Legal and Ethical Challenges, Part 1: General Population.

Several federal and state laws and regulations, as well as ethical medical principles, govern the emergency clinician's practice of care. Although some common legal-medical and ethical principles are shared with other medical specialties, emergency medicine and emergency psychiatry have unique legal and ethical challenges. This article presents and discusses these challenges, including the physician-patient relationship, malpractice, confidentiality and privilege, duty to report, decision-making capacity and vicarious decision-making, the Emergency Medical Treatment and Labor Act, right to treatment, hospital admissions, involuntary commitment, forced medication administration, and child and elder abuse.

Sentimentos de familiares de pacientes internados na emergência psiquiátrica: um olhar sobre a família / Sentimientos de familiares de pacientes internados en urgencia psiquiátrica: una mirada sobre la familia / Feelings of relatives of patients hospitalized in the psychiatric emergency care unit: a look on the family

RESUMO O presente estudo teve como objetivo compreender os sentimentos dos familiares que chegam à emergência psiquiátrica com um ente em agudização dos sintomas do transtorno mental. Trata-se de uma pesquisa descritiva-exploratória com abordagem qualitativa. Participaram 20 familiares de pessoas com transtorno mental atendidos na Emergência Psiquiátrica de um Hospital da Rede Pública do Interior do Estado de São Paulo. Para coleta de dados, utilizou-se um roteiro de entrevista individual. As entrevistas foram áudio-gravadas e tratadas conforme análise de conteúdo temática de Bardin. Os dados resultaram em duas categorias: A internação no serviço de emergência psiquiátrica como alívio da sobrecarga familiar; e A agudização do transtorno mental como gerador de angústia e tristeza para a família. Desta forma, compreender os sentimentos predominantes nos familiares dos pacientes no ato da internação no Serviço de Emergência contribui para a elaboração de estratégias para a construção de uma atuação profissional humanística visando à inclusão da unidade familiar em todas as etapas do cuidado.

RESUMEN El presente estudio tuvo como objetivo comprender los sentimientos de los familiares que llegan a urgencia psiquiátrica con un ente en agudización de los síntomas del trastorno mental. Se trata de una investigación descriptiva-exploratoria con enfoque cualitativo. Participaron 20 familiares de personas con trastorno mental atendidos en la Urgencia Psiquiátrica de un Hospital de la Red Pública del Interior del Estado de São Paulo. Para la recolección de datos, fue utilizado un guión de entrevista individual. Las entrevistas fueron audio-grabadas y tratadas conforme análisis de contenido temático de Bardin. Los datos resultaron en dos categorías: La internación en el servicio de urgencia psiquiátrica como alivio de la sobrecarga familiar; y La agudización del trastorno mental como generador de angustia y tristeza para la familia. De esta forma, comprender los sentimientos predominantes en los familiares de los pacientes en el momento de la internación en el Servicio de Urgencia contribuye para la elaboración de estrategias para la construcción de una actuación profesional humanística, pretendiendo la inclusión de la unidad familiar en todas las etapas del cuidado.

ABSTRACT This study has the objective to understand the feelings of relatives that arrive at the psychiatric emergency care unit with a family member in a moment of acute symptoms of mental disorder. It is an exploratory, descriptive research with a qualitative approach. The study has 20 families of individuals suffering from a mental disorder who were assisted in the Psychiatric Emergency Care Unit of a Public Hospital of the Interior of São Paulo state. For data collection, individual interviews were used. The interviews were audio-recorded and treated according to content analysis of Bardin. Data resulted in two categories: Internment in psychiatric emergency service to relieve the family burden, and The crisis of mental disorder such as anxiety generator and sadness for the family. Thus, to understand the feelings prevailing in the patients' relatives at the moment of hospitalization in the Emergency Care Unit, there was the elaboration of strategies for the construction of a professional humanistic performance seeking the inclusion of the family unit in all stages of the care.

[Use of restraint in psychiatry: Feelings of caregivers and ethical perspectives]. / Usage de la contention en psychiatrie : vécu soignant et perspectives éthiques.

