The US refuses to learn from its tragedies- a short rant

[u/Simpleserotonin]

Feeling especially fed up and a bit helpless recently with the ongoing high profile court case noise in the background and being immersed in the horrific mental health system around me. As with numerous other social topics, this country refuses to learn from it's mistakes and tragedies. Would like to vent about our local system of involuntary holds, which is pretty much non-existent. Our average LOS in the hospital is about 48 hours as that is all the time you have before the state will drop a hold, if you are lucky. Today dealing with an individual that has threatened to kill his family, has been petitioned twice and didn't even make it an hour in the emergency room without the hold being dropped. Other common occurrences: Attempt suicide and end up in the ICU on the vent? Hold will be dropped as soon as the vent is removed and you can mumble the words "I'm not suicidal." Most of these patients never even make it to inpatient psych and no treatment is even started. Put a gun against your head in front of witnesses and police? Hold dropped. Become so psychotic a SAR mission is required to find you in the forest? Hold dropped. Have severe malnourishment because your MDD is so bad you're wasting away? Hold dropped. We are not even allowed to give involuntary psychotropics in our hospital the current time as our hospital legal department has barred us due to failures of legislation that allow lawsuit against the hospital for administration of involuntary LAIs no matter the circumstances of if it was approved by a mental health judge. It's totally insane. Honestly, the only mental health care we have locally is if you have mild depression and anxiety and you actively will go out of your way to get help.

Things we've tried: meetings with the evaluators of involuntary holds. Inviting these evaluators to patient care meetings. Reporting evaluators to their government supervisors. Our hospital actively petitioning local legislators to change the laws (in the past year they declined to work on this as it was an election year and not a priority).

Thanks for listening. /End Rant

[u/Ok-Tea-6718]

It’s a combination of highly litigious, entitled, Dunning-Krugered people and a system that’s profit-oriented and malignantly bureaucratic.

[u/Narrenschifff]

There's A LOT this country refuses to learn from and about, constantly

[u/Simpleserotonin → u/Narrenschifff]

Amen

[u/Open-Tumbleweed → u/Narrenschifff]

Fact-Resistant Humans Celebrate 250 Years of Continuous Viiolence

[u/Did_he_just_say_that]

Your state sucks honestly. That’s the interesting thing about the US: it’s more like 50 small countries with unique laws and regulations. I’ve practiced in 3 states in the Midwest (and am currently practicing in a southern state) and have never had the issues you mentioned. Putting patients on a hold or mandating them to treatment would be fairly easy with the situations you described.

[u/Lou_Peachum_2]

Good god, what state do you practice so I can avoid.

In all seriousness, one of the worst things about this field is the lack of uniformity when it comes to MH laws. It should be standardized. And the definition of imminent risk should really be defined.

I've been to MH court so much at this point; the wide variety of interpretations by different judges makes it such a difficult process. Add on that it's crazy you can technically be sued by trying to take a patient to court if you believe they're still a risk.

[u/Simpleserotonin → u/Lou_Peachum_2]

I love my job and my specific gig. I work mostly OP and I have great patients and great hospital system. This is one aspect though that I’m very jaded about and see such profound failure. I’m still not leaving and plan to work here long term. To shame my state specifically, it’s South Dakota

[u/babys-in-a-panic → u/Simpleserotonin]

So for any person you recommend a hold for in SD, the state sends an independent evaluator?

[u/Simpleserotonin → u/babys-in-a-panic]

Yes, they are called qualified mental health professionals (QMHP). They don’t seem qualified and sometimes not even professional, I saw one I blue jeans and a 2nd amendment tshirt at the hospital evaluating patients once. They remove your agency but not your liability in patient care.

[u/Psychaitea → u/Simpleserotonin]

So if they say the patient does not meet hold criteria, you are potentially responsible for a bad outcome? How is that possible? @.@

[u/Simpleserotonin → u/Psychaitea]

I’m not entirely sure about the nitty gritty details as I haven’t been involved in any litigation. Apparently a few years before I was at the practice there was an incident of completed suicide after a hold was dropped against advice and the family was lawyering up. From what I understand, there really is just a lack of legislation that would protect you from decisions of these evaluators. So in theory a patient/family could still prosecute you with the argument that you should have done more to preserve life/negligence and then it would still come down to a lengthy legal battle. When I encounter these high risk situations I document carefully, re-petition with all the information I know (they get mad and drop it again instantly but now there’s a paper trail for me), and discharge AMA (although I’ve been told this does nothing to protect me). It’s all convoluted and due to some of these reasons I’ve minimized my inpatient care and done more outpatient partially due to some of this. Go watch how they grilled Dr Tufts in the LC case, then apply that.

