By Stacey Kusterbeck
Psychiatric patients are routinely boarded in emergency departments for hours or even days, raising significant safety issues. There is growing concern about the ethical implications of this controversial practice.1,2 “Clinicians have an ethical obligation to assess decision-making capacity, to respect patients’ rights to refuse treatment and to leave a facility against medical advice, and to provide stabilizing treatment to patients with emergent medical problems,” according to John C. Moskop, PhD, a professor emeritus of internal medicine at the Wake Forest University School of Medicine.
Additionally, clinicians must respect the decisions of psychiatric patients with decision-making capacity and must provide treatments that restore the decision-making capacity of patients who have lost that capacity. “Ethicists can participate in the formulation of policies on informed consent, surrogate decision-making, and involuntary commitment,” says Moskop.
One central ethical concern is that emergency departments typically are not equipped to provide long-term psychiatric care. Some patients receive inadequate mental health support. “Extended periods of boarding can diminish patient autonomy. Patients may feel powerless and neglected,” says Nasuh Malas, MD, MPH, division director and service chief of Child and Adolescent Psychiatry at University of Michigan Health System. Prolonged waiting, uncertainty, and a noisy, chaotic environment can cause irritability, discomfort, and sleep difficulties, resulting in behavioral escalation.
Unlike inpatient settings, the emergency department is oriented to acute care and brief management of crises. “The emergency department may not have built ethics consultation into their regular practice as the inpatient and intensive care settings have, due to the more longitudinal nature of care in those settings,” explains Malas.
Malas says that clinicians can respect the autonomy of psychiatric patients boarded in emergency departments by:
- providing patients with all necessary information in an understandable, clear way. This allows patients to make informed decisions.
- providing choices when possible. “When choices exist, provide information about risks and benefits, to allow for dialogue and patient engagement,” advises Malas. There are a variety of choices that a psychiatric patient can make while in the emergency department. Patients can decide what and when they would like to eat, the timing of their medications, how frequently they want updates from the care team, and what comfort items to use. Safety concerns may limit some of those choices, if access to an item puts patients or others at risk for harm. Even so, clinicians can involve patients in the discussion. “When a choice does not exist, the rationale should be explained. The patient should be allowed to ask questions to clarify understanding,” says Malas.
- maintaining open, honest, and consistent communication with patients about their evaluation and treatment plan.
- involving relevant family members or advocates in care discussions. These individuals can do a lot to support the patient’s overall well-being.
“Ethicists can play a crucial role in ensuring that patient dignity, autonomy, and safety are maintained, even in challenging circumstances,” underscores Malas. Malas says these are unethical practices that may occur with psychiatric emergency department boarding:
- failing to provide adequate psychiatric evaluation and treatment during boarding periods;
- using restraints or seclusion for extended periods as a means to manage behavior when prevention efforts or less restrictive intervention can be appropriately used;
- failing to adequately involve patients in treatment decisions;
- failing to obtain proper informed consent for interventions;
- prioritizing emergency department efficiency over the specific needs of psychiatric patients, thus exacerbating their condition.
“Ethicists can play an important role when complex issues surface,” says Malas. In Malas’ experience, ethics consultations are helpful in these scenarios:
- When clinicians are considering involuntary treatment or restraint. Ethicists can ensure that the patient’s rights and well-being are protected.
- When patients require limitations on rights because of safety concerns that may infringe on autonomy. Ethicists can reconcile patient, staff, and overall care needs to reach a decision on the next steps.
- When patients have complex needs or comorbid conditions, including end-of-life or quality of life concerns.
Ethicists can offer guidance on balancing competing ethical principles. This kind of conflict arises in cases such as a young adult with an eating disorder presenting with severe malnutrition and dehydration who is refusing essential nutrition or hydration, including a nasogastric tube. Clinicians may struggle to determine if the patient has the capacity to make informed decisions about their care.
“In these situations, psychiatric consultation can be helpful in helping the emergency department team assess decision-making capacity, if that is difficult for the emergency department team to ascertain, as well as guide assessment and treatment planning,” suggests Malas. If the decision is made to deliver care against the patient’s wishes, an ethicist can discuss how to do so while also respecting the patient’s autonomy.
“When immediate interventions are necessary but pose significant ethical concerns, an ethics consult can help clarify the most ethically sound course of action — particularly if there is a question about patient capacity to make informed decisions,” says Malas.
References
1. Moskop JC, Derse AR. Adolescent boarding in the ED: Issues of autonomy, nonmaleficence, and distributive justice. Am J Bioeth. 2024;24(7):139-143.
2. Sommerhalder MS, Seltzer RR, Meyers DL, et al. Navigating the ethical dilemmas of youth boarding in the emergency department: Strategies for respecting developing autonomy while also reducing risk. Am J Bioeth. 2024;24(7):135-139.
Psychiatric patients are routinely boarded in emergency departments for hours or even days, raising significant safety issues. There is growing concern about the ethical implications of this controversial practice.
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