Psychiatry & Psychotherapy Podcast - Deciding for Others: Involuntary Holds and Decision Making Capacity

Episode Date: September 28, 2019

This week on the Psychiatry and Psychotherapy Podcast, I am joined by Dr. Mark Ard, a chief resident physician at Loma Linda University's Psychiatry program, to talk about holds and capacity evaluations as it relates to medicine and psychiatry. By listening to this episode, you can earn 1.25 Psychiatry CME Credits. Link to blog. Link to YouTube video.

Hello and welcome to the Psychiatry and Psychotherapy Podcast. I'm here to talk about getting rid of burnout, increasing job satisfaction, and feeling like an expert in what you do. One thing that created a lot of burnout and angst for me was trying to get continued medical education right at the last minute. So why not join the CME membership and do CMEE while listening to this podcast? Go to Psychiatrypodcast.com, sign up, sign in, take the test, and the certification is email to you in seconds. Welcome back to the podcast. I am joined today with none other than Dr. Mark Ard. He is now a fourth-year resident at our beloved psychiatry residency program that I'm a part of, Loma Linda. And he does an amazing job teaching medical students. He got Teacher of the Year Award. And he is going into

C&L, potentially. And we're hopefully going to court him to say. stay here, but you know how that goes. And he is passionate about CNL constantly as in psychiatry. And one of the big things that comes up in CNL is putting people on holds against their will and doing something called a capacity evaluation. And so he has submitted an article where he's kind of merging these two different things. We tend to think about them differently. So tell me a little bit mark about why you think today this is important for the general psychiatrist therapist, future trainee to understand. Yeah, I go back to actually my first year of medical school. We rotate through the, with the ethics team, and I remember sitting in on discussions with our

clinical ethics team on some of the most ridiculous cases, very complex medical situations, a lot of cognitive impairment, and patients having to make. very difficult decisions or family members having to make decisions. I remember thinking like, this is super interesting that this happens. And doctors are put in this position. And I actually did a master's in ethics while in medical school to focus on this. And then going into psychiatry, you really see how often we as psychiatrists help make decisions for patients when they're unable to.

And there are times, I think in our patient population, more than most other medical specialties where patients maybe even for a brief period of time or depending on the condition for a longer period of time really struggle to make decisions that keep themselves safe, keep others safe, or lead to their best life. And we have to help them do that and their processes in place. And then within the consultation and liaison world, you get to do that in the hospital setting where there's also medical issues at stake as well and patient's ability to make those decisions. I think, you know, if you're a psychiatrist, really understanding how the medical hold process works and the protections that are there for patients, I mean, of course, we'll talk about it

in the context of California, but it really applies in all the states. It's helpful to review that. And if you're not a psychiatrist, you don't write these holds. It's helpful to know, like, what the people that are writing them are thinking. And then when it comes to capacity evaluation, I think what we're doing with involuntary holds, at the end of the day, it really is a capacity evaluation. We are making the determination that a patient can't make the choice that they're trying to make for reasons that become apparent through the evaluation process. And a lot of times we as psychiatrists or mental health professionals, you know, ethicists don't have to be doctors or psychiatrists. We might get called in as second opinions to help primary teams

make these difficult decisions or work with patients to come to the best solution. So I think I think it's important for everybody in mental health. Yeah, and I think actually often it's poorly understood. You know, often holds are ridden in such a way that it's not really a viable hold. Capacity evals are asked for when you don't really need to be a psychiatrist to do a capacity eval. So I think I'm hoping that you can kind of flush some of these things out. And also, I think you have uniquely looked at how they're similar. right?

Yeah, yeah. And at the end of the day, if you're, if you have somebody who wants to leave a hospital and is a danger to themselves, others greatly disabled, you know, these criteria for psychiatric holds, and you're going to hold them there. What you're really saying is, I understand this choice that you're making, but you're not able to demonstrate that you can make this decision. So we're going to keep you here.

