Sending ED Psych Patient Home? Protect Yourself Legally
Sending ED Psych Patient Home? Protect Yourself Legally
Obtain consult; chart decision making
A young man presented to an emergency department (ED) and reported hallucinations after taking over-the-counter herbal stimulants and diphenhydramine. “The ED diagnosis was ‘acute psychosis resolved.’ The next morning, he jumped from a building and killed himself,” says Stephen G. Reuter, JD, an attorney with Lashly & Baer in St. Louis, MO, who defended the emergency physician (EP) named in the subsequent lawsuit.
The chart lacked any family history or explanation that indicated what the EP was thinking, says Reuter, and the patient’s mental status wasn’t well-documented before he was released.
Reuter says that the case would have been easier to defend if the EP’s diagnosis had been “acute psychosis due to ingestion of over-the-counter stimulants and herbal remedies and diphenhydramine,” which was supported by the toxicology screen. Also, he says the chart should have included a psychiatric consultation, or at least documentation of the EP’s own examination indicating that the patient was alert and answering questions.
“What I would have liked to have seen in the chart was a description of the mental status of the patient several times in the chart before discharge,” says Reuter. “This would have allowed us to show ongoing monitoring by the EP, and at the same time, improvement in the patient’s condition.”
There was a defense verdict for reasons that had nothing to do with the care provided, reports Reuter, but the EP’s poor documentation made the case much more difficult to defend.
The patient’s family’s expert testified that the EP, at a minimum, should have obtained a psychiatric consult, should have more fully examined the patient in the ED a number of times after the initial evaluation, and should have kept the patient in the ED for observation for a longer time.
Obtaining a psychiatric consult is the best way, in the vast majority of cases involving psychiatric diagnoses, for EPs to minimize legal risks, according to Reuter. If a patient is discharged from the ED after a psychotic episode, a plaintiff’s attorney will look at what kind of monitoring the patient received, whether there is documentation of serial exams, what toxicology screens were drawn, whether a psychiatric consultation was obtained, and what the chart says about the reason the EP thought it was safe to discharge the patient, says Reuter.
“With psychiatric patients, the EP does not really have much objective data to consider and the reliability of the patient is quite questionable,” says Reuter. “So, the best risk management tool in these cases is to document every basis of the treatment/discharge decision.”
Case Suggests Limited Exposure
In one North Carolina malpractice case involving a psychiatric patient who shot pedestrians and was injured when law enforcement subdued him, the plaintiff claimed that providers did not properly prescribe antipsychotic medications after a course of commitments and counseling.1 “One can foresee how the scenario could easily have involved an EP for not beginning involuntary commitment procedures or otherwise intervening if the patient had presented in a psychotic episode,” according to Ryan M. Shuirman, JD, an attorney with Yates, McLamb & Weyher in Raleigh, NC.
The North Carolina Court of Appeals reversed the trial court’s entry of judgment for the plaintiff against the defendant psychiatrist. “The Court of Appeals provides a good analysis of proximate causation and whether a psychiatric patient’s violence to himself or herself or others was foreseeable, although the emergency medicine context may be different given the brief window emergency medicine providers have to see patients and make decisions,” says Shuirman.
Shuirman says the opinion seems to reflect that “EPs should have even less exposure in such cases, because imposing liability on EPs, when their interaction with the patient is so limited, would encourage them to be more likely to begin involuntary commitment procedures as a way to avoid being sued.”
EPs Face “Perfect Storm”
An emergency medicine physician dealing with psychiatric patients “may face the perfect storm of a patient with a complex set of diagnoses and an atypical presentation of an acute problem,” says Shuirman.
Shuirman says that relying on potentially unreliable sources of history can expose the EP to liability risks, as family members are unlikely to concede that they are not close to the patient even if they aren’t directly involved in the patient’s psychiatric treatment. “This is only magnified when a claim is made and litigation ensues,” says Shuirman. For instance, in a wrongful death case, the damages awardable compensate the beneficiaries of an estate for the lost relationship with the decedent. “It is, thus, necessary for the beneficiaries to establish that they were close to the decedent, because the closer they were, then the more value their lost relationship would have before a jury,” says Shuirman.
Shuirman says it’s particularly important for EPs to articulate what positive findings were made and to identify any pertinent negatives when documenting a neurologic examination in psychiatric patients, as questions will be raised when there are elements of the exam that are performed but not documented. “This can be most important when there is a negative finding that turns out to be central to a legal claim,” he says.
If an examination cannot be completed, for any reason, the plaintiff’s lawyer will question why not. “Contemporaneously documenting the reason for an incomplete exam will go a long way to explaining this years later when deposition testimony is taken,” Shuirman says.
Reference
1. Williamson v. Liptzin 141 N.C. App. 1 (2000).
Sources
For more information, contact:
- Stephen G. Reuter, JD, Lashly & Baer, St. Louis, MO. Phone: (314) 436-8326. Fax: (314) 621-6844. E-mail: [email protected].
- Ryan M. Shuirman, JD, Yates, McLamb & Weyher, Raleigh, NC. Phone: (919) 719-6036. Fax: (919) 582-2536. E-mail: [email protected].
- Leslie Zun, MD, MBA, Professor and Chair, Department of Emergency Medicine, Mount Sinai Hospital, Chicago (IL) Medical School. Phone: (773) 257-6957. Fax: (773) 257-1770. E-mail: [email protected].
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