Exercising Restraint – The Role of the Neighborhood ER in Treating Mental Illness0

“How do you know I’m mad?” said Alice.  “You must be,” said the cat, “or you wouldn’t have come here.” –Lewis Carroll

The challenges facing the local Emergency Room are as varied and complex as the patients it serves.  From trauma surgery to heart attacks to poisoning and beyond, today’s ER must be prepared for just about any health related issue, ready to quickly and accurately diagnose and treat whatever comes through its doors.  Fortunately, the advent of superior diagnostic technology has made the path between illness and wellness increasingly more linear.  So is the case, at least, with matters of the body.

However, when a patient’s illness is mental in nature, the role of a hospital becomes much more complicated.  What happens when a mentally ill patient gets sick in the outside world and must seek help not in a psychiatric care facility, but the neighborhood Emergency Room?  Unlike a trauma or stroke victim, whose injuries typically present as physical, issues of mental health are much harder to pinpoint, diagnose and treat in a timely fashion, as it is primarily the patient’s judgment that falls under question. Proper medical treatment of a mentally unstable patient requires not just the delivery of emergency medicine, but an understanding of the decidedly nonlinear practices of psychiatric medicine as well.  If that was not enough, it also often involves the ability to navigate additional legal hurdles and a host of ever-evolving ethical considerations unique to the psychiatric patient.

Recent advances have attempted to ensure that acute care hospitals afford psychiatric patients the same caliber of service as those presenting with physical ailments, with some success.  Passed in 1986, the Emergency Medical Treatment and Active Labor Act (EMTALA) is a United States Act of Congress that requires every hospital to treat any patient with an emergency condition in such a way that, upon the patient’s release, no further deterioration of the condition is likely.  No hospital may release a patient with an emergency medical condition, physical or mental, without first determining that the patient has been stabilized.  For those who come to the ER with severe mental disabilities, this can create an unusual situation where understanding, patience, and compassion are of great importance.

Though these regulations mean well, the reality they impose often puts hospitals in an awkward position, stretching their already limited resources to include a patient body that brings with it an increased demand for high-level, time-consuming care.  Once admitted to the ER, psychiatric patients often have to wait hours or even days before they are issued a bed within the hospital.  To make matters worse, a disproportionate number of mental patients in the ER also abuse alcohol and / or drugs, making it impossible for doctors to accurately assess the extent of their health until detoxification has been established.  In the interim, beds, services, and staff that would otherwise be used for Emergency Room patients presenting with physical conditions become tied up in the often long wait that comes with getting mental patients situated and provided for prior to diagnosis.  In truth, when it comes to any underlying psychiatric disorder most ERs are only equipped to offer mental patients a hot meal, a place to sleep, and protection, not only from the dangers of living on the streets, but often from themselves.

Treating the mentally ill presents a host of challenges to any ER, and includes addressing methods of communication and adherence to proper modes of conduct.  Even with today’s psychiatric advances and new procedures for doctors to employ when treating the mentally disturbed, the concept of patient safety remains at the top of any hospital’s list of priorities.  The very nature of mental illness can force gray issues when it comes to the acceptability of certain of these methods, such as the use of physical restraints on patients. Psychiatric concerns are unique in that they may force a hospital into the unenviable position of having to choose between a patient’s basic right to freedom and the need to protect the patient from himself.

From the hospital’s perspective, the need to balance prevention of self-inflicted patient harm, as well as harm to other patients and hospital staff, with the above-referenced concerns justifies the use of restraint in certain situations.  While a doctor can never legally use restraint as a means to prevent a voluntary patient from leaving the hospital prior to assessment, since every medical patient has the initial right to leave against medical advice, such an alternative does unfortunately continue to serve a purpose when all other options have been exhausted.

Due to the extremity of such a step, the regulations governing how a hospital may restrain a patient who has been assessed as a danger to himself or others are complex.  Again, the safety and well-being of the patient must always be of primary concern.  Though the laws differ by state, most hospitals agree on a set group of principals by which to abide should this step become necessary:

  • Restraints will be used only for adequately justified situations that are medically necessary based on individually assessed patient needs and behavioral risk factors.
  • Restraints will never be used as a means of coercion, discipline, convenience or retaliation by staff.
  • Restraints will not be based solely on prior history of use or history of dangerous behavior.
  • Preventative or alternative strategies will be used to help staff focus on the patient’s well being and will be incorporated into the patient’s plan of care.
  • Medication used to control behavior will be identified on patient’s medical record and included in patient’s plan of care.
  • Informed consent will be obtained prior to administering any psychotherapeutic medication.
  • The patient’s dignity, rights and well-being will be preserved and physical needs will be met while protecting the patient’s health and safety.

These categorizations, while understandably vague at first glance, do provide a much needed structure on which Emergency Room physicians can rely when a patient presents with issues of mental instability and questionable judgment.  Unlike patients dealing with physical ailments, the mentally ill must be treated under their own subset of conditions, taking into consideration the hidden complexities of the human mind.  Though no doctor ever wants to supersede the rights of a patient, on occasion he or she must be both willing and able to step up and accept responsibility for the well-being of another when that person is no longer able to distinguish between what is harmful and what is not.  The ethics put forth by the Hippocratic Oath demand nothing less.


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