In essence, that is stating that they don't have the capacity to make this decision. You have to justify. at least to yourself, if not in your documentation, why you're making this determination based off the evidence in front of you. And that's really the essence of a psychiatric hold. And I think that we aren't really taught it that way. We're taught it very medical legally to protect ourselves because you are protected when you write holds in a certain way and justify them in a certain way. But really understanding the ethical underpinning of these holds as a capacity evaluation really puts it all together. and helps you understand not only why it might be appropriate to hold somebody in an emergency room,

but it might be appropriate to hold somebody who just came out of surgery and is delirious trying to leave the hospital. It's the same idea. They're incapacitated. And I really want to understand those as really the same idea. Okay. Great. And Mark did a prior episode with me as well on placebo. If you like this episode, check that one out.

That one was a lot of fun. and he is my weightlifting buddy, although, you know, you're a resident. I'm in attending, I feel like the normal sort of barriers don't apply to me, although I don't usually feel it with most people, but I would say especially for Mark, we're like colleagues already. And he is also the top score in our residency for the, what is it called? In training exam? In training exam.

Yeah, anyways. Okay. So tell me about. probate versus LPS. Yeah, I thought we'd start with a big picture view of what it means to say that somebody can't make decisions. So again, we're going to focus a lot on California, but I think that if you're outside of California, you should look into your state's laws.

They really do kind of mimic this idea, that there are times where a person cannot make decisions for themselves because of, for lack of a better word, an organic illness. a brain injury, developmental disorder, dementia, and really you need somebody to come in and make a decision for them. So that would be a probate level conservator, so somebody making decisions for them assigned by a court. And what we're saying is where we presume that somebody can make a decision for themselves, we have actually taken this person to court and shown evidence that, no, they actually can't make decisions for themselves in broad areas for them, for their medical decisions, kind of all their medical decisions. They can't make decisions about their money. So we assign

either a family member or somebody, a state representative, to make decisions for them. This is the idea of a probate conservator. Sometimes we grant them dementia powers, meaning if you're my conservator, you're going to make my medical decisions, but you might also admit me to a locked dementia ward against my will because you have been granted the powers to make that decision. And then on the other side, this is what we in psychiatry deal with a lot. And again, in California, this idea of psychiatric holds, but we operate under the Lantern-Petish Short Act, so LPS, we'll often call it. It's a whole separate part of the law.

And really what it says is because of your severe mental illness or your chronic alcoholism and inability to really abstain, you're gravely disabled. You cannot provide food clothing or shelter for your self. And I don't really expect you to be able to do that at least in the next couple months. And I need to assign somebody to make all the decisions for you to make your decisions on where you're going to live, what medications you're going to take, because you're unable to do that. And I had to take you to court to get this right.

Or in the case of psychiatric conservatorship, you know, a psychiatrist initiated this process to get somebody assigned to make decisions for you. And I think that's the big picture view, and this is a very long-term situation. But I think it's helpful to start with this view is, well, what do we do for people that really cannot make decisions for themselves, kind of for the rest of their life? And we have a process both. The way I like to break it down is, do you need a psychiatrist or not? If you don't need a psychiatrist, you go this probate route. And if you do need a psychiatrist, you go the psychiatric route.

Yeah, I think that's helpful. And I think, you know, as we're thinking about this, when I think about it, I think about this is often the most loving thing you can do to someone who needs this sort of service. How does someone get on probate? So it's a complicated process. There's a petition you have to make to the court. There's a long waiting list, especially if you're trying to assign a, a, uh, a county representative. So if you know an elderly person, a lot of times it ends up being an elderly person, but it could be somebody with, like I said, developmental delays that is not

able to make decisions for themselves. You submit to the court, it costs money. You could do this, you know, to a grandparent. You can start this process. And maybe you're saying I should be, you know, my grandfather's conservator because, you know, as he's aged, he's not able to make decisions about his finances or decisions about his medical care. Let's start that process through the court system, and it could take months to get this right. Yeah. And I think it also protects them because I've had a lot of patients who have come to me

who have been pulled into various schemes and swindled out of large amounts of money. You know, they'll have someone who starts to work for them in their house, and then slowly that person will get access to their bank accounts and slowly start making withdrawals before the family members can realize, like, you know, $100,000 is gone, and then this person has just disappeared. So we're really trying to protect people. And already we're starting to have a discussion about values, which will come up when we talk about capacity. But at the end of the day, and you said, this is something loving that we could do for a family member, what we're saying is, you know, grandma, grandpa,

I know that you value life. I know you love seeing your grandchildren. I know there's still things that bring you happiness and joy. But because of your advancing illness, you're not able to make the best decisions about stuff like surgery, medications, maybe even where you're going to live. And I need to have somebody make that decision for you so you can live the best life possible under the new limitations that are slowly advancing upon you. What role does a psychiatrist play with probate and LPS? So probate conservatorship, we do have some role. Our assessment does carry some weight in this process when you're petitioning a judge to take away rights of somebody.

