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Holding voluntary patients - illegally?

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You are reading page 3 of Holding voluntary patients - illegally?. If you want to start from the beginning Go to First Page.

Yes? I appreciate you weighing in and I'm not being facetious either.

Just as I'm trying to figure if a legal right exists for me to keep a patient against their will when they do not fit criteria for a legal hold, you would need to figure out if a legal right exists for you to (possibly?) falsely imprison them.

Again, if a patient is medically/mentally stable and does not meet criteria for a mental health hold, "

But who is making this determination? In California only a psychiatrist or a trained ancillary profrssion with LPS designation can assess for or place a patient on a legal hold. I am currently going through this training. The Dr.s at my facility generally trust my judement and will ask me over the phone. Is the patient holdable? If I say yes they get someone over to officially assess the patient.

It's been my experience that when a patient requests AMA on night shift. The staff does everything to get them to agree to stay because they (the staff) don't want to handle the work involved and will pass it off to the day shift in the AM.

Hppy

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I have never had a patient "wait" until we filled out all our paper work, never. In my experience once a patient wishes to go AMA, I get that signed if possible or document that the patient left to unknown location, ensure documentation is there is patient stated " XXXXX." If the patient left and I am not sure I call the police to do a safety check and document that too. There have been times that I let the patient know if you do not wait until your doctor can come in and you leave I will call the police to show up at your home for a safety check, this sometimes de-escalates them to stay in bed until the doctor comes in, gives them a chance to perhaps change their minds.

If someone told me I had to do...well I am sort of a rebel and would more than likely tell that person where to go.

I took my then infant daughter who was 8 months old out AMA from a military hospital in Germany 30 years ago. She could not keep anything down and had diarrhea. She was in the hospital 10 days and they could not find anything wrong with her other than FTF. They started her on pedialyte and wondered why she had diarrhea, was just discussing TPN/G-Tube. Before I took her out I contact a German Pediatrician who said they would take her if I brought them to her. My girlfriend and I went up to the military hospital took her out of peds without much a word (I was so upset with them) and immediately brought her to the German doctor who after 48 hours in a German hospital cleared her, found nothing, but she was very hungry and they fed her orally. Her weight was in the middle percentile and she was exceeding all her milestones of growth before she went in to the military hospital, she lost 5 pounds when I brought her to see the German doctor. It was scary and I was 7 months pregnant with twins. I had my twins in the German Hospital.

It has been my experience people who feel going AMA is the answer are either afraid of the care they/loved ones are NOT receiving (and no one is listening) or just plain old ornery and not getting what they want.

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In the hospital I used to work at, we had the patient sign AMA papers, thats if they would sign them... If they were going to leave, we would try and talk them into staying, but if they were going to leave, they were leaving, with or without an MD order..

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Patient: "Am I on an involuntary hold?"

Nurse: "No, you are here voluntarily."

Patient: "Um, I've changed my mind about being here and I choose to leave. I understand that I am doing so against medical advice and that doing so places me at risk for relapse as well as acute conditions possibly leading to permanent injury, disability, or even death. I acknowledge those risks and voluntarily accept them. Despite your urging me to stay, I choose to leave."

Nurse: "OK, I need to talk to the physician and to case management first."

Patient: "Am I being held here involuntarily?"

Nurse: "No, you are not on an involuntary hold."

Patient: "Then I choose to leave... right now."

At this point in the conversation, any attempt to prevent the patient from leaving (that is, physically or chemically restraining them in any way - and yes, locked doors count) would likely constitute false imprisonment as well as assault and battery. If you have reason to question their capacity to make the decision for themselves, you'd better be able to clearly articulate it.

Personally, I'd step out of their way and notify the charge nurse and physician... but I would not touch them nor in any way try to prevent them from leaving. If the person controlling the locks wants to take on the false imprisonment issue, so be it. If I were the one controlling the locks, I'd unlock them and encourage them to return at any time without prejudice.

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Look at it this way: if a medically stable med-surg patient decided at 0300 that they wanted to leave the hospital, would you open the door and let them go right then and there? Probably not, right? I'd bet you'd make them wait to see the doctor in the morning.

Encourage them, yes. Make them, not a chance.

Stable or not, unless they have been deemed to lack capacity or you can clearly articulate why you believe they do, it is both unethical and illegal to prevent them from leaving.

If the patient is willing to hang out for a few minutes and the doc is sufficiently concerned, said doc can get out of bed and drag him/herself in to deal with the situation him/herself. Otherwise... off they go.

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Patient: "Am I on an involuntary hold?"

Nurse: "No, you are here voluntarily."

Patient: "Um, I've changed my mind about being here and I choose to leave. I understand that I am doing so against medical advice and that doing so places me at risk for relapse as well as acute conditions possibly leading to permanent injury, disability, or even death. I acknowledge those risks and voluntarily accept them. Despite your urging me to stay, I choose to leave."

