Handcuffs on a pile of pills

Emergency Department Psychiatric Holds: A Form of Medical Incarceration?

Wait times and length of stay in emergency departments are a hot topic and often result in a variety of identifiable harms that include medical error and failures to meet quality care measures. Patients with psychiatric conditions, including suicidal ideations, risk for harm to others, or psychosis, are particularly vulnerable to increased emergency department (ED) lengths of stay. The length of ED holds for psychiatric patients can be three-fold that of similar holds for medical patients. Lack of access to appropriate care, comorbid medical illness, or violent behavior can all contribute to this.

Increased length of stay impacts the efficiency of the ED itself, increasing wait times, utilizing human resources and physical space. It has a more important impact, however, on the patient. Patients may be held in a small room with constant observation for days with little or no access to natural light, bathing facilities or contact with family or friends. They may be dressed in paper gowns, told when to eat, when to sleep and confined to their room for days at a time, emulating the conditions in a maximum security prison. Emergency Departments, through no fault of their own, are becoming holding cells for patients who are both vulnerable and often marginalized.

The result is often deterioration of an already fragile state, including increased proclivity to become combative and higher chances of becoming either chemically or physically restrained. Empathy, compassion, privacy and patient-centered care are difficult to maintain by the need to accommodate these holds. Patients are often moved to a wall space or common area where they eat, sleep and discuss their very personal care within earshot of other patients or visitors. The demands on EDs for managing patients with psychiatric crisis is increasing. This however, cannot replace the need for ethical treatment of this vulnerable patient population. There is an imperative for EDs and policy makers to address the issue of ED psychiatric holds, and to ensure that they are treated ethically, with empathy and compassion that is the basic human right of any person in need of care.

It is beyond the scope of this essay to debate the ethics of mandatory treatment. Some have argued that patient autonomy should supersede paternalistic treatment of a psychiatric disorder, even when there is a risk for suicide.  In the United States, the laws regarding mandated treatment lean towards protecting the patient, with an aim towards regaining lost autonomy as the result of their disease. This debate aside, if mandated treatment is to be the norm, then it must be insured that there is an ethical approach to this general policy.

The Changing Landscape of Emergency Care

Most emergency departments are set up to take care of medical complaints. The providers who work in these departments are similarly trained to deal with short, problem-focused visits, rather than longitudinal care. The patient with an acute psychiatric crisis can fall into that category. It may be that they are intoxicated, or simply require medical stabilization. More often than not however, the case is more complex and may often require placement in a long-term psychiatric facility. When that is the case, the landscape begins to change. Previous therapeutic sessions become interrupted, medication schedules disrupted and interactions with the ED staff become sporadic and limited. This can be very disruptive and even harmful for many patients.

To address this, many EDs designate special areas for evaluating and treating patients with an acute psychiatric crisis. These rooms are often devoid of medical equipment to ensure the safety of patients and staff. Patients are usually restricted to these rooms for the duration of their stay, again as an overall safety and accountability measure. When these stays exceed 12 to 24 hours, or, in some cases, a week, then this begins to develop into a medical incarceration.

Even prisoners are allowed two hours of “yard” time a day, something that because of lack of resources is often not possible in the setting of an ED. Even worse is when these designated beds become full. In that case, patients are often boarded on a wall space, creating even greater loss of autonomy and dignity. This is also likely to have a significant impact on the patient’s right to confidentiality, which should be an imperative in this setting.

Lack of Access Contributes to Crisis

There is no easy solution to this issue.

Lack of access to psychiatric beds is a national issue. This creates holds of patients in an already burdened emergency care system, where even medical patients can spend upwards of 24 hours awaiting an in-patient bed. This then requires a re-evaluation of how ED and ED providers should address this problem. First and foremost is ensuring that patients are allowed to engage in autonomous decision making, even when treatment is mandated.

There need to be policies at all levels that address how these holds are accommodated, with assurances that patients receive ongoing therapeutic communications, access to the outdoors or a sunlit room, daily hygiene schedules and maintenance of medication regimens. The use of wall space, while often necessary in the setting of overcrowding, should not be permitted as a place for patient interviewing, exams or as a sleep-space.

Even more urgent is a need to increase access to psychiatric treatment facilities. These beds have been slashed across the country as funding is pulled away from state-run psychiatric hospitals. This has created a crisis of lack of access that will only continue to get worse as ED visits for psychiatric issues continues to escalate. There is an urgent need for reinvestment in funding these beds, both at a state and federal level. Funding should ensure not only bed space, but for quality, evidence-based care and rehabilitative services.

Changing the Paradigm

Emergency department holds of patients with psychiatric crisis has become a necessity in a landscape of ED overcrowding and lack of acute psychiatric care beds. While it is easy to say, “we need the beds”, “we don’t have the security staff” or “it’s just the way we have always done it”, this is not an ethically-guided approach to this problem. Regardless of space and resources, all patients have the right to have autonomy in their care, to be treated in a confidential environment and to maintenance of their ongoing treatment plan. Empathy, compassion and dignity apply to all patients. What at times equates to literally “storing” people on a wall bed violates all of the tenets. The system is broken. There is an imperative to re-examine the “that’s how we have always done it” argument, and invoke policy towards improvement.


Stephen Wood

Stephen P. Wood, MS, ACNP is an acute care nurse practitioner practicing emergency medicine in Boston, Massachusetts, and a fellow in bioethics at the Center for Bioethics at Harvard Medical School in Boston.

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