"Unholdable" patients are ethical dilemma

Physicians' hands may be tied

One emergency physician might feel comfortable giving a medication by injection to a man distraught from hallucinating and in danger of attempting homicide, while another might prefer a psychiatric consultation for almost all of the psychiatric patients seen in the emergency department.

Similarly, one primary care physician might feel comfortable prescribing for depression or anxiety, whereas another might prefer to make a referral.

Ethically, emergency and primary care physicians must limit their practice to their skills in serving people with psychiatric issues, but "the level of this skill varies enormously," says Roger Peele, MD, DLFAPA, chief psychiatrist at the Behavioral Health and Crisis Center of Montgomery County in Rockville, MD.

Legal requirements for involuntary admissions vary by state, says Peele, with most requiring that the person be dangerous to others or dangerous to themselves, including inability to take care of their basic needs.

If the physician involuntarily hospitalizes a patient and knows that the patient's condition does not meet the criteria for involuntarily admission, the list of ethical violations can be long, warns Peele. These include not providing competent medical services with compassion and respect for human dignity, not dealing honestly with patients, not respecting the law, and not respecting the rights of patients.

However, if a physician fails to involuntarily admit a patient who is possibly dangerous, he or she may inflict harm on self or others, not get the treatment he or she needs, or the patient's condition may deteriorate, warns Katrina A. Bramstedt, PhD, a clinical ethicist and associate professor at Bond University School of Medicine in Australia, and former faculty in the Department of Bioethics at Cleveland (OH) Clinic Foundation.

Furthermore, some patients present seeking treatment in a locked-care facility but are denied admission, sometimes due to the lack of bed capacity. "This can emotionally deter them from seeking treatment in the future, feeling abandoned by the profession," she says.

Other complex situations involve third-party payers refusing to provide benefits coverage for locked-care even while health care providers deem such care necessary. "Ethical dilemmas can arise when resources of money and bed space are in tension with the clinical need for locked psychiatric care," says Bramstedt.


  • Katrina A. Bramstedt, PhD, Clinical Ethicist, Bond University School of Medicine, Queensland, Australia. Email: txbioethics@yahoo.com. Web: www.AskTheEthicist.com.
  • Roger Peele, MD, DLFAPA, Chief Psychiatrist, Behavioral Health and Crisis Center, Montgomery County, Rockville, MD. Phone: (240) 777-3351. Email: RogerPeele@aol.com.
  • Paul L. Schneider, MD, FACP, Associate Clinical Professor of Medicine, University of California, Los Angeles School of Medicine, Chair, Bioethics Committee, Veterans' Administration Greater Los Angeles Healthcare System. Email: Paul.Schneider@va.gov.

Ethics "lost in the process" of involuntary admission

The decision as to whether a patient should be held involuntarily has become purely a legal and political decision, and "ethics get lost in the process," argues Paul L. Schneider, MD, FACP, an associate clinical professor of medicine at the University of California, Los Angeles School of Medicine and chair of the Bioethics Committee at the Veterans' Administration Greater Los Angeles Healthcare System.

"One of the biggest issues that I face very commonly is the dilemma of the 'incompetent but unholdable' patient," says Schneider. When physicians consult with psychiatry about a patient they believe needs to be held, they often learn that the patient doesn't meet the criteria for involuntary admission.

"The psychiatrist says, 'As much as you might think this person should be holdable, I wouldn't be able to win in mental health court,'" says Schneider. "Do we let this person go in order to do the legal thing, even though we feel it's unethical?"

Patients with dementia commonly fall into this dilemma, because local mental health courts determined it is not an illness that makes a patient holdable, he explains.

There is more room for ethicists to be involved in these cases, Schneider underscores. "A moral tension is set up when ER doctors consult psychiatry, who recommend the perfectly legal thing to do, but it's not the most ethical way to go," he says. "That dilemma is a very ripe area for ethics consultations."

Holding the patient anyway can result in several negative repercussions, he says, including the psychiatrist having to go to court and be scrutinized by opposing attorneys, and the doctor possibly being held liable for false imprisonment.

The result is that involuntary holds are reserved only for the "worst cases," says Schneider, which doesn't include patients who reject potentially life-saving treatment because they don't understand their medical condition. For instance, a schizophrenic with gangrene who doesn't comprehend the risk of refusing surgery likely wouldn't meet the criteria.

"Very commonly psychiatry will come back and say the patient is not holdable because they are coming here for their gangrene, and mental illness holds can't be used for a medical condition," he says.

The psychiatric determination of decision making capacity determines whether the patient is holdable or not, he explains, when in reality these are two different things.

"Psychiatrists will say, 'You can't do anything about a patient who is incompetent but not holdable, and my argument is, 'Yes you can, and you need to,'" he says. "Clearly, violent acts in society are highlighting the need for more scrutiny in this area. The public generally doesn't know about the extent of this problem."

Individual mental health practitioners have learned to influence their behavior based on the local political environment, he adds.

"There needs to be a lot more public discourse on the issue," says Schneider. "We are letting people go on a daily basis who don't really understand the details of what medical care they are refusing, but we let them go because our psychiatrists say that we have to."

This scenario has led Schneider and his colleagues to develop a system in which patients in this category could be held by another means other than what state law currently allows — that of a surrogate hold. Physicians would go to a surrogate decision maker and ask for consent to hold their family member.

"If a patient is lacking decision-making capacity, I think we owe them a surrogate decision maker who has capacity, out of empathy for the patient," he says. "When we allow a person to leave who doesn't understand, we are allowing them to go without that function."