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now I'm going to introduce you to the
topic of forensic psychiatry and we'll
see how the legal system can overlap
with mental health there are a lot of
things we're going to consider here
including confidentiality civil
commitment informed consent criminal
matters we're going to look at
competency versus capacity and medical
malpractice so let's get started now on
the civil side of things by talking
about confidentiality information
between a doctor and a patient should be
confidential it is the physicians duty
to hold matters revealed by the patient
in the course of treatment in strict
confidence from unauthorized third
parties in the United States we have
something called HIPAA which is the
Health Insurance Portability and
Accountability Act this is a federal
statute that imposes a number of
requirements on the disclosure of
information and the protection of
patient privacy in clinical care and
research so I want to introduce you to
Jane and we're going to follow the story
of Jane in this case study throughout
this lecture
Jane is a 33 year old woman she comes to
the emergency room by ambulance and
isn't an acute state of distress she's
sobbing uncontrollably she has cuts on
her arms that are actively bleeding she
talks about wanting to end it all she's
unable to provide any further history to
you and is very agitated she's so
agitated that an empty bottle of pills
falls out of her purse and you notice
it's a bottle of alprazolam and you know
that that's a controlled substance a
benzodiazepine that's highly addicted
could be deadly in both overdose and
withdrawal so how would you proceed now
with your assessment of this woman who's
agitated and not giving you a lot of
information and has arrived in the
emergency room so there are a lot of
things that you're going to consider
so there are emergent issues here and
you're going to address them immediately
once she's medically cleared you're
going to be thinking about wanting to
get a psychiatric calm
involved down the road they're going to
be then some next steps in her
management and safety plan and
eventually when she's well you're going
to be thinking about her disposition and
transfer outside of the hospital but
first things first she's in the
emergency room and you're assessing her
for safety and also for possibly acute
intoxication or withdrawal from
benzodiazepines
and she's refusing to talk to you
because she's too agitated so what do
you do next
well you're going to of course
emergently treat her by checking her
vital signs and so forth you're also
going to consider calling collateral
information you'll review the EMS record
that brought her to the hospital so as a
provider when you learned that this
patient has a history of suicide
attempts because you've reviewed
previous medical records from your
hospital you see that she's had suicide
attempt she's abused benzodiazepines and
also have an alcohol use disorder you
also learned from EMS that there's a
small child that was in the home you've
checked her vital signs and also gotten
a blood alcohol level you've made sure
to secure her ABCs and make sure she's
medically okay once she's medically
stabilized you'll assess her further for
safety so you'll probably put her on a
benzodiazepine taper because she's going
to be a risk for withdrawal which could
be deadly you'll treat her with thiamine
and folate and you're probably going to
admit her once she's emergently
stabilized but ready for transfer she'll
probably go to the intensive care unit
for a little while and you're going to
get a social worker involved to consult
regarding what's happening with this
child at home and once you're ready
you'll consider a psychiatry consult to
the medical unit once the patient's been
stabilized in the ICU and the purpose of
the psychiatric consult is to do a more
thorough risk assessment to find out you
know what the best setting of care for
Jane will be so when is it okay to
breach confidentiality well when you
don't have a lot of information about a
patient and you're in an
Mergent setting that's one place where
confidentiality can in fact be breached
a patient can waive the right to
confidentiality and tell you to call
whomever you like when a patient is
found to be incompetent then you can
breach confidentiality when records are
requested for legal purposes that's
sometimes okay to breach confidentiality
and whatever there is a risk of harm to
a third party
then you must intervene as a physician
so you learn from collateral sources who
you contacted because gene was
emergently at risk will you learn from
them that Jane has a psychiatrist and
that she is actually a single mother
with a small child at home she's been
seeking psychiatric care for a while the
EMS team tells you that the home was in
severe disarray with dirty dishes
everywhere an empty pill bottles lying
around and there was a four year old at
home crying who appeared malnourished
with bruises on her arms legs and
abdomen so what's your obligation now
regarding this child
so remember you have it a duty to
protect third parties from harm so you
want to also make sure that because this
is a minor that you have your social
services team or you yourself make sure
that child is actually protected this
was probably done by EMS but you want to
confirm that in fact Child Protective
Services are involved in this case so
what is the physicians duty if he or she
suspects child abuse well although it
varies by jurisdiction the duty is to
report all cases of suspected child
abuse to the appropriate government
entity and a breach of confidentiality
is ethically permissible when there is a
need to protect the patient or third
parties so it's important to remember
the bottom line really is that there is
a basic duty to protect a potential
victim if a therapist knows of a
patient's potential for substantial harm
to an identified or readily identified
individual when it comes to protecting
third parties we go back to the key case
Tarasov versus California and although
this case can vary state to state it
really sets the precedent for the need
to either warn or protect third parties
from harm let's talk now about
commitment
so commitment is the process of
hospitalizing a person against his or
her will this is referred to as
involuntary civil commitment in the
Supreme Court case of O'Connor versus
Donaldson ruled that a harmless patient
could not be confined against their will
without treatment if they could survive
in a less restrictive setting so that's
something very important to understand
when a patient is hospitalized against
their will they have a right to what is
called a writ of habeas corpus now what
is that well it's a petition that a
person can file with the court if they
feel that they have been illegally
deprived of their liberties let's go
back to the case of gene who appears to
have made a suicide attempt so in the
case of Miss Jane when she eventually
Sobers up and she's doing a bit better
you learned that she is actually feeling
very suicidal she complains of wanting
to die and she tells you that she's
hopeless about her future you recommend
to her that she go to the inpatient
psychiatry unit for further treatment
but Jane knows that child protective
services have been called and she's very
upset and she says I won't follow your
recommendations I'd rather go home and
die so how are you going to get Jane the
psychiatric treatment that you now know
she needs because she's threatening to
harm herself so here's where you
consider hospitalization and it's
important to know about the different
types of admission to an inpatient
psychiatry unit of course this can vary
by states and countries but in general a
voluntary admission is when a patient
requests help and they agree to go to
the inpatient unit they agree to the
spirit of treatment working with their
doctors and nurses to making a plan and
then leaving once they feel safe
an involuntary admission refers to in
the United States what's called a
commitment process in an involuntary
admission is something that happens when
a patient is at risk of harming
themselves others or cannot meet their
basic needs of life so what is civil
commitment well it's really the
deprivation of fundamental rights
guaranteed under the US Constitution so
before a state or entity can deprive an
individual of their frontal fundamental
rights a proper procedural protection
must be granted which is called due
process all individuals can only be
involuntary involuntarily committed only
if they are a danger to themselves or
others so in the case of Jane she was
definitely a harm to herself it's
possible her child was at harm and also
there's a question if she was able to
meet her basic needs of life meaning was
she so depressed and suicidal that she
had become gravely disabled there was
evidence of that in her home by being in
complete disarray with empty bottles
lying around so again the commitment
criteria or criteria to involuntarily
admit someone to an inpatient psychiatry
unit requires harm to self harm to
others or an inability to meet demands
of ordinary life such that they're
gravely disabled so Jean ends up getting
admitted to the inpatient psychiatry
unit against her well because of a risk
of serious harm
once there Jane quickly sees the benefit
and she agrees to treatment and agrees
to become a voluntary patient she says I
want to work with my treatment team she
forgoes her right to file a writ of
habeas corpus she forgoes her right to
have a court hearing for the purpose of
civil commitment but rather she says now
I'd like to be voluntary I want to stay
here and I want to work with my team so
you end up recommending to Jane that she
avail herself of therapy and you also
recommend she takes some medication to
help
symptoms
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