It's sometimes helpful to have a psychiatric evaluation. On the LPS side, on the psychiatric conservatorship side, that's really where we initiate things. We say, you know, not only are you gravely disabled, but like this looks like it's going to be there for a long time. time. The most common indications like schizophrenia, severe bipolar disorder, I don't expect you to be able to regain the function to make these decisions for yourself. And this process starts in a locked psychiatric hospital as we, you know, and we'll go through the hold process. But, you know, you came in on an initial hold. You went through multiple court processes and you were placed on a temporary conservatorship. It lasts for weeks to months. There's another

judicial evaluation, and finally you are placed on a long-term conservatorship, and a public guardian is assigned to you. And that's really initiated and moved forward by psychiatrists. That's good. Okay, let's go through the holds, 5150, 50-250, 50-50, and walk me through all of those. I think it's helpful to go through these. Like I said, this is California. Other states might be more conservative and more liberal, and really this revolves around patient rights. But I thought what would be helpful is to understand what happens during these process. You might know somebody that was placed on a 5150 hold. You might be wondering, you know, what protections exist for patients. So if we imagine somebody coming in in a severe manic episode, right, and the decisions they're making are putting

themselves at risk, putting others at risks, and really they are not able to provide for themselves. This is somebody that might think they have, you know, superpowers can raise the dead, heal the sick, and are, I think. Untreated bipolar. Used to have a suicide rate of 20%. Yeah. It's lower now. Considerably lower.

And this is a type of patients before we had interventions available that you might have to chain to the wall, right? I mean, there's nothing you could do to keep them or yourself safe. Well, until South Patriar, you know, had the moral reforms and they let people walk around the campuses and stuff. But these people are danger themselves, danger to others, or unable to take care of their food, clothing, and shelter, and in that state, sober.

And sober, right. And I think, I mean, about the interventions used, I think over time we hopefully have become more civil in the interventions that we've used. But in the emergent setting, like, you know, if you've dealt with somebody in an acute manic episode that thinks that what they're doing is justified the limits of those actions. can be extreme and really put people at danger. So they get brought in.

A police officer picks them up or a friend or family member brings them in. They're evaluated and they're placed on a 51-50 involuntary hold, often thought of as the three-day hold, 72-hour hold. I want to quote it because it's really important to understand what is involved in that hold. So it's as a result of a mental health disorder, right? The evaluator has at least come to the initial. conclusion that I think something mental is going on here. It's not a head injury. I don't think you're swinging at me because you have a severe infection or fever. It's as a result of a mental health disorder. You're a danger to others, yourself, or gravely disabled. And we're going to hold you

for up to 72 hours for assessment, evaluation, crisis intervention, or placement for more evaluation and treatment in a special facility. And in that law, and I think, People often forget this. There's a line that says, if the person can be served without being detained, they should be provided all of these things, evaluation, intervention, inpatient or outpatient services on a voluntary basis. So already we're getting this idea of capacity, right? I'm offering these things to you voluntarily,

and you're not demonstrating the capacity to accept these things voluntarily, so I'm involuntarily holding you. And under this section of the law, I can do that for three days. So that's where things start. Yeah. And like I said, I think the biggest thing that I see screwed up in this is often people put people on a 5150 when they're intoxicated. Sure. Or they put them on a 5150 and their justification is their diagnosis. Like you're on a 5150 because you're depressed.

That's not why I'm not letting you go home. I'm not letting you go home because of the risk that you pose or your inability to demonstrate how you're going to provide for yourself. Yes, you might be depressed. Yes, you might be bipolar. Yes, you might have schizophrenia. But the diagnosis doesn't dictate the hold criteria. The hold criteria themselves.

