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40 Cards in this Set

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__________ is a legal process for admitting a mentally ill person to a psychiatric tx program, usually involuntarily, involves a court or judicial procedure

Civil Commitment

"Legal 2000"

In order to be commited, pt must be mentally ill w/ decrease in judgement, inability to excercise self-control & care for self.

What does this EXCLUDE?



mental retardation




What mental illness are mc to require commitment?

Schizophrenia & schizoaffective disorder- during psychotic sxs, d/t med issues

Bipolar disorder- during manic episode, d/t med issues

Major Depression- w/ psychotic sx, extreme negativity, & suicidal ideation

PTSD- d/t stressors or drug use

Borderline & antisocial personality disorder- d/t stressors or drug use

Conduct disorder (in children)

In order to admit a mentally ill pt, they must meet 1/4 criteria w/i the past 30 days.

What are the criteria?

criteria a = unable to care for self, "gravely disabled"

criteria b = suicidal actions, threats, or intent

criteria c = Self-mutilation

criteria d = Danger to others

Pts who meet criteria a- unable to care for self, often do better w/ _____________, rather than commitment to hospital

placement in alternative communities

What is the MC criteria for admitting pts?

criteria b- suicidal

Who is at highest risk for suicidal actions, threats, or intent?

-Single White Old male (or Native American)

-Prior suicide attempts*

-Family hx of suicide

-Schizophrenia, major depression, bipolar disorder, substance abuse/dependence, personality disorders (same)

-Psychosocial stressors: relationships or legal problems (young), financial ruin, shame, failure, declining health (elderly)

Pts admitted for criteria c- self-mutilation, mc have what mental illness?

Borderline personality

*frequently a manipulative aspect

*some say converts psychic pain into physical pain & gives sense of control

What is the best predictor that a pt is a Danger to others & meets criteria d?

Past hx of violence!

-Psychotic states predispose to violence, esp w/ paranoid delusions or hallucinations

-Hx of abuse, victimization, & family violence predispose

-recent stressor & current affect of fear, anger, confusion, or humiliation also predispose

In nevada, pt must meet have previous hx of violence OR threat of violence w/i the past _____days to be comitted for criteria d

past 30 days

*must judge the dangerousness of threats or acts rather than degree of danger represented by pts mental state

In addition to selecting a criteria, clinicians must also provide ____________ on Legal 2000 paperwork

detail of observed behavior that support criteria

*important to write down everything!*

Once pt meets criteria (documented) pt must undergo _______________

Medical evaluation

(must be medically cleared, includes preg test, toxicology, breathalyzer)

What findings on medical evaluation make the pt non-committable (cannot be transferred to a mental health facility*)?

What do you do in this case?

Intoxication (needs to go to detox)

Medical problems or dementia causing behavior

Medically unstable

Acute crisis situation (homelessness, job loss, relationship problems)

*Admit pt to hospital & leave Legal 2000 open but incomplete, get risk management involved & have evaluated by psychiatrist

If a pt who is not medically cleared is evaluated by psychiatrist &

found to not have underlying psych illness, Legal 2000 is discontinued.

If sx are d/t substance abuse, refer to substance abuse program & discontinue Legal 2000.

What if pt does have psychiatric diagnosis?

If pt does have psychiatric diagnosis--> tx until medically cleared, then re-evaluate;

if tx successful & no longer meets criteria--> discontinue

if pt has not significantly improved--> commit & transfer to mental health facility

Once pt has met criteria & obtained medical clearance (do NOT have medical problem causing sx OR any other unstable medical condition) you sign & complete Legal 2000 form.

What is the next step?

Court is notified w/i 72 hrs & pt is put on calendar for court hearing

Upon notification, the court appoints a team of clinicians to see pt & report back to court w/i 5 days. If the team finds pt meets criteria, what happens next?

Pt goes to court & judge decides whether or not pt meets criteria to commit

*at any point in process, pt may become stabilized & Legal 2000 may be discontinued--> pt discharged

If a pt does not come in for evaluation, they cannot be committed.

What are the options if pt does not come in on own?

Friends or family may try to convince pt or go to court to have mental heath warrant

Police involvement if pt acutely dangerous

Diff btwn competency & capacity

Competency = mental soundness necessary to make decision

(all adults competent unless proven by court)

Capacity = ability to make informed decision

(determined by attending physician)

If competence is in question-

Consultation psychiatrists may determine capacity in medical settings, forensic psychiatrist determine for legal issues (court, will, etc).

