Sometimes, there is simply no choice but to hospitalize people against their will and to use physical force to keep everyone safe, especially when patients are delusional, disorganized, and agitated. This is not something that should be done lightly. Involuntary treatment initiates a process whereby the treatment team becomes the adversary to the patients they are trying to serve. It makes for long and difficult days for everyone. Furthermore, when it comes to suicidal patients, we don’t know if involuntary care prevents suicide. Still, it can be very difficult to let a suicidal patient leave an emergency department if the doctor believes the patient is at risk of dying.
Explore This IssueACEP Now: Vol 36 – No 07 – July 2017
We know very little about involuntary psychiatric treatment. There are no national statistics on how many people are involuntarily hospitalized each year, and there are no statistics on how common it is for people to be traumatized. What we do know is that in the battle over involuntary psychiatric care, there are no organized patient groups lobbying for legislation to make forced care easier. There are, however, organized groups of people who call themselves “psychiatric survivors,” who feel they have been injured by what psychiatrists have to offer. There is no doubt that our treatment of those with psychiatric disorders needs to be more thoughtful and respectful. Ultimately, forced care puts us in the very awkward position of being the adversaries to the people we are trying to serve.
Smoothing the Way for Psychiatric Treatment
So what’s a doctor in the emergency department to do? I would contend that if, after careful assessment and consideration of less restrictive alternatives, there is no choice but to involuntarily hospitalize a patient, the first action should be to try to convince the patient to sign in voluntarily. This seems obvious, but it doesn’t always work out that way. Why would busy doctors expend the effort to convince patients to sign in if they could more easily force care?
Remember that Eleanor came to the emergency department seeking help; she would have signed in to the hospital, but that option was never offered.
Obviously, the use of physical force should be avoided unless absolutely necessary to maintain a safe environment. While restraints, seclusion, and the forcible injection of medication may be necessary to keep everyone safe, the ED setting is one where patients easily escalate. They may have been brought from their homes by the police in handcuffs, and they may be required to wait hours or even days for evaluation and admission. From the point of view of anguished patients, this is embarrassing and difficult. Force should not be used for strict adherence to policy—for example, to force a person in no obvious physical distress to have admission lab work. It didn’t serve United Airlines well, and it doesn’t serve psychiatry well!