By Marcy Phipps, RN
(Identifying details of the patient and clinician mentioned in this post have been changed to protect their anonymity.)
Last week I took care of a woman who’d shot herself in the abdomen. This was the third suicide attempt she’d survived. She was physically compromised, to say the least, and was looking at a long recovery. Her despondence was palpable.
A clinical psychologist came to evaluate her and determined that she was experiencing major depression with suicidal ideations.
Red For Danger/via RichardO, Flickr
Usually, such patients are “Baker Acted.” In accordance with the Florida Mental Health Act, commonly referred to as the Baker Act, individuals who are deemed to be a danger to themselves or to others are held involuntarily and transferred to a treatment facility.
But because this patient stated to the psychologist that she was not only willing to seek mental health treatment, but also planned on checking herself into a facility near her home, she didn’t qualify to be involuntarily hospitalized. She was free to leave at any time.
As the psychologist explained to me, the first criterion of the Baker Act only considers whether or not the person in question is refusing treatment. According to Florida Statute 394.463, as long as said person does not refuse to be examined, the Baker Act does not apply.
Although the psychologist assured me that he would find a way to provide the patient with a “safety net,” I found it ironic and slightly shocking that the only thing stopping her from leaving the hospital and carrying out her intentions was the physical self-harm that she’d already inflicted.
Towards the end of the day my patient suffered a coughing fit that left her gasping for breath. When I asked her if she was alright, she seemed to forget herself for a moment and replied, “I hope so.”
It seemed a strange thing for her to say.
And since she doesn’t qualify for the Baker Act, I hope so, too.
Marcy Phipps is an RN in St. Petersburg, Florida. Her essay, “The Soul on the Head of a Pin,” appeared in the May issue of AJN, and she has contributed several posts to this blog in recent months (here’s the most recent).
I’m not a lawyer but I wonder if this is a correct interpretation of the law. Most states prefer mental health patients to be admitted voluntarily have mechanisms in place to convert involuntary patients. Although in Zimeron v. Burch the supreme court held that patients who lacked capability to make the decision could not be admitted voluntarily because voluntary admission lacked procedural safeguards of involuntary admission.
If in the judgment of the responsible and legally authorized clinician the patient had a mental disorder and was a danger to herself from suicidality she should be admitted voluntarily or involuntarily. If as the patient wanted to go elsewhere for treatment or wanted to go home first, then the clinician needs to make a judgment. If he determines that the danger is too high to release her with a promise to go elsewhere, than the clinician should have admitted her or transferred her in a secure manner to a secure facility – voluntarily if she consents or involuntarily if she does not.
If the clinician judged that it was safe to make a plan which allowed her to be on her own to pursue admission then he could proceed to discharge her with a plan to go to another facility.
These are very, very difficult clinical judgments but there isn’t any “legal” loophole, if in the clinician’s judgment she was safe enough to arrange her own admission, then he could discharge her. On the other hand, if in his judgment she was at risk to act on her suicidal impulses unless admitted directly to psychiatric unit directly from the ICU or ER, then she could be involuntarily admitted directly to a the mental health unit. Indeed, if that was his judgment than involuntary admission is the only ethical option.
To Fuzzy, one ethical basis for civil commitment is that patients with mental disorder are acting in an altered mental state which can be changed, i.e. treated, after which the patient will agree that treatment was warranted. This has been called the “thank you” theory of commitment (Credit to Dr Stone). We know empirically that many patients are not thankful after coerced treatment. However, my clinical experience was that mental health patients with suicidality are ambivalent. In fact, much assessment and treatment of suicidality related to mental disorder relies on patient report the accuracy of which depends on the patient being ambivalent.
At the same time, I can’t help but think that if an adult wants to kill themselves, we really ought to let them. Anyone who has tried this much, is in this much mental pain….if they really want to die, why are we keeping them alive?
It seems that we’re always trying to do the right thing for our patients, whether they want us to or not. It’s very disheartening that the only time a psychiatrist/psychologist sees a patient is after the patient has been medicated with Haldol, Seroquel, Risperidone, etc AFTER the crisis is over and the patient “appears” stable. One of the big failures, overall, of our health care system is mental health.And that is tragic. Your patient saying “I hope so” could be a “I don’t know, you’re the nurse, you tell me” type of response or actual concern that she may have something physically wrong with her. The disconnect between a psych patient’s psyche and physical well being astounds me. But I guess that’s why they’re a psych patient.