Tuesday, October 16, 2012

Words Mean Something

In my  role as a social worker at a medical teaching facility, in a psychiatric department, I've witnessed, written, and read a lot of petitions.  Petitions in Michigan are the initial paperwork needed to hospitalize someone involuntarily.  They're pretty serious stuff.  The petition itself, which anyone can fill out, doesn't take away a person's rights; for that,  two physicians, one of whom must be a psychiatrist, must compete a certificate saying that they agree the patient needs to be hospitalized against his will.

Yes, I said I have written them, and will continue to write them , but only when I'm convinced that a person's symptoms are due to a mental illness and only if those symptoms endanger the patient him or herself, or endanger others.  But I will never like doing it.

Psychiatrists have gotten so used to having patients petitioned and certed that at times they seem to forget the reasons why one is necessary.  No better example of this can I think of than the problem with transportation.

Psychiatric beds are at a premium in Michigan and many other states.  There are never enough, and at times at the hospital I  spend my entire shift calling other hospitals to find a bed for someone, and then end up having to send them up to 150 miles away for treatment, away from any support networks they might have.  No one likes this situation, but ambulance teams are especially nervous about it.  What if a person decides at about mile 100 that they don't want to go to the hospital anymore?  What can they do?  Letting the person out of the ambulance seems inappropriate, but if the person is a voluntary patient without a legal document mandating they be hospitalized, they can't by law keep the person from leaving.

So ambulance drivers started asking if people could write petitions and certs.

The only way to solve such a problem is on an individual basis considering individual patients'  circumstances, state of mind, and how ambivalent they are (or aren't) about treatment.  But the residents who come through, brand new each month, eventually decide that they always have to do a petition and cert "for the ambulance."  "The ambulance won't take them without a cert."  "I have to do a cert for transport [for a patient who does not meet criteria for involuntary commission]"  "But we HAVE to do it because the other hospital wants us to!"

You don't have to do anything, I  remind them.  You're the examining doctor.  Ambulance drivers cannot write certs and they can't tell you to write one.  You can only do so if it is clinically appropriate to do so.

I complained to my boss about this once.  My boss is my social work/crisis worker/keeping-your-head-about-you-when-everyone-else-is-losing-theirs hero.  He knows everything.  "I can't convince these people they don't have to do a cert 'for transport'", I complained.  This was despite the fact that I had successfully educated all  the ambulance drivers I spoke to about this.  "Right.  We never do one for transport.  We do it only for patients who we wouldn't want to leave the ambulance."  I pondered this.  I decided to take that attitude about it.  Because we do have a responsibility, if we do not think the patient will be safe unless hospitalized, to ensure that they actually get to the place they've agreed to go (unless they really do have the capacity to decide to jump out of the ambulance and walk home if they want to, which is unlikely if they need hospitalization).

From then on, I would tell a resident, "You are not writing a cert 'for transport'.  You are writing a cert because you believe the patient is ambivalent about her plan to sign in and you don't want her to leave the ambulance until she gets to the other facility."  "Well isn't that the same thing?"  NO!  Words mean something!

It was my contention that by using the phrase "petition for transport" or "cert for transport" the young psychiatrists were gradually convincing themselves that, contrary to everything they actually knew, it was appropriate to write a cert or petition every time they transferred someone from the ER to another hospital.
Maybe after all is said and done, we end up with as many petitions and certs as we would have in the first place.  But at least the residents, or any other professionals in the ER, wouldn't be convincing themselves or others that "it's OK to write a petition or cert just because the patient is riding in the ambulance."  Maybe it's splitting hairs, but I think it really matters.    

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