They speak for themselves. And already there's patient protections, right? So one thing that I think people forget is you can't be forced to take medication if you're on a 72-hour involuntary hold. All I'm saying is I can't let you go from here because I don't think you're safe. To get you to take medications is a whole separate court process. So already there's some patient protections built into that. You have access to patients' right advocates. And all of this happens on this first 72-hour hold.

So then California takes that further. We have a 52-50, a 14-1. day extension, right? And this is after the end of 72 hours, a psychiatrist has evaluated you and they say, you know, even after 72 hours, your mental health disorder is not resolved enough to where you're demonstrating the capacity to be safe to yourself, others, or provide for yourself. So I'm going to extend this 72-hour hold up to 14 days. And oftentimes, patients are told incorrectly that you're on a 72-hour hold, you're on a three-day hold, then you'll get to go.

And many times, and I've wanted to say this to calm people down, and I think that nurses or EMTs that are only seeing a patient for a moment and maybe they're agitated that they're on a hold will say something like, you'll go home in three days. Well, that's not necessarily the case. As I'm treating you and evaluating you, I might extend that up to 14 days. And if I've done that, you get even more protection. In California, you automatically get a sort of,

or a probable cause hearing, right? Within four days, you're going to have a representative from the court hear your case and determine whether I, the doctor, have met a probable cause threshold, meaning, you know, there's a significant amount of evidence for what I'm doing, extending these 14 days. That's built into the system. You get that automatically. And then if the court representative says, yes, the doctor has shown probable cause, you can disagree with that and ask for a request of a writ of habeas corpus, right? So you get to go to court and argue in front of a judge why you should not be kept up to an additional 14 days.

And there's an entire process built in to protect patients and really allow them to demonstrate that the doctor was wrong. I don't need to be held. So I think that these are the things that we deal with 95% of the time in the basic inpatient psychiatry. I think one of the big things is how you talk to the patient about this. you know like you said if if they'll be voluntary and you feel like you would be safe putting them voluntary yeah there may be situations where you don't feel comfortable putting them voluntary because you think they may change their mind when you're off shift well actually they at the end of a 51 50 as it expires they can choose to stay voluntary and then if four days later they decide to leave the hospital and you don't think that that's appropriate you can initiate this 5250s

and they are credited for all those days they stayed voluntarily as part of those 14 days. The way that I describe it, that's good. Yeah, and the way that I describe it is posture means everything, right? If you're in a locked inpatient psychiatric ward because of your mania, if you're looking into the ward, right, you're looking at the unit, you as the patient are looking into the unit and saying, yes, I want to be here, I want treatment because I understand that I need it, then you should be there voluntarily. If you're staring at that locked door saying, I want out, then you're going to be there involuntarily.

And it may seem like it's the same thing. You're going to be there. But posture means everything. Like, I'm going to treat you one way or the other. I'm going to have compassion for you, one way or the other. I want to help you. But your posture dictates whether you're going to be held there involuntarily or voluntarily. Yeah.

So I think I would say if you're having this conversation with the patient, it's best to listen to them. to listen to their concerns, their desire to leave, to empathize and validate it. To really see yourself as like, what would it be like for you to be in their shoes and want to leave? And I think you can empathize with the distress

and say, of course, you want to leave. Of course, it's incredibly hard. And of course, you know, like, you don't, I hear you don't want to be here. So you can, I think if you start with that empathy and then just say, you know, I'm wondering if I can explain to you why I think it's important for you

to be on this hold at this time. So ask for permission. And if, you know, if they're manic or if they're psychotic and they can't interact with you in this level, then maybe don't. But to start with empathy, of course it's distressing. Like no one wants to be held against their will. I have a patient who 10 years later still remembers being put on a hold. And she was only on hold for one day. and I was the resident that admitted her

and now I'm the attending treating her and she'll still bring it up. And she even confuses it like she doesn't remember that I tried to get her out and that I needed her to stay through the night so that she could see the attending. And I'm not sold that inpatient hospitalization is the right thing for everybody in every circumstance, right?

