Regulating psychiatric practice Flashcards
What are exceptions to informed consent
Incompetence Emergency situations Patient waives Therapeutic privilege Involuntary commitment
What are exceptions to inform consent in minors
Emergency situations Emancipation Maturity Specific situation is covered by statute Foster care exception
Canterbury v Spence
Informed consent
Reasonable person standard
The reasonable medical practitioner standard
Natason v Kline Nature of condition Nature of treatment Likelihood of success Alternative treatments Risks of untoward consequences
Subjective patient based consent
Scott v Bradford
All material risks that could affect decision
Three elements of informed consent
Information
Voluntary
Competence
What are elements of competence
1) communication of a choice
2) understanding relevant information provided
3) appreciation of the situation and its consequences
4) rational decision making
Olmstead v. L.C. by Zimring
1) such services are appropriate
2) the affected persons do not oppose community-based treatment
3) community-based services can be reasonably accommodated, taking into account the resources available to the public entity and the needs of others who are receiving disability services from the entity.
Lake vs Cameron
Least restrictive environment for non dangerous people
Jackson v. Indiana
a person charged by a State with a criminal offense who is committed solely on account of his incapacity to proceed to trial cannot be held more than the reasonable period of time necessary to determine whether there is a substantial probability that he will attain that capacity in the foreseeable future.
Elizabeth Packers
Dangerous to self and others
Lanterman Pettus Short Act
California
Ended indefinite commitment
Josiah Oakes (1845)
case introduced concept of “danger to self or others”
67 yr of age, Oakes committed by his family because he became engaged to younger woman instead of properly mourning death of his wife
court ruled that right to confine insane person applied only to those considered dangerous to themselves or others
Lake v Cameron (1966)
Lake v Cameron (1966): landmark case upheld concept of least restrictive treatment alternative; police found 60-yr-old Lake wandering; at commitment hearing, psychiatrists testified she had organic brain syndrome associated with aging; patient not dangerous but at risk for wandering and encountering harm;
Lessard v Schmidt (1972): Lessard picked up by police, confined for 10 days, and diagnosed with schizophrenia
Lessard brought class action suit with civil rights attorney, arguing that civil commitment statute in Wisconsin violated due process;
court held that statute unconstitutional
case set high-water mark for civil commitment and addressed criminalization of civil commitment
proposed safeguards similar to those required for criminal proceedings;
state required to prove beyond reasonable doubt that patient mentally ill and dangerous;
patient maintains Fifth Amendment privilege against self-incrimination
O’Connor v Donaldson (1975):
Donaldson paranoid delusions; his parents committed him to state hospital, where he remained for 15 yr; patient repeatedly demanded friend offered to take patient home with him; Donaldson brought suit and jury awarded compensatory and punitive damages; Fifth Circuit Court affirmed decision and US Supreme Court reviewed case; issue for Court whether state can involuntarily commit nondangerous individuals capable of surviving safely in freedom by themselves or with help of willing family members or friends; Court cited constitutional right to liberty, ruling that state could not confine nondangerous individual
O’Connor v. Donaldson, 422 U.S. 563, 576, 1975)
Courts have interpreted this case in two different manners. Namely, either that a finding of dangerousness is constitutionally required to justify involuntary hospitalization (Stromberg, 1982), or that the nondangerous mentally ill cannot constitutionally be confined without the provision of meaningful treatment.
Addington v Texas
In Addington v. Texas, the U.S. Supreme Court shed light on, and set forth the acceptable evidentiary standards for, commitment proceedings. (See Addington v. Texas, 441 U.S. 418, 1979.)
The Supreme Court held that applying the “clear and convincing” standard provided an acceptable balance between providing due process protections and not making it burdensome to have an individual committed.
the Court ruled that the “clear and convincing” standard should be applied to commitment proceedings
What are standards of proof
“preponderance of the evidence” (i.e., more likely than not),
Clear and convincing an intermediate standard between preponderance and beyond a reasonable doubt
the higher “beyond a reasonable doubt” standard used in criminal cases).
Parham v. J.R., 442 U.S. 584, 608, 1979.
In this case, the U.S. Supreme Court held that a postadmission hearing was not necessary to protect a minor’s interests. Instead, the justices found that a neutral fact finder, such as a physician, could determine whether or not the commitment was appropriate, after a complete review of the reasons for the minor’s hospitalization. The Court preferred this method to full-blown legal proceedings and believed that a traditional medical evaluation was preferable to a more formal adversarial hearing. In fact, the Court found that turning to the judicial system rather than a “trained specialist” on such matters “can turn rational decision making into an unmanageable enterprise.”
Zinermon v. Burch, 494 U.S. 113, 1990.
The Court held that the hospital should have allowed the option of voluntary admission only to patients who were competent to consent to such an admission.
Can a voluntary patient be detained
a voluntary psychiatric patient must notify hospital staff of their request for discharge. In over 30 states, this must be done in writing. The hospital treatment team is then allowed to continue the hospitalization for a period ranging from 4 hours up to 5 days, depending on the state; in some jurisdictions, only business or court days are counted. In some states, the continuation of the admission is contingent on the hospital’s application for an involuntary commitment. In others, this is not required.
Kendra’s law: supports outpatient civil commitment in New York
Duke study found that outpatient commitment >6 mo in duration associated with fewer hospitalizations, less violence, and fewer arrests;
implementation of Kendra’s law associated with increased treatment adherence, improved social functioning, and lower rates of arrest, hospitalization, and homelessness;
American Psychiatric Association Council on Psychiatry and the Law issued position statement on involuntary outpatient commitment
stating that goal to mobilize treatment resources, enhance effectiveness, and improve adherence
council recommended that statutes authorize initial commitment period of 180 days and permit extensions based on specified criteria shown at hearings
Civil commitment
DsmV language and Language from statute definition
Causal connection between mental illness and behaviors
What is the effect of AOT in New York
Analyses of Medicaid claims and state reports on 3576 patients involved in New York’s AOT program yielded similar results (Swartz et al. 2010, 976). Compared to periods of time prior to the initiation of an AOT court order, AOT participants experienced a 25% reduction in psychiatric hospitalizations and over a 30% decrease in inpatient admissions after the AOT orders were renewed for 6 months. Significant declines in inpatient lengths of stay also were evident, with the average pre-AOT duration of hospital admission lasting approximately 18 days, compared to 11 days during the first 6 months of the court order and 10 days during subsequent months of mandated outpatient care.
Youngberg v. Romeo (1982)
the Supreme Court did finally address the substantive due process rights of mentally retarded persons involuntarily committed to institutions. The Court specifically addressed whether such persons had rights under the Fourteenth Amendment to “(i) safe conditions of confinement; (ii) freedom from bodily restraint; and (iii) training or ‘habilitation’” (Youngberg v. Romeo 1982, 309). The Court opine (Rosner)
Rosner, Richard. Principles and Practice of Forensic Psychiatry, 3rd Edition. CRC Press, 20161228. VitalBook file.
Civil Rights of Institutionalized Persons Act, 42 U.S.C. Sec. 1997 et seq.
The “reasonable-modifications” regulation states that public entities must make “reasonable modifications” in order not to discriminate “‘on the basis of disability.” However, these public entities are not required to “fundamentally alter” the nature of their programs (28 C.F.R. 35.130(b)(7)).
