I guess my question is, if the hold is not valid till time of transfer, how can they keep a patient against their will in the time the medical issie is being resolved?
There is some variance from state to state, but in addition to certifications and emergency psychiatric holds there are also medical holds. If a patient is not medically cleared and does not seem to have appropriate decision making they may not be free to leave.
Some potential examples include patients who are altered on substance, hepatic encephalopathy, meningitis, neurotoxic effects of methotrexate, and so on.
In these cases many states have said that a psychiatric hold is not appropriate unless the patient is medically cleared during psychiatric evaluation. Some others still allow for their emergency holds to be used during these events. Certainly if you are in a state that has this practice then the hold is effective immediately, not later when medically cleared or during transfer.
You must also consider that a psychiatric hold may still be appropriate in the medical patient. For example a patient who is gravely disabled as a results of not being medication complaint and who has schizophrenia and presents with infectious tenosynovitis needs medical treatment and cannot make their own decisions, however their lack of competency may simply be from their baseline mental health issues and not from their medical condition.
Holding patients against their will is very complex whether it be a psychiatric, medical, or legal reason. Determining competency is a very difficult process. That being said in this case the nurse/case manager is incorrect. The time on the orrigonal emergency hold is not suspended. Either they are being held on a medical hold, they must renew the emergency hold, seek certification in the courts, or arrange for transport to a state designated facility that can honor holds.
Unfortunately this is very poorly understood outside in most medical areas, but especially outside of the areas with the most exposure to it like emergency services, intensive care, and psychiatric facilities. There is also often not a perfect answer, legislation doesn't account for every possible patient presentation. Even in my state which has a pretty clear and robust system for holding patients against their will we are often placed in situations where the presentation doesn't quite fit. It is key for facilites to keep good legal counsel, psychiatrists, a strong ethics team, and so on for the odd cases and one should not just assume or state what they think is correct if they don't know.
To prove how complex these situations can get I'll present a case which is drawn from several similar experiences we've been challenged with.
EMS presents to you a patient who is gravely disabled as a result of profound mental retardation. This patient ran away from his group home, and is brought into the emergency department as the group home does not feel like they can safely care for the patient and does not have the reasonable ability to keep residents inside of their facility. The patient has been certified by the state as not being capable of making their own decisions. The patient does not have any new psychiatric or medical illness. Since they do not have a medical illness they cannot be admitted to the hospital. Since they do not have a new psychiatric illness and do not require medication stabilization it is not appropriate to admit them to an acute psychiatric ward. During the state certification it was determined that this patient must have a proxy for their medical and psychiatric decision making, but does have the right to live in the community and not in a long term mental health facility. As part of the certification the courts determined that family is not an appropriate proxy, but rather combination of the current residential facility and the county adult protective services department while allowing as much decision making by the patient that is reasonable and prudent.
Can this patient be placed on a new psychiatric emergency hold?
Can this patient be placed on a medical hold?
Can you appeal to the courts to change the certification?
Can EMS transport this patient against their will to the emergency department from the field?
Can you hold this patient against their will in the emergency department on their current certification?
It is determined that there is not appropriate facility for the patient in state and eventually an appropriate facility is found in another state. The facility accepts the patient pending approval from the current decision making proxy and the promise that the current residential state will pay for the patient's long term care.
Can this patient be transported against their will to another state against their will?
Is their certification still valid during transport?
Is their certification still valid when their arrive to their new facility which is in a new state and hence not the one that originally certified the patient?