INTRODUCTION: The return of restraint in psychiatry raises many ethical issues for caregivers. However their experience is little explored in literature. OBJECTIVES: Our objective was to study the feelings of caregivers facing restraint with regard to an ethical perspective and to identify areas for improvement. METHOD: Between November 2011 and February 2012 a descriptive cross-sectional epidemiological study was performed in two psychiatric emergency services and two closed units in which doctors and nurses were individually interviewed using semi-structured questionnaires. Five topics were explored: indications and contexts, impact on the patient, caregiver-patient relationship, perspective on the practice and feelings of caregivers on which we insist particularly. Results were presented in tables with percentages and possibly diagrams. The notable responses of caregivers were also cited. RESULTS: Twenty nurses and nine psychiatrists, mostly female, were recruited. They all had participated in experiments of restraint. The self-aggressiveness, the aggressiveness against other persons and agitation were the most frequent indications. In the patients, caregivers identified misunderstanding (79.3%) and anger (75.9%). The majority of nurses (75%) felt that there was an improvement in the caregiver-patient relationship after the episode of restraint compared to what it had been in the moments preceding this measure. The emotional experience of caregivers was rich, intense and predominantly negative type of frustration (35% of nurses; 66.7% of doctors), anger (30 and 33.3%) and lack of feeling (35 and 44.4%). The feelings of doctors and nurses were not completely similar. For caregivers it was "a difficult but necessary experience" (82.75%), "an act of care and safety" (68.9%). All psychiatrists and almost half of the nurses (45%) said they did not feel the same when they used seclusion. In their opinion, seclusion entailed a less painful experience because of its therapeutic properties. More than half of the caregivers thought that there were alternatives to restraint: the strengthening of containing function in the hours before the use of restraint; the use of seclusion at the time of the decision to restrain. They identified contexts (80%) encouraging the use of restraints, not only related to the patient, the lack of resources but also institutional contexts, in particular conflicts or divisions in the health care team. DISCUSSION: The misunderstanding of the patient led us to wonder about the quality of the information he/she received: it was sometimes too formal and did not take into account the uniqueness of the patient. The frustration of caregivers could concern the lack of resources but also be directed towards a patient or caregiver. In addition, there were often cleavages between doctors and nurses that stemmed from a misunderstanding, also with rivalries and power struggles. From the literature and caregivers' reflections we identified three prospects to reduce the use of restraint and modify feelings of caregivers: 1) develop better crisis management upstream through increasing resources and improving training; 2) promote patients support in using ethical principles of autonomy and beneficence by showing them solicitude, inviting them to tell themselves and helping them to regain their own experience; 3) develop an afterthought in setting up institutional reflection time by restoring a central role in clinical team meetings in psychiatry, possibly supplemented by supervision, but also through regional ethical spaces. CONCLUSION: In our investigation, we found that caregivers had a predominantly negative experience with frustration, anger and a lack of feeling. Among caregivers we also identified awareness of ethical issues that may be for the first time for a change.

Clinical and ethical dilemmas in the psychiatric care of patients who border on the edge of being able to live safely and independently.

In the current economic environment and era of health care finance reform, mental health budgets have faced cutbacks across the nation, and they may face even deeper reductions in the future. Diminished funding for care of patients with severe psychiatric illness creates significant ethical and clinical dilemmas. Throughout medicine, physicians' professional virtues and obligations of beneficence may conflict with the need to balance respect for patient autonomy and deliver clinically appropriate, humane, and ethical care within a limited budget. This article uses a case presentation to highlight this struggle at the interface of psychiatry, ethics, and the emergency room in the care of people with severe mental illness.

An unusual case of subterfuge in the emergency department: covert administration of antipsychotic and anxiolytic medications to control an agitated patient.

Pediatric, nursing home, and institutionalized psychiatric patients frequently receive medications covertly or against their will. Surreptitious medicating of emergency department (ED) psychiatric patients may occur but has not been reported. We discuss competing ethical, therapeutic, and legal issues in potential conflict during the treatment of an acutely psychotic patient who had homicidal and suicidal ideation and presented to a busy, urban ED. The practice of covertly medicating may not be uncommon in EDs, but fear of professional censure probably inhibits open discussion and documentation of such events. No specific statutory, ethical, or case law in the United States seems to control this type of situation.

Duty of care in the emergency department.

This paper explores issues that relate to the management of deliberate self-harm in the emergency department (ED) from a New South Wales perspective. A scenario that is typical to the ED is presented to illustrate the dilemma that nurses face and the implications for clinical practice. Confusion and concern regarding the treatment and detention of this type of patient in the ED can often result in the inappropriate use of the Mental Health Act. It is preferable for clinicians to be aware of the treatment options they have under duty of care rather than relying on the unfounded reassurance provided by scheduling a patient under the Mental Health Act. Communication and negotiation skills are highlighted as attributes that clinicians must develop and enhance to effectively manage difficult presentations to the ED.