Resident Seminar April 13, 2009

1. Resident Seminar April 13, 2009 How the “Legal 2000” Works

2. Introductions • Melissa Piasecki, M.D. • University of Nevada School of Medicine

3. Objectives • At the end of this session you will be able to: Describe commitment standards Complete a valid Legal 2000 form Follow the process for filing petitions (to extend legal hold beyond 72 hours)

4. Law and Medicine • Different Languages • Different Values • Different Rules

5. Rules and Values • Medicine: we should treat patients who are ill (suffering); duty • Law: individuals have protected rights against intrusive and unwanted treatments; statutes • State: protection of public and individuals

6. The Conflict • Patient best interests– Treatment! • Individual Liberty Interests– Freedom! • Public Safety • Law serves to address conflict • Judges serve to rule on conflict

7. Nevada Revised Statutes (NRS) • http://search.leg.state.nv.us/nrs/searchnrs.html • Mental health Law is Chapter 433A and B • Varies from state to state

8. Mental Illness is NOT By Legal Definition: • Substance Intoxication, Delirium, Withdrawal or Dependence as a primary problem • Mental retardation • Dementia • Seizure disorder

9. You Cannot Involuntarily Hold by Legal 2000 • Medical problem • Substance Intoxication, Withdrawal or Dependence as primary problem • (Contrast with other states: Alaska) • Mental retardation • Dementia • Delirium

10. Legal 2000: The Certificate • 2 pages, 3 sections • Each page must be signed, dated and timed to be a valid document • All sections must be completed • Shelf life: 72 hours

11. Involuntary Admission: The Certificate Page 1 Police, MSW, PhD, MD “Behaviors that you have personally observed”

12. Page 1 Continued Behaviors that put person at risk for: 1. Suicide or self-mutilation 2. Violence towards others 3. Inability to meet basic needs (food, shelter, medical care) resulting in death or disability within the next 30 days

13. Criteria • Objective (observable) • Do NOT include need for treatment, non-adherence to medication

14. Which are Behaviors? • “Psychotic”→ • “Bizarre” → • “Suicidal” → • “Manic” →

15. Which are behaviors that raise the question of imminent risk of harm to others, mutilation, death or disability? • Responding to internal stimuli • Not taking antipsychotic • Paranoid • Urinating in trash can • Arguing with family • Not taking showers • Preaching on the street • Harassing casino workers

16. Be Explicit! • How might the patient’s behavior lead to problems? • “Paranoid” compare with: • “Paranoia about electricity led to shutting off power. Temperature in apartment found to be 105 degrees. Patient treated for hyperthermia in emergency room and remains delusional.”

17. Be Explicit! • How might the patient’s behavior lead to problems? • “Impulsive and inappropriate behavior” compare with: • “Patient’s impulsive behavior this morning led to her disrobing in public and standing in the street facing on-coming traffic. She was pushed away from a car, narrowly escaping serious injury. ”

18. Look for the incontrovertible • What would any reasonable person find a serious risk to self or others?

19. Certificate Page 2 • Psychiatrist, psychologist or general MD • “Paint a picture” of your observations and how patient behavior is dangerous to self or others

20. Summary • Two pages must be completed, dated, timed • Information must specifically address harm to others 4. This allows for up to 72 hours of hospitalization

21. “72 Hours” Now What? Prepare and file petition the day before certificate expires MD examines the patient and signs DA signs the petition Sends the case to court Wednesday “precourt”- patient must be presented Thursday hearing before judge- patient has right to be incourt

22. Precourt • Send the whole chart with the patient • Chart the behaviors that meet criteria • Complete the form that targets this information • Let the hospital representative know about behavior and discharge planning

23. What if it Certificate Expires and No Valid Petition is Filed? • Judge dismisses petition • Physician must discharge patient • Patient can decide to stay as voluntary • Liability goes to clinicians

24. Can I Just Start Another Certificate if the First Expired? • No. • Can file as late as Wednesday in certain circumstances

25. Commitment Hearing • Thursday at 9:45 am • NNMHAS Courtroom • Family Court judge or master • Sworn Testimony of treatment team member

26. Commitment Standard • Judge Commits (up to 6 months) or Dismisses the Petition based on the evidence presented • “Clear and Convincing” Evidence required for commitment • Evidence that significant bodily harm will likely come to patient or others

27. Committment • Up to 6 months • Often much less • Can be discharged at any time • Public Record • Gun ownership

28. Committed • Does NOT mean incompetent • Separate determination • Does NOT allow for involuntary assessment or treatment • Denial of rights procedure • ONLY allows for involuntary hospitalization • When to discharge?

29. Questions?

30. Special Cases • Patient started out voluntary then was put on a certificate • 72 hour hold decreases to 48 hours • Petition must be filed within 48 hours

31. Special Cases • On a Legal 2000 but “elopes” • Call the hospital police and RPD/ SPD • Tarasoff alerts if necessary

32. Special Cases • Patient left the hospital and came back 1 day later • Complete a new Legal 2000 Certificate

33. Special Cases • You suspect the patient’s self-harm behavior is attributable to Borderline PD • Personality disorders fall within NRS definition of mental illness • Involuntary admission criteria include self mutilation

34. Special Cases • The patient met criteria when they first came in but now they do not • Patient must sign in voluntarily or be discharged • Some institutions require a second opinion

35. Special Cases • Patient wants to continue (agrees to stay under a hold for 7 days) but won’t go to pre-court • Call Public Defender: 337-4818 • Only the patient’s attorney can arrange for the continuance

36. Special Cases • Patient is not medically stable for transfer • Public defender can continue the case after speaking with the patient • Petition must be filed within 72 hours

37. Special Cases • Patient has a legal guardian with authority to consent to medical treatment • Guardianship does not allow for psychiatric hospitalization– court approval required • It does usually allow for involuntary medication

38. Special Cases • Patient will deny all problems and not appear to meet criteria at Pre-Court • Go to pre-court and present your findings • Send good documentation of patient’s risk behavior

39. Special Cases • Legal 2000 poorly written (by someone else) and does not describe behavior adequately • Go to pre-court and present your findings • Bring other clinical documentation

40. Summary • NRS requires strict observation of • Behavioral terms on Legal 2000 • Criteria for commitment • Time limits • You can make a difference in the court process • Good luck!