Saturday, January 10, 2009

Psychiatric Holds

In the next class, we will be talking about issues in autonomy and consent. One really big issue within these topics is how to approach dilemmas that involve patients with mental illness. You may know that the Harborview ER has its own psych ward and psychiatrist (plus a resident) in house 24 hours a day. Not every emergency department will have such a resource. In fact, few do. Emergency providers must be familiar with the law, or at least with hospital procedures relevant to detaining a person.

Dr. Cooper will be giving a lecture on Wednesday about what is needed to establish consent. Needless to say, the mentally ill fall short on several accounts. (Can you name which?) The interesting thing is that each state defines autonomy differently. "5150" for example, refers to California's involuntary detainment statutes. We live in a state that is among the most protective of individual autonomy. It is very difficult to detain someone in Washington.

There are three ways to learn about Washington's system.
  1. Read the law. Start here and here, and focus on this section and the laws referenced. Make sure you are caffeinated.
  2. Look at a description not written in legalese. (This description of Washington's Involuntary Treatment Act is published by Snohomish County)
  3. Have someone explain it to you. We can go over it in class.
One or two of our cases on Wednesday may deal with this issue, so if you have a chance to read about it, you'll be one step ahead.


  1. I read this week's reading on-line and had a sickening, familiar feeling. I'm the veterinarian in the class, and am familiar with 'overpowering' my patients frequently. Losing patience when we are put in the position of inflicting health care on a patient who does not want to be treated is not unique to ER physicians or pediatricians. One of the most important lessons I've learned in practice has been to recognize when I need to step back and get control of my amygdala--my own shorthand for taking a deep breath. Remarkably, that (breathing deeply) is the best single solution I have found, and actually has been proven to be physiologically effective.

  2. Psych holds are very complex and seem to be navigated with ease with those in the Psych Emergency. It seems to boil down to two things: being suicidal or homicidal. Then the DMHP is able to decide if the threat is serious. However until the point of their arrival, the patient is held legally - a lot of the time against their will.