I think that being in a locked psychiatric hospital for a lot of times is so, distressing, it actually might be a big setback for care. And I'm trying to balance safety, safety of yourself and other people with what is best for you. And a lot of times, there are plenty of patients that we would rather them be on an inpatient ward if they wanted to. But they actually have really good resources outside of here. They have good family involvement. And we let them go, even though we think it might be better, you know, to be here for treatment. And so it is a case by case basis, and we are doing everything we can to validate and give you an opportunity to demonstrate that you have the capacity to choose to leave.

Right. And also, again, at this point, we have not forced anybody to take medications. If I think you should take medications and you're disagreeing with me, it's a completely separate court process where I have to, again, demonstrate that you're not able to refuse this medication. So I think of like a classic schizophrenic patient who is severely psychotic and is refusing medications because they're so paranoid of that medication. We'll go through the court process and get involuntary medication order and we'll give them medication. And then a few days, weeks later, you know, sometimes they can reflect on it and be like, oh, I was really in a bad situation.

Now that I'm on this medication, I see that, you know, the thing I was paranoid is not real. Yeah. I've also had manic patients who come back to me a week later, and they literally don't remember the first three days of the hospital. They don't remember being put on a hold. They don't remember, they don't remember, like, that whole time period. It's like so weird to me. It's weird to me, too. I've just recently had a few patients that I've picked up that told me about their manic episode, and that's exactly how they describe it.

I literally don't remember most of it. But my mom says I wasn't sleeping for a week straight and I was blessing people in the street. I mean, like, you were doing things that were so abnormal to your normal behavior and you were putting yourself at risk. You don't remember any of that. To me, that's actually a sign like, I think the thing that happened to you was a manic episode. Yeah, 100%. So in California, you know, at this point, you might have been in a hospital for 17 days, right? You've had a probable cause hearing.

Maybe you've went to court for your writ of habeas corpus. maybe you went to the hospital or to the court again for an involuntary medication consent, and yet there's still more. California has a few different options, and we don't have to go into all the details of them, but they could be extended for different periods of time up to three months if you pose a significant danger to other people. I think of the psychotic patient who is intent on killing somebody, and we can extend that hold up to an additional 180 days.

as we continue to evaluate and treat them. We do know that schizophrenic patients in the first psychotic break have increased violence. We know that by and large, 95% of violence in America is not caused by someone with mental illness. So although we're talking about these people who have a mental illness and can get homicidal, it's a very small percentage of actual violence,

violent events. Right. And I mean, somebody with schizophrenia is much more likely to be a victim of violence than there to be a perpetrator of violence. These are very select population that we deal with. Actually, that's a good aside because I think when I talk about what I do to the general public, they have a picture of somebody who might have told them about a mental illness that somebody diagnosed them with. But when I think about the people that I'm treating on an inpatient ward, there's a good chance, unless you work in the mental health field, you have no. exposure to somebody this ill. So when I think of severe, you know, untreated schizophrenia or bipolar disorder, this is somebody that I deal with on a daily basis, but most people just have,

have no understanding of how ill this person really is. Yeah. And like I said, the people with bipolar prior to treatment, you know, prior to the advent of lithium, stuff like that, 20% committed suicide. That's a very high percentage. So we are saving lives by admitting people with mania to a psychiatric hospital and giving them life-saving treatment. And I think it's so hard being impatient because your patients are grumpy and unhappy at you. And they're at the worst or the worst. Or if they're manic, they're trying to convert you to whatever mania is telling them. is the cure to the world.

But you're in the midst of all of that affect. And in the midst of that, you're holding people against their will, and so they're really upset at you often. And it's a really tough job. It's really tough. Like when I cover on the weekend, it's more exhausting than my normal job.

