatric problem has an emergency medical condition and is therefore subject to federal law regulating transfers [42 C.F.R § 49.24(B)]. Under the Emergency Medical Treatment and Active Labor Act (EMTALA), psychiatric patients must be medically and psychiatrically stable prior to transfer from an ED, or the physician must attest that the benefits of transfer outweigh the risks of transfer. If the transferring hospital has the ability to stabilize a psychiatric emergency, it must do so prior to transfer. The central issue is the definition of psychiatrically stable. The use of chemical and or physical restraints to prevent harm to self or others may qualify as a stabilizing intervention. In addition to stabilization, EMTALA mandates contact with the accepting facility and transfer of pertinent medical records.

Transport. The actual physical movement (transport) of a patient who has been committed may be problematic. He or she must be safely moved from the ED to a psychiatric facility that may be located some distance away. Certain patients actively resist transport, and both physical and chemical restraints may be necessary. The safest method (both legally and physically), uses a police or sheriff transport team, though this option is not universally available. If the patient resists transport, the police are clearly empowered to prevent elopement. The legal justification for using hospital security to restrain a person during transport off hospital grounds may be questionable in some states.

Rights of Committed Patients

The emergency physician must be aware of the legal rights of committed patients. They have rights to counsel, to remain silent, to receive treatment in the least restrictive environment, to refuse certain treatments, and to have access to medical records under select conditions. Patients also have the right to refuse antipsychotic medication in the non-emergency setting. It is interesting to note that after the legal process runs its course, most refusing patients wind up taking their medicine.68

Once a patient has been committed, they are transported/admitted to a psychiatric facility where they may be held for a fixed period of time, usually 48-72 hours. After this time, the patient may appeal his or her commitment and have the right to a judicial hearing. In general, most patients do not appeal their detention.69 When a hearing does occur, judges rarely overturn decisions made by physicians.70,71 Patients with schizophrenia and schizoaffective disorder and those dangerous to others are particularly unlikely to be released by a judge.72 These appeals are rarely adversarial and clinical concerns usually take precedence over legal issues.73 In many states, the emergency physician is exempt from attending these hearings despite having originally committed the patient. They may ask to be excused by signing a statement on the commitment papers. Interestingly, many civilly committed patients later admit that they needed to be hospitalized.74

Malpractice Issues

While the most immediate risk in dealing with psychiatric patients involves physical assault, there are medical-legal risks as well. Nearly 2% of closed claims against emergency physicians involve psychiatric issues, especially the failure to prevent suicide.75 This malpractice trend began in the 1970s when, for the first time, physicians were successfully sued for failing to recognize suicidal risk and for failing to take appropriate action to prevent suicide. Such "appropriate action" may include civil commitment and/or physical restraint.76 The failure to prevent suicide results in the highest average indemnity in emergency medicine malpractice cases—an average of almost $400,000 per closed claim.77 This even surpasses the average indemnity for missed pediatric meningitis.

There are also legal risks in failure to commit patients who pose a danger to others. If a physician does not commit a dangerous patient who later harms another, the physician may be liable. This is especially true if the physician is aware of a direct verbal or written threat. In addition to committing any mentally ill patient who is dangerous, the physician must warn any intended victim (Tarasoff v. Regents of University of California).78 This duty to warn supersedes physician-patient confidentiality.

While a physician may be liable for failure to commit, they may be sued by either patients or mental health activists for their commitment decisions.79 Failure to follow statutory guidelines in the commitment process poses the greatest legal risk. Physicians are liable when patients are deprived of their liberty by means of civil commitment without due process.80 The courts mandate that physicians exercise " proper and ordinary care and prudence" when making commitment decisions.81 The ED record is the best means of documenting "proper and ordinary care and prudence." Importantly, many states provide immunity from civil or criminal prosecution as long as the physician follows the statutes and is not grossly negligent.

Philosophical Issues

Physicians, philosophers, jurists, and mental health activists have debated the philosophical issues associated with civil commitment for decades. The medical perspective is utilitarian or paternalistic, arguing for what the physician sees as the best interests of the patient, while civil libertarians champion patient autonomy.82 During the 1960s and 1970s, legal concerns generally emphasized patients’ rights. Since 1980, there has been a shift toward assuring community security, perhaps because of the significant rise in crime and homelessness.83 These conflicting ideals have created tensions as the civil liberties of the mentally ill are balanced against the safety of the general public and the patient’s need for appropriate therapy.84

Because no gold standard exists, the decision to commit an individual patient is subjective. Some researchers feel that there is good interobserver reliability in assessment of dangerousness.85,86 Others point out that the process of civil commitment is inconsistently applied, and the rates of commitments vary greatly from year to year.87 One study showed only moderate agreement between emergency physicians and psychiatrists regarding the need for psychiatric admission.88 Unfortunately, there is no literature to demonstrate which group of physicians can better predict suicide or interpersonal violence. At least one author has stated that "the proposition that violence can be validly predicted clinically is seen as having little empirical support."89

Special Circumstances

Unusual circumstances are the norm when dealing with civil commitment. Certain problems that tend to recur in the ED are worth addressing here. There is no single "right answer" to the following dilemmas, but certain broad principles apply.

Family Issues. In general, family members who bring patients in for psychiatric evaluation are supportive of commitment.6 More often than not, the family of a schizophrenic will insist upon civil commitment when the patient is acting bizarrely. At times, however, the patient and the family will provide very different stories. The family may state that the patient is suicidal or homicidal while the patient denies it. Consider that some relatives of committed patients may have punitive attitudes toward the patient.90 Accusations and counter-accusations may turn into a confusing "he said-she said" encounter for the emergency physician—clouding the issue of who should be committed. In general, the physician should err on the side of protecting life. In such situations, a history of psychiatric hospitalizations, a history of violence, the use of psychotropic medications, and prior suicide attempts may weigh heavily in commitment decisions.