If a person determined to lack capacity what happens?

referred for a competency hearing (rarely goes to court)


have guardian appointed (substitute decision maker)

What is the mc reason for competency hearing in medical setting?

Refusal of treatment

(usually d/t pts poor understanding of tx or mental illness impairing capacity)

General consent is usually given in admission documents, but procedures w/ risk require informed consent.

What is necessary for informed consent?

knowledge & comprehension (understand tx benefits & risks)

competence (mentally sound)

voluntary (consent is pts own free choice, not forced)

reliability (pt is not indecisive, NOT delirious)

What are the EXCEPTIONS to getting pts informed consent?


Incompetence or lacking capacity--> get consent from guardian or substitute decision maker

Waiver- signed waiver of consent

Therapeutic privilege

What is necessary for a pt to be competent?

able to communicate a choice

able to understand relevant info (intact memory & comprehension skills)

appreciating situation & consequences (recognize illness exists, probable consequence of tx refusal)

manipulating information rationally (able to use logic to compare benefits & risk)

Interruptions to Competence--> unable to communicate choice

(no longer require informed consent)

Impairment of consciousness


Thought disorder (schizophrenia)

Disruption of short memory

Severe ambivalence

Severe aphasia w/ inability to write

Deficiencies in Competence--> unable to appreciate situation & consequences

Pathological distortion or denial of reality

Delusional perception of illness, tx, or motivations of caregivers

Factors that impinge on Competence--> unable to manipulate information rationally

Psychotic thought disorder

Delirium & dementia

Extreme phobia, panic, or anxiety

Euphoria or mania



Elderly male has been dx w lung cancer & refuses surgery. He is cooperative, oriented w/ good memory & language skills. No apparent delusions or hallucination. He equivocates whether he believes he has cancer. He says he does not want to be cut on or discuss other tx. He won't explain why but says "we all have to die sometime".

Does this pt require informed consent to operate?

YES--> cannot operate if pt refuses

*pt is able to communicate choice, understand relative info, appreciate situation & consequences, & manipulate info rationally


Levels of competence varies w risk/benefit ratio


*more favorable risk/benefit ratio--> lower standard of competence to consent & higher competence to refuse (ex: LP for meningitis)

*research studies require high competence

Refusal of tx require _____________ to proceed w/o consent

Court intervention

(prove incompetent)

How is capacity evaluated?

(if determined to lack capacity--> appoint substitute decision maker or court incompetence hearing (rarely go to court))

Mental status exam--> orientation, memory, cognitive skills, presence of delusions & hallucination

Obtain auxiliary info from family, caregivers, etc

Assess pts understanding--> educate if necessary

Tx reversible conditions & reassess**

Document thoroughly!!!


You can commit an incompetent pt to force them to undergo medical tx


civil commitment is ONLY for psychiatric tx!

How do you tx an incompetent pt

Tx w/ least restrictive tx alternative-->

Sitter or chemical restraints (benzo) if emergent

try to avoid physical restraints, if necessary document

if not emergent--> need surrogate decision maker

If pt is COMPETENT, tx or holding (restraining) w/o consent, can result in______

tx---> Battery charges

restraining--> False imprisonment

If a pt is incompetent (or self-injurying), failure to tx or restrain pt, can result in _______

Negligence charges

What are the 4 elements necessary to prove Negligence?

Duty (once you see pt, you are responsible for them)

Breach of duty (failed to provide or inappropriately provided)

Damage (substantial damage resulted)

Causation (connection btwn breach & damage)

Negligence may result from omission or commission. What is the difference?

omission = failure to act

commission = inappropriate action (wrong thing)

Medical Ethics applicable to Psychiatry:

Respect rights of pts & safeguard pt confidences w/i restraints of law

Protect pt records w/ extreme care

Circumspect info to disclose to others about pt (only if possibility of harm)

Maintain confidentiality (HIPPA)

Breaching confidentiality requires....

Written consent of pt

(may want for insurance, disability, etc)

What should you do if someone files a malpractice suit or requests records?

Refer it ASAP to lawyer or insurance carrier

Do NOT respond independently

Do NOT ignore


Malpractice suits against Psychiatrists are rare

*Mc reason is for suicide


*pts desire confidentiality, have long term relationships w/ provider, & tx are less likely to cause harm