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. 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. A Probate Court
can step in to request a hold if an individual is unwilling to be assessed. This is known as an
involuntary commitment order or an order to apprehend. Involuntary commitment is the first step
toward involuntary hold and therapy. 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

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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 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. 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 take up to a year (twelve
months), while an inpatient treatment can take up to half a year (six months)
(GeorgiaLegalAid.org, 2022).
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

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or uninsured patients to public clinical facilities (hospitals) without (at minimum) mental
screening. The goal is to ensure transferred patients are stable and present no threat to themselves
or others. 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,
including (1) little interest/pleasure in activities, (2) feeling depressed/hopeless/interest, (3)
trouble staying asleep, falling asleep, or sleeping too early, (4) having little energy/feeling tired,
(5) overeating/poor appetite, (6) feeling bad about yourself, (7) trouble concentrating, (8)
speaking or moving slowly for other people to notice, and (9) thoughts of being better off while
dead or thoughts of hurting self (National HIV Curriculum, n.d.).
An Evidence-Based Violence Risk Assessment Tool that Could Potentially be Used to

Screen Patients

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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. A score of zero indicates that the risk of violence is
minimal and that no action is required. A score of 1-2 shows the risk is moderate and preventive
measures are required. Finally, a score higher than two implies the risk of violence is “very
high,” meaning a plan must be developed to manage the risk in addition to preventive measures.

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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