Oh, for the most part, I think of my med management clinics, and in a month, I might have to hospitalize somebody against their will once, Maybe. If that. If that. And usually they need treatment and all I got to do is call family member and bring them in and surround them with people that will help them. They don't really need to go to a psychiatric hospital. That's another myth that I think most patients have is that if I say I'm at all suicidal, my mental health professional will lock me up. I have patients talk to me about suicide every day. I don't lock them up because I know there's reasons why they won't kill themselves. And they've had this for months or years. And it's not getting worse or it's like it's getting better. And so I think it's really important to put out there like these patients who are suicidal,

who need to be put on a hold, have a plan. You know, they've written letters to family or friends. They don't have any family support often. And the course of their illness, when we look at it, we're highly suspicious that things are going to get worse because they have no follow-up. or no plan to actually do anything that will actually keep them from getting worse. Yeah, they have intent, plan, means, psychological motivation and lack of support. And really those are the things that raise that risk.

And often very high anxiety. Yeah. People who are suicidal with higher anxiety are more at risk, you know. And then, and then they drink or they use some other drug that just turns off that shred of the frontal lobe that's holding everything together. And all of a sudden they follow through on this thing that they've been thinking about or planning about or stuck on this suicidal thought.

I mean, this is why substance use is so scary in this group of people because even though they had reasons not to do it, you turn that off, you know, when you get drunk in a depressed suicidal state. And these are the people that I see in the emergency room that I say, now you can't go home like this. Yeah. Yeah.

And sometimes it's just a gut feeling. And sometimes it's like the hair on your back kind of stands up. Or you're like, you know, like this person, there's something about this person that this one needs to come in. Whereas, you know, if they have family to go to, if they have a partial program or a daytribun program, they can start right away. If they have really good follow up, that's a very different situation. Yeah. So I think, you know, now that we kind of have in perspective, of what happens from the day somebody gets placed on an involuntary hold all the way up through

three-day hold, 14-day hold, temporary conservatorship while there's somebody assigned from the county to make decisions, all the way to a long-term conservatorship, which lasts for a year and it has to be renewed every year. That's the process that we go through. And I think it's good to transition now into this idea of capacity. And I want to pause on this weird. law in California because I think it really feeds into this idea of capacity. So in California, 5150s really only apply in a psychiatric hospital that's been like approved to be a psychiatric hospital. We do treatment and then evaluation there. What happens to a patient who has, is suicidal or gravely disabled because of their psychiatric illness, but they're on like a general

acute care hospital, right? They just had a surgery or they're being treated for pneumonia. So California has a section of a law. It's a completely separate section. And we call it as the 1799 section of the law. And really what it says is that you as a doctor, a surgeon, internal medicine doctor, you are protected from holding somebody against their will if that person cannot be safely released from a hospital because of their mental disorder. It's just basically a copy paste of the 5150 criteria and present a danger to yourself. others are gravely disabled.

And you as the medical doctor are supposed to find a psychiatric hospital for them when they're medically stable. You treated their pneumonia, but they're still suicidal. You treated their pneumonia. They're still psychotic and gravely disabled. And now you think, okay, you know, you don't longer need to be on my medical ward. You can go to a psych hospital. It's your job to find them a psychiatric hospital.

And under this section of the law, you can keep them 24 hours. And historically, it is impossible to find a psychiatric hospital. hospital in 24 hours when you're still kind of recovering from your pneumonia or you have a cast on or you have surgical staples, right? So any plans to change that, Mark, Arden? Oh my gosh. If I could put on a short list of missions, it would be to fix this section of the law because it doesn't make sense. It is a solution in search of a problem. Yeah. And most people who aren't in the maybe therapist, they may not realize how hard it is to get into a psychiatric hospital at times.

And what do I do with that person who does have a mental disorder is trying to leave my hospital and their pneumonia really is just clearing up, right? And the reason I cite this law, and if you're not in California, and you think, well, what the heck is this? It's important because I am consulted as a psychiatrist, as a consul-liason psychiatrist when our team is called into evaluate patients, and they're trying to leave the hospital, 99% of the time they're trying to leave the hospital.

And some good intention, surgeon or internal medicine physician, places them on the 799 hold because they can. You don't need to be a psychiatrist to do this. You know, they click a button, and all of a sudden everybody will stop them from leaving, and then they'll call psychiatry, and I'll go evaluate them. And this is not a mental health disorder.