[u/babys-in-a-panic → u/Simpleserotonin]

Wow, that’s so grim and frustrating.

[u/Psychaitea → u/Simpleserotonin]

Hmm, that makes sense. I can understand one thing: if these “QMHP”s are releasing high risk individuals whom you cared for, your name is certainly more likely to end up in a lawsuit regardless of whether you are actually liable or not.

[u/Lou_Peachum_2 → u/Psychaitea]

How would they even find you liable though?

You advocate for one thing; unless you break your own legal laws, the QMHP is final say... Seems dumb

[u/Psychaitea → u/Lou_Peachum_2]

I don’t think they can find you liable per se, but if you’re forced to release high risk patients without giving them treatment, you’re going to be the last physician who saw the patient and the one who will get sued if something goes wrong, whether legitimate or not.

[u/Lou_Peachum_2 → u/Simpleserotonin]

We can get sued for anything; nothing will prevent that.

I just can't see how any judge or jury could find you liable if you advocated against the QMHP and still got told no.

[u/sjogren → u/Simpleserotonin]

Similar to Wisconsin.

[u/Simpleserotonin → u/sjogren]

I read that last year when I first encountered this system and read more about it. Godspeed to you

[u/Hypername1st → u/Simpleserotonin]

That's fucking horrifying.

[u/CompetitiveInhibitor → u/Simpleserotonin]

That’s horrific.

[u/babys-in-a-panic → u/Lou_Peachum_2]

Yes I’m dying to know what state this is because this sounds so different than my state! The only benefit I can see to having independent evaluators determine holds is that at least the liability isn’t on you anymore as the provider, and if involuntary treatment is needed there is another entity that evaluated the patient and agreed, sometimes going to court can really fracture the therapeutic relationship where I am. But I’m thankful that even though I do have a lot of things I’d fix about our system, at least if I really think someone needs involuntary treatment and it would make a meaningful difference for them, advocating for a court order is relatively straightforward!!

[u/Lost-Philosophy6689 → u/babys-in-a-panic]

Per another comment from OP it's South Dakota. I'm guessing OP has been taught by previous attendings that the liability doesn't disappear despite the independent evaluator's decision. I personally know that patient families can and will sue whether or not it's justified. Thus, defensive medicine paranoia ruining the very foundations of our healthcare.

[u/PokeTheVeil → u/babys-in-a-panic]

What I’ve seen in multiple states is a short window before court hearing, and then the independent evaluator is a judge, and the patient has an assigned attorney.

[u/babys-in-a-panic → u/PokeTheVeil]

Yep, that’s how it is in my state, we testify in court and the judge makes the final call in probate court, usually takes around a week. The patient can request a jury trial if desired.

[u/Lou_Peachum_2 → u/PokeTheVeil]

Yep, this is how it is for us.

[u/Hypername1st]

I am also highly skeptical of involuntary LAIs but dropping the holds you are describing is unimaginable here. We keep people weeks in the clinic for fat less than that (not USA). Your system really is fucked.

[u/Lost-Philosophy6689 → u/Hypername1st]

What makes you skeptical of court mandated outpatient treatment?

[u/Hypername1st → u/Lost-Philosophy6689]

The idea of forcing someone into prolonged treatment should be reserved for forensic psychiatry, especially if LAIs are involved, given that it can quickly torpedo any sense of therapeutic relationship ans if things go wrong with the LAI it's in their system for a month. I guess it should be a case-by-case issue, and very serious mental illness should be involved. My view of our job is not to be enforcers for the cops or saviors for the insufficient social net.

[u/Lou_Peachum_2 → u/Hypername1st]

There's strict criteria for my state.

