Refusal of Emergency Psychiatric Treatment
January 10, 2024 | Health System Risk Management
Emergency medicine and emergency psychiatry face unique legal, ethical, and regulatory challenges, particularly when caring for patients in acute psychiatric crisis. Patient refusal of emergency psychiatric care may lead to conflicts between the patient and the patient's physicians, health systems, caregivers, and family. Emergency department (ED) procedures come under rigorous scrutiny regarding this issue. The ED is often an individual's initial contact with the mental health system, and it is increasingly used as a safety net for diagnosing and managing psychiatric illnesses for adults, adolescents, and children. (1)
Healthcare organizations must ensure that the handling of a patient's refusal is in compliance with state and federal statutes and regulations, as well as relevant case law. In some situations, mental health advocates may intervene to promote the patient's fundamental right to choose or decline treatment.
Patients and their advocates may refuse treatment of a patient's psychiatric emergency for a variety of reasons, including concerns about the side effects of medications, stigma around mental disorders, distrust of physicians, or denial that they have a mental disorder or are experiencing a psychiatric emergency. Agitation, depression, delusional thinking, or other states may indicate that a patient lacks the capacity to accept treatment in an informed manner. Whatever the reason, clinical staff can become caught in a conflict between a patient's right to refuse treatment and their obligation to address the patient's needs.
An American Psychiatric Association task force on psychiatric emergency services defines a psychiatric emergency in part "as a set of circumstances in which . . . the behavior or condition of an individual is perceived by someone, often not the identified individual, as having the potential to rapidly eventuate in a catastrophic outcome."(2)
In some circumstances, this conflict may result in involuntary treatment or admission when patients are deemed a danger to themselves or others. The safety of both patients and staff is paramount; thus, clinicans may override and supersede a patient's consent—including refusal of consent from a parent or guardian of a pediatric patient presenting danger to themself or others—if the circumstances warrant such action. Once safety is established, emergent medical needs may then take priority over behavioral health needs. Skilled and disciplined interventions in...