On rare occasions, family members may adamantly oppose civil commitment for their loved one. While such devotion signals strong family support and a potential for outpatient management, a family cannot overrule a physician’s commitment decision. Mentally ill patients who are truly and acutely dangerous to themselves or others should be hospitalized despite family objections.

Incarcerated Patients. Police may bring prisoners who have attempted jailhouse suicide to the ED for evaluation. Once such patients are medically cleared, they may return to jail under a suicide watch, with follow-up by prison mental health services. Prisoners who attempt suicide do not necessarily require immediate psychiatric hospitalization.

Systems Abusers. Some patients feign suicidal ideation to obtain hospital services. The "hidden agenda" may include desire to escape cold weather or need for food. Such patients may present to the ED stating "I want to kill myself. Admit me to the psych floor." The emergency physician is not required to commit such patients but must perform an examination to determine true suicide potential. If such a patient wishes voluntary admission, this can be the responsibility of the admitting psychiatrist.

Commitment of Minors. Formal civil commitment is rarely used in the case of unemancipated minors. Parents or legal guardians may place a child into a psychiatric facility without the necessity of formal commitment. In some states, a minor may be voluntarily admitted without consent of the parent. Difficulties may arise if a minor presents to the ED after a suicide attempt and the parents refuse hospitalization. If the emergency physician determines that the minor is truly suicidal, commitment may proceed despite the objections of the parent or guardian.

The Intoxicated Patient. Many controversies surround the management of a suicidal or violent patient who is intoxicated. While the violent alcoholic may exhibit self-restraint while sober, the depressed alcoholic may remain a serious suicidal risk even while not drinking. Many physicians and mental health professionals discredit suicidal statements made during intoxication and hold the patient in the ED until sober. If the patient does not exhibit suicidal ideation at that point, he or she is often released. This approach may be acceptable in the case of vague suicidal statements made while intoxicated, but is problematic in the face of a potentially lethal suicide attempt or a prior psychiatric history of severe depression. Alcoholics are impulsive and have a higher risk of suicide than non-alcoholics.

Managed Care Patients. Hospitals may have separate commitment processes for insured vs. indigent patients. They may admit patients with certain insurance plans to their psychiatric unit but transfer other patients based upon whether the patient is uninsured or belongs to a particular managed care organization. Such economic transfers are regulated by federal transfer law. (See previous section on transfer.) At times, the needs of the patient run counter to the desires of managed health care organizations.91 Managed care organizations may refuse payment for psychiatric hospitalization and ask that the patient be sent home to follow up with the primary care provider or a designated therapist. As always, the emergency physician’s duty is to the patient, not a third party payer.


Civil commitment provides many traps for the unwary physician. The emergency physician must determine dangerousness and mental illness in patients presenting to the ED with altered mental status or psychiatric complaints. (See Figure 1.) If a person is a danger to self or others, the physician has a duty to act. Such actions may include search for weapons, physical and/or chemical restraints, medical clearance, and civil commitment. Medical clearance is a serious undertaking, and a meticulous history, mental status examination, and physical examination may need to be supplemented by diagnostic testing. Careful documentation of the need for restraint and commitment provides the strongest defense in the case of subsequent litigation. (See Table 5.)


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Physician CME Questions

41. Justification for civil commitment is based upon:

A. mental illness and dangerousness.

B. family request.

C. drug abuse.

D. unusual behavior.

42. Which of the following is true of rapid neuroleptization?

A. The maximum safe dose of haloperidol is 10 mg within a single hour.

B. There is less need for repeat dosing with droperidol than haloperidol.

C. Lorazepam produces the neuroleptic malignant syndrome.

D. Never give haloperidol in combination with lorazepam.

E. Benzodiazapines are contraindicated in amphetamine toxicity.

43. "No harm" contracts:

A. protect the physician from malpractice liability if a patient later kills himself.

B. are a safe alternative to civil commitment in patients believed to be at high risk for suicide.

C. are legally binding.

D. are of debatable value in preventing suicide.

44. The best single predictor of violence is:

A. past history of violence.

B. cocaine intoxication.

C. alcohol intoxication.

D. depression.

E. presentation to the ED after midnight.

45. All of the following are associated with organic illness that masquerades as psychiatric illness except:

A. disorientation.

B. abnormal vital signs.

C. clouded consciousness.

D. patients older than 40 years with no previous psychiatric history.

E. auditory hallucinations.

46. Which of the following is liable for commitment decisions made by psychiatric social workers about patients presenting to the ED?

A. The psychiatrist

B. The ED physician

C. The managed care organization

D. The patient

47. All of the following are true except:

A. Emergency physicians have a duty to warn intended victims of dangerous patients.

B. Reasons for physical restraints must be documented.

C. Emergency physicians are not liable when suicidal patients escape from the ED and commit suicide.

D. Chemical restraints are legal in the emergency setting when the physician exercises professional judgment.

E. Awards against physicians who fail to prevent suicide are higher than in cases of missed pediatric meningitis.

48. Which of the following statements is true?

A. Parents need a court order to commit an unwilling child to psychiatric care.

B. Prisoners who attempt suicide must be committed to a psychiatric facility.

C. Patients who attempt suicide while intoxicated are not dangerous to themselves.

D. Psychiatric transfers are regulated by federal transfer laws.

E. Parents can refuse to allow their child to be committed after a suicide attempt.