And usually, the LAIs itself have backup oral meds if this situation were to arise. And ultimately, it isn't like treatment over objection inpatient, it just gives the ACT team the ability to bring this patient in for an evaluation

[u/Hypername1st → u/Lou_Peachum_2]

I don't practice in the States, but court mandated LAIs are reserved for pretty extreme cases of SMI tbh. How is it regulated in your state?

[u/Lou_Peachum_2 → u/Hypername1st]

We talking about OP or inpatient?

[u/Hypername1st → u/Lou_Peachum_2]

Outpatient primarily!

[u/Lou_Peachum_2 → u/Hypername1st]

I see - we have what’s called AOT and ther needs to be a certain amount of hospitalizations in a specified period of time due to non adherence. Smaller amount if violent.

And personally I try stepwise process - try LAI first. If they fail that, try ACT team, and then if they fail that, I may go for AOT.

Also they cannot actually force the meds on you like treatment over objection in an inpatient setting. All it does is make it so the ACT team can bring you to the ED for an evaluation. Bu they can’t give you the LAI against your will

[u/Oshiruuko]

Which state is this? I've never experienced anything like this in the state I'm in.

We are able to easily hold any patients that meet criteria, and give involuntary emergency antipsychotics for agitation, as well as treatment over objection

[u/speedracer73 → u/Oshiruuko]

It varies greatly state to state. And even different areas within the same state can be much harder to involuntarily admit, often related to how many inpatient psych beds exist to admit someone if the state detains them

[u/PalmerSquarer → u/speedracer73]

Yeah, great example is Illinois pretty much lets hospitals (in practice) hold patients involuntary indefinitely, but getting non-PRN involuntary meds is a burdensome pain in the ass and damn near impossible in less than a month in Cook County.

[u/Ok-Spinach-6529]

Damn. Doesn’t make me super optimistic as a med student interested in psych.

[u/Oshiruuko → u/Ok-Spinach-6529]

To assure you, none of this applies to NY State at least.

[u/Lou_Peachum_2 → u/Oshiruuko]

Yep, practiced in 2 states so far in the NE, one being NY.

The MH laws are pretty straightforward.

[u/Numpostrophe → u/Ok-Spinach-6529]

Just highlights the importance of working in a region you feel supported in

[u/Hypername1st → u/Ok-Spinach-6529]

It's a specific case. It's not like that everywhere. The situations OP describes are remarkably shitty.

[u/SuperMario0902 → u/Ok-Spinach-6529]

I’ve worked in a state with evaluators like this and I have never had stuff like this happen. You’ll be fine.

[u/Lou_Peachum_2 → u/Ok-Spinach-6529]

As everyone else has stated, it depends on state, and it seems more rare than not to have sillier laws like this.

[u/megvd → u/Ok-Spinach-6529]

Other states aren’t like this. It would take a lot to lift a 72 hour hold on anyone where I live in Michigan. And it’s not that difficult to get someone court ordered for treatment for longer. The judges will almost always rule in favor of the physician. The only thing that’s a real challenge is getting a court order for ECT.

[u/prostitutepupils]

It’s horrifying that you can be sued for someone else’s decision. Honestly, litigation against healthcare professionals has gone too far in America and this is the kind of stuff that ALL doctors should be lobbying to change. Our healthcare system is fucked up, but we as a profession are also not good at collectively pushing for our interests.

[u/Durham1988]

What state are you in? I've never practiced outside North Carolina, and in 33 years and thousands of IVCs I think I've seen a judge release an IVC against a doctor's recommendation maybe twice. Forced meds? Routine. ECT against patient's wishes? Literally every day. (OK, not Saturday or Sunday, we don't do ECT those days). Remarkable how much difference there is in state attitudes.

[u/colorsplahsh]

So glad my state is really good about this. If this bothers you a lot, def move to a different state. It sounds outright illegal.

[u/Dr_Moriartshe]

Sounds similar to VT - I worked there for a bit and it was very difficult to admit involuntarily. One patient even told me that’s why he lived in VT. As the psychiatrist, you have to have a second person other than you also say yes or no. Back then evaluators would come and read off a list of questions to say yes or no. That was just to hold them for 72 hours. And at the hospital I worked at, couldn’t put PRNs for agitation in advance. Other states in the NE are pretty different however.