Beyond Blue

Following up on last Friday’s question — whether or not to take a loved one to the hospital — is this question: What if she refuses to go?

Again, Dr. Mark Komrad, M.D., has some answers:

The criteria for filing a petition for emergency evaluation can be made only if the petitioner has reason to believe that the individual has a mental disorder and presents a danger to self or others. Certain mental health professionals and law enforcement officers may file a petition without getting a judge’s approval. The mental health professional must deliver the petition to a law enforcement officer in order to have the person picked up and transported to the ER. If called directly, the police officer may make the determination himself from observations and from information obtained by the family or others present. A number of counties have mobile crisis teams who can be called and cal determine if the person needs hospitalization and if there are alternative resources, and the team can issue petitions and work with the police to transport the individual to the hospital.

Alternatively, a family can go to the nearest courthouse and ask for the magistrate who handles “emergency petitions” for medical/psychiatric situations. You can fill out a petition, and a judge will decide if the criteria are met and order the police to find the person and take the individual to an ER. There is much wisdom among NAMI members about the most effective way to fill out a petition to ensure that the judge has all relevant information.

Remember that once in the ER, whether the person has arrived there voluntarily or in the company of police, the process is only beginning. The first step is a proper medical and psychiatric evaluation. The result of that process will decide whether or not the problem can be stabilized right there in the ER. If it can, perhaps the patient can then return home. If not, there may be alternatives such as community crisis beds or referrals to rehabilitation programs. If those are not appropriate or available, then the emergency medical team will make their recommendation for hospitalization.

A patient can accept or refuse that recommendation. If the person refuses, then the team must determine whether or not to hospitalize the patient involuntarily. At that point, the criteria requires that a person has a mental disorder, needs inpatient care, presents a danger, is unwilling to go voluntarily, and there is no less-restrictive alternative. If someone meets those three criteria, they are sent to the nearest available psychiatric unit. However, if the person is medically unstable, say after an overdose, they may not be transferred to a psychiatric unit medically and physiologically stable. Not every emergency room is attached to a hospital that has a psychiatric unit in the same hospital, so it’s not usual for patients to have to then be transported from one particular emergency room to another hospital nearby, where there is a psychiatric unit with an open bed.

Once admitted to the psychiatric unit, there are two possible paths. One path is for the inpatient treatment team to offer the patient to change the status from involuntary to voluntary. That means that the person would be able to ask to leave the hospital. The staff would have a right to keep the patient there for up to 48 hours after they asked to leave, for further treatment, or to try to convince them to stay. Alternatively, the team may decide to maintain the original involuntary status and take the person to an administrative law hearing in front of a judge within 7 to 10 days. These hearings are held right in the hospital. The judge reviews whether the patient meets the criteria for involuntary admission, and decides whether to retain or immediately release the patient. Family is often encouraged to attend this hearing to provide information and testimony that can help the judge make the decision, and it is a particularly vital role for family members in this process.

Many people are unaware that when asked on legal forms if they have ever been “involuntary committed” to a psychiatric hospital, they only have to say “yes” if they have gone through such an administrative law hearing and been retained in the hospital by the judge. If all they have experienced is the process up until that point, or if the judge releases them from the hospital at the hearing, they can legally answer “no” to this question.

Hopefully, you or your loved one will never have to go through this process. But it is good to know that it’s there if you need it, what to expect, and how to get the best possible outcome from this system. It is designed to bring treatment to a group of people whose illness puts them or others in peril and degrades their judgment about how ill they are, as these kinds of illnesses sometimes, sadly, do.

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