Nurse: "OK, I need to talk to the physician and to case management first."

Patient: "Am I being held here involuntarily?"

Nurse: "No, you are not on an involuntary hold."

Patient: "Then I choose to leave... right now."

At this point in the conversation, any attempt to prevent the patient from leaving (that is, physically or chemically restraining them in any way - and yes, locked doors count) would likely constitute false imprisonment as well as assault and battery.

Are you talking about an acute care medical setting, or a psychiatric setting? Because it's not true in a psychiatric setting, which was the original point of the thread.

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I think the bolded statement is what it ultimately comes down to....

If upon admission, a pt. signs consents that impose various conditions on treatment and/or discharge, then the pt. will be held to those conditions while there. Therefore, if one of the things they agree to is that AMA discharge will be requested in writing before a certain time, or have to wait until the next day to be processed, then why wouldn't the facility be within its rights to expect a pt. to go along with the restrictions that were spelled out from the beginning.

Now, if there was no prior notice given of the facilities policies, or if the pt. hadn't agreed to certain conditions on admission, then maybe they would have a legitimate complaint of being held against their will, or whatever.

Whether the facility is for-profit or not has no bearing in this matter, because it's simply a matter of what the patient agrees to at the time of admission.

If a lot of patients are confused by the delays @ AMA discharge, then perhaps there needs to be better explanation when the papers are being signed at the time of admission of the policies that the patient is/will be expected to comply with.

Yep, it used to be in the paperwork (not sure why it was removed) and the common reply to that from detox patients was "I was so intoxicated/I was withdrawing so badly upon admission, I signed so many papers, I don't remember..."

That's another question altogether - and I'm not saying the patient is right about that. Also something I wonder about though.

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Of course the nurse would contact the physician. The individual would be seen ASAP by the physician if s/he is readily available, or the nurse would contact the physician by telephone and review the situation, just as you would contact the physician re: any significant change in the client's status or condition, and they would figure out what to do about the situation.

So then it's really no different than how we'd do it in psych.

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Since no one who's come along so far is familiar with the law in Nevada, none of us can answer that specific question for you. As I said earlier, if no one at your facility is familiar with the state rules/regs on this question (which I find hard to believe), the state department of mental health can advise you. Have you spent your six years working in psych in Nevada, specifically? If so, how is it you don't already know the answer? Is this the first time this question has come up in your career? Knowing the legal requirements of admission and discharge in psychiatric settings in the state in which you're practicing is important.

I've searched the Nevada statutes and could not find an answer. I haven't asked everyone in my facility as I'm not keen on being marked as anything (even if for a valid reason). I have asked a number of people and, no, they do not know the answer. Figured I'd ask here first before going to the nursing board, dept. of mental health, etc.

Yes, I've worked as a psych nurse both privately and publicly in NV for 6 years. Why don't I know the answer? Ninety-nine percent of my admissions have gone along with the process rather easily. There have been a few instances that escalated to the point of calling a house sup/doc/admin immediately and those patients were discharged quickly. Still, that didn't answer my question of whether we were, up until that point (after the pt. requested AMA), falsely imprisoning them.

Knowing the legal requirements, etc. is important. I agree. In this case, I would assume with false imprisonment being both a tort and a felony, that the law would be fairly identical or at least extremely similar across the entire country.

I am very well-versed in our state's process of initiating a legal hold, certifying it, petitioning patients for court, etc. Most nurses in my facility come to me when they have questions regarding this process. But let's not act like every nurse knows every law. This particular, nuanced question was apparently never important enough to be taught in nursing school (in NV), at various orientations/in-services, etc.

Not a big fan of being accused of some sort of negligence for seeking out the answer to a question that no one seems to know the answer to.

Again, I assume a patient would have every claim to false imprisonment in the same circumstance nationwide. Given that, why can't anyone here answer completely in the affirmative? Maybe because there is confusion and we're nurses, not lawyers.

But who is making this determination? In California only a psychiatrist or a trained ancillary profrssion with LPS designation can assess for or place a patient on a legal hold. I am currently going through this training. The Dr.s at my facility generally trust my judement and will ask me over the phone. Is the patient holdable? If I say yes they get someone over to officially assess the patient.

It's been my experience that when a patient requests AMA on night shift. The staff does everything to get them to agree to stay because they (the staff) don't want to handle the work involved and will pass it off to the day shift in the AM.

Hppy

In NV, various people can initiate a legal hold (LSW, RN, MD, police officer) and it then must be certified by a psychiatrist or psychologist. I've initiated many legal holds.

We do the same as well - try everything we can to talk a patient into staying - which usually works.

Patient: "Am I on an involuntary hold?"

Nurse: "No, you are here voluntarily."

Patient: "Um, I've changed my mind about being here and I choose to leave. I understand that I am doing so against medical advice and that doing so places me at risk for relapse as well as acute conditions possibly leading to permanent injury, disability, or even death. I acknowledge those risks and voluntarily accept them. Despite your urging me to stay, I choose to leave."

