NRNP 6675: PMHNP Care Across the Lifespan II

An involuntary hold is a legal process through which an individual is confined in a
mental clinical facility because of a treatable mental condition against their wishes. This paper
examines the state of Georgia’s laws for involuntary psychiatric holds for child/adult mental
emergencies and the state’s differences among emergency hospitalization for evaluation and
psychiatric hold, inpatient commitment, and outpatient commitment. It also explores legal and
ethical issues associated with the EMTALA legislation within the milieu of treating psychiatric
patients and defines the difference between capacity and competence. It also identifies evidence-
based suicide risk assessment and violent risk assessment tools that can potentially be used to
screen patients for involuntary psychiatric holds and emergency commitments.
The State of Georgia’s Laws for Involuntary Psychiatric Holds for Child/Adult Psychiatric

Emergencies

In Georgia, an order for an involuntary hold for a child/adult can only be issued after an
assessment by doctors who must confirm that an involuntary hold is necessary. There are three
options in which a person can be forced to undergo an involuntary assessment: (1) court petition
(two or more individuals who have witnessed a patient’s behavior within 48 hours of the case
hearing data may request the Probate Court for an involuntary evaluation, (2) a doctor’s request
(the doctor who believes the patient requires involuntary assessment signs a 1013 Request Form
and hands it to the court, and (3) law enforcement (a person is taken in for evaluation by a peace
officer). If the judge of the Probate Court issues an apprehension order, the Sheriff’s deputy
escorts the said individual to a clinical facility (hospital) for a mental evaluation by a physician.
The individual can be held for a maximum of 48 hours for assessment. If the physician concurs

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that the individual meets the criteria for inpatient treatment, the patient can be held up to five
extra days in the facility (GeorgiaLegalAid.org, 2020).
The Differences Among Emergency Hospitalization for Evaluation/Psychiatric Hold,

Inpatient Commitment, and Outpatient Commitment in Georgia
The law differentiates between emergency hospitalization for evaluation/psychiatric hold
and inpatient and outpatient commitment in Georgia. As indicated above, the Sheriff’s deputy
can take a patient to a hospital for emergency evaluation upon an order by the judge of the
Probate Court. The patient is admitted to and held by the clinical facility (psychiatric hospital)
for up to 48 hours commissioned by the Department. If the physician agrees that the patient
qualifies or meets the criteria for inpatient treatment, the hospital can hold the patient for an extra
five days. If a different chief medical officer, psychologist, or doctor feels the patient is eligible
for further treatment, the law allows them to petition for involuntary treatment/therapy in the
Probate Court. A hearing is usually conducted ten to twelve days after filing the petition. If the
Probate Court concurs that psychiatric therapy is required, an outpatient treatment order can
commit the individual up to a year (twelve months), while an inpatient treatment can commit up
to half a year (six months) (GeorgiaLegalAid.org, 2022).
Capacity vs. Competence

In the mental health context, “capacity” is the functional determination that a person
(usually a mentally incapacitated individual) can or cannot make an informed decision, such as
offering informed consent, in certain situations. The capacity of a patient to make informed
decisions is usually established by psychologists, physicians, or clinicians. On the other hand,
“competence” is a person’s ability to partake in legal proceedings; it is usually determined or
established by a judge (Buppert, 2021).

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Legal and Ethical Issues Associated with Emergency Medical Treatment and Labor Act

(EMTALA) When Treating Psychiatric Emergencies

The Emergency Medical Treatment and Labor Act (EMTALA) was passed in 1986 by
Congress as part of the 1985 COBRA (Consolidated Omnibus Budget Reconciliation Act)
regulation. EMTALA was explicitly created to discourage hospitals from transferring Medicaid
or uninsured patients to public clinical facilities (hospitals) without (at minimum) mental
screening. The legislation mandates Medicare-participating facilities (hospitals) with emergency
units/departments to screen/assess and treat all emergency clinical conditions (including
mental/psychiatric emergencies) without discriminating, regardless of color, creed, race,
nationality of origin, insurance status, and ability to pay (Brenner et al., 2021). However, when
treating psychiatric emergencies, mandatory screening can raise the ethical question of patients’
autonomy to make personal decisions without interference from clinicians (Buppert, 2021). At
the same time, the requirement by EMTALA to mandatorily screen patients even without
insurance can pose multiple legal issues, for example, what legal procedures hospitals can take to
recoup their money and who should be liable for the loss.
An Evidence-Based Suicide Risk Assessment Tool That Could Potentially be Used to

Screen Patients

The Patient Health Questionnaire-9 (PHQ-9) is the most appropriate tool to screen a
patient’s suicide risk. This 9-item checklist asks the patient to respond to whether they have been
bothered by stress and suicide-related thoughts and behaviors within the past two weeks in nine
different area, including thoughts of being better off while dead or thoughts of hurting self
(National HIV Curriculum, n.d.).

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An Evidence-Based Violence Risk Assessment Tool that Could Potentially be Used to

Screen Patients

An evidence-based violence risk assessment tool that can potentially be used to
screen/evaluate patient violent behaviors/thoughts is the Broset Violence Checklist (BVC). On a
scale of 0-6, this six-item checklist can help clinicians predict the patients’ imminent violent
behavior (Almvik, 2020). The six items include attacking objects, physical threats, boisterous,
verbal threats, irritability, and confusion.

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References

Almvik, R. (2020). The Broset Violence Checklist (BVC) is a 6-item checklist which assists in the
prediction of imminent violent behavior (24 hrs perspective). https://www.risk-
assessment.no/
Brenner, J. M., et al. (2021). Ethical issues in the access to emergency care for undocumented
immigrants. Journal of the American College of Emergency Physicians Open, 2(3). doi:
10.1002/emp2.12461
Buppert, C. (2021). Nurse practitioner’s business practice and legal guide (7 th ed.). Jones &
Bartlett Learning.
GeorgiaLegalAid.org. (2020). What should I know about involuntary treatment for mental health
and substance abuse issues? https://www.georgialegalaid.org/resource/what-should-i-
know-about-involuntary-treatment-for-mental-health-and-substance-abuse-issues
National HIV Curriculum. (n.d.). Patient Health Questionnaire-9 (PHQ-9).
https://www.hiv.uw.edu/page/mental-health-screening/phq-9