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40 Cards in this Set
- Front
- Back
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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" |
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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? |
excludes; epilepsy mental retardation dementia delirium intoxication |
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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) |
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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 |
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Pts who meet criteria a- unable to care for self, often do better w/ _____________, rather than commitment to hospital |
placement in alternative communities |
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What is the MC criteria for admitting pts? |
criteria b- suicidal |
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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) |
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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 |
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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 |
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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 |
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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!* |
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Once pt meets criteria (documented) pt must undergo _______________ |
Medical evaluation (must be medically cleared, includes preg test, toxicology, breathalyzer) |
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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 |
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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 |
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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 |
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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 |
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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 |
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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) |
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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) or have guardian appointed (substitute decision maker) |
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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) |
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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) |
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What are the EXCEPTIONS to getting pts informed consent? |
Emergency Incompetence or lacking capacity--> get consent from guardian or substitute decision maker Waiver- signed waiver of consent Therapeutic privilege |
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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) |
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Interruptions to Competence--> unable to communicate choice (no longer require informed consent) |
Impairment of consciousness Mutism Thought disorder (schizophrenia) Disruption of short memory Severe ambivalence Severe aphasia w/ inability to write |
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Deficiencies in Competence--> unable to appreciate situation & consequences |
Pathological distortion or denial of reality Delusional perception of illness, tx, or motivations of caregivers |
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Factors that impinge on Competence--> unable to manipulate information rationally |
Psychotic thought disorder Delirium & dementia Extreme phobia, panic, or anxiety Euphoria or mania Depression Anger |
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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 |
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T/F Levels of competence varies w risk/benefit ratio |
TRUE *more favorable risk/benefit ratio--> lower standard of competence to consent & higher competence to refuse (ex: LP for meningitis) *research studies require high competence |
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Refusal of tx require _____________ to proceed w/o consent |
Court intervention (prove incompetent) |
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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!!! |
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T/F You can commit an incompetent pt to force them to undergo medical tx |
FALSE civil commitment is ONLY for psychiatric tx! |
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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 |
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If pt is COMPETENT, tx or holding (restraining) w/o consent, can result in______ |
tx---> Battery charges restraining--> False imprisonment |
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If a pt is incompetent (or self-injurying), failure to tx or restrain pt, can result in _______ |
Negligence charges |
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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) |
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Negligence may result from omission or commission. What is the difference? |
omission = failure to act commission = inappropriate action (wrong thing) |
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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) |
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Breaching confidentiality requires.... |
Written consent of pt (may want for insurance, disability, etc) |
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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 |
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T/F Malpractice suits against Psychiatrists are rare *Mc reason is for suicide |
TRUE *pts desire confidentiality, have long term relationships w/ provider, & tx are less likely to cause harm |