Nurse: "OK, I need to talk to the physician and to case management first."

Patient: "Am I being held here involuntarily?"

Nurse: "No, you are not on an involuntary hold."

Patient: "Then I choose to leave... right now."

At this point in the conversation, any attempt to prevent the patient from leaving (that is, physically or chemically restraining them in any way - and yes, locked doors count) would likely constitute false imprisonment as well as assault and battery. If you have reason to question their capacity to make the decision for themselves, you'd better be able to clearly articulate it.

Personally, I'd step out of their way and notify the charge nurse and physician... but I would not touch them nor in any way try to prevent them from leaving. If the person controlling the locks wants to take on the false imprisonment issue, so be it. If I were the one controlling the locks, I'd unlock them and encourage them to return at any time without prejudice.

I totally agree with you. Especially if you get a particularly litigious patient. I'm not touching them until I need to. But I'm also at this point not unlocking the doors. I can't imagine a jury would ever find me liable for not opening the doors in this case. I think they'd find issues with the hospital's policies and training.

Still, I'd love to have the law on my side and be able to justify any of my actions in real time.

Are you talking about an acute care medical setting, or a psychiatric setting? Because it's not true in a psychiatric setting, which was the original point of the thread.

Unless you work in a completely involuntary, locked facility, I don't think there's a difference - that's my point. I would think a voluntary patient in my hospital would have every single right (in terms of AMA) that a voluntary patient in a medical setting would. The only difference is the doors are locked. So they can't just walk out. My hunch is any lawyer worth their salt could easily make a false imprisonment claim if such a patient was not allowed to walk out of a facility for any significant amount of time.

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. There have been times that I let the patient know if you do not wait until your doctor can come in and you leave I will call the police to show up at your home for a safety check, this sometimes de-escalates them to stay in bed until the doctor comes in, gives them a chance to perhaps change their minds. .

I find that a lot of my patients are deterred from AMA discharges when the find out that they won't be getting any discharge medications. A lot of the time the MDs won't prescribe meds for an AMA discharge, or will prescribe a minimal supply and certainly not give them any of the fun ones (read: benzos). Suddenly the patient has a change of heart and decides that maybe they could wait until talk to the MD.

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Again, if a patient is medically/mentally stable and does not meet criteria for a mental health hold, what is your response to them getting up and walking out of a non-locked facility? Tackle them? Restraints? That's crazy. Is someone going to sit on the witness stand and say "Well yea, we restrained him. Why? Because there wasn't a doctor's order for discharge."

That would be battery and I prefer not to skate outside the law. And I don't think anyone here is suggesting you do the same.

Again, I work just psych. I handle it the way it was outlined to them in the admission policy. My patients know that if any patient wishes to leave, even if they were admitted voluntarily to the unlocked unit, they have to be assessed by certified personnel to determine if they are safe to be discharged. Until that assessment happens, they are not able to leave--and they agreed to this as a condition of their admission. Fortunately, I happened to be one such person that can do this assessment. So if it's my patient, that saves some time.

If they really want to bust through the doors and run, that's on them and we won't stop them...but considering they don't get their belongings out of storage/safe until they're discharged and ready to be officially walked out of the building (milieu safety issue), they'd be running through the streets in socks without any of their stuff. And I can't simultaneously asses a patient and pull their shoelaces from storage, so guess which task will get my priority?

After the assessment, I then contact the MD to discuss the situation and a decision is made. If the patient is not safe to be discharged (danger to self, danger to others, and/or gravely disabled), I place the patient on a psychiatric hold (I am certified to do that as well) and transfer the patient to the locked unit until the MD can reevaluate them.

If there are no criteria for a hold and the MD agrees with the discharge, the patient is discharged. They may or may not get discharge medications prescribed, that is the MD's call. Though not getting discharge medications has a surprising way of changing more than a few patients' minds about going AMA.

Discharge planning isn't usually able to be done due to time constraints: we'll just give them a list of community resources and wish them well.

Yep, it used to be in the paperwork (not sure why it was removed) and the common reply to that from detox patients was "I was so intoxicated/I was withdrawing so badly upon admission, I signed so many papers, I don't remember..."

That's another question altogether - and I'm not saying the patient is right about that. Also something I wonder about though.

That is another debate: is a person who is under the influence of drugs/alcohol really able to give informed consent?

On a similar note, if they're still impaired when they want to go AMA (as in admitted a couple of hours ago and changed their minds), would they be considered capable of making an informed decision about that as well?

Edited by Meriwhen

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But are you saying that a med-surg patient can just walk off the medical floor without any form of discharge order (either in person or given via phone) from the MD? Basically just elope?

Absolutely.

Unless the patient lacks capacity, autonomy and self-determination rule supreme.

They're patients, not prisoners...

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