You know, Eric Chung out of UCLA published a paper on the medical hold which really doesn't exist. It's an idea that they develop, though, that other hospitals use some form of too, where UCLA came up with this rule for how to stop people who don't have capacity, which we'll define here soon, that are trying to leave the hospital, and it's not a psychiatric issue. And lo and behold, like, it happens a lot. And before you have a hospital policy to deal with people like this,

you just inappropriately put them on psychiatric holds. You call psychiatry inappropriately, and you're just trying to do the best you can, but there is no legal process. Yeah, there's no such thing. It doesn't exist in a law. So the patients who are wanting to leave, but not appropriate to leave, and do not have like a mental disorder. Right.

Are those, you're classifying a lot of those as delirious or like TBI? Yeah, yeah, traumatic brain injury or delirious or developmentally delayed or dementia. Yeah, I think that that would be the group of people. And I think it helps. to understand informed consent because what will happen sometimes is, you know, the surgeon or hospitalist will let the patient go as long as they'll sign an AMA form, like against medical advice. You want to leave the hospital? Sign this form. You can go. If you're letting somebody do that, you're letting them make a decision. You're saying they have the informed consent to make

this decision. And you think about what it takes to give informed consent, right? So you have to understand. You have to make a decision voluntarily. I have to disclose to you all the information about your decision. I have to recommend a plan that you either agree with or disagree with. You have to comprehend that plan and then you have to decide and I have to authorize it. All these things need to happen for you to partake an informed decision process. And letting somebody go against medical advice that has no idea where they are or what's going on is not an informed decision. And those seven things, by the way, will be in the resource library so that you guys can

have those things for your notes. Because essentially that's how you write an informed consent note, right? Right. And for certain things, you think about a surgery, right? If I'm going to do an informed consent for a surgery, you need to demonstrate all these things. Your signature is not, you know, in and of itself, consent for me to do this surgery.

And a lot of times we do implied consent, right? Like if you're getting your blood drawn, you stick your arm out, I'm holding a needle. We have that look in our eyes that I'm about to poke you. That's implied. consent. But it's because you are, you're showing me the signs or actions that what I'm about to do make sense to you. And if at any point you don't like it in here, like we should have a discussion about it. Maybe we should have some actual paperwork. That's informed consent. And I think

that that is our transition into capacity. So informed consent is, um, competence to understand and decide. Two is voluntary decision. making, three, disclosure of material information, four, recommendation of a plan, and then five, they have to comprehend three and four, which is they have to comprehend the disclosure of the material information and recommendation of a plan, and then six, they have to make a decision in favor of a plan, and seven, authorization of the plan. Right. or, you know, six, the decision against the plan would be their actual decision.

I disagree with that thing. And my informed consent is that I don't want to do the thing that you're recommending. Yeah. So capacity. Man, that term comes up a lot. And if you look in the literature, it's pretty interchangeable with competence. We spent a lot of time, the whole first, you know, part of this podcast talking about conservatorship and when a judge gets involved. I think the easy way to think about it's a easy way to think about.

it is if you got to go to court, it's a competence question. I assume you're competent until I have to take you to court to show that you're not. Capacity instead is very specific and you have to demonstrate capacity for the decision you're going to make. So one of my most frustrating consults that we get as an inpatient psychiatric consult team is consult for capacity. That's like what it's written on the order. And the first thing I think is like capacity. to do what? Like, what is the patient trying to do? What are you trying to do that they're not letting you do? Like, what are we evaluating? Right. Yeah. And it's frustrating because a lot of these physicians could do it themselves and quickly determine capacity. So this isn't something

that psychiatrists get special training for. Right. We're not really needed for this. Right. In fact, when I do a capacity evaluation as a psychiatrist, it's a second opinion. And I make that very clear that you, the hospitalist or surgeon, should document your capacity evaluation. I kind of help you do that, but you need to come up with a decision. And then I get a second opinion. If we disagree or it's like a super difficult case, we should call clinical ethics and get a third opinion because we really want to think about this thing that we're about to do.

That's really good. So tell me what is like the criteria for capacity. Yeah. So there are, I think of five criteria. for capacity. And the literature talks about these first four, and then this fifth one is kind of built into it. But first thing, and it seems obvious,

is to have capacity to make a decision requires you to make a decision. So I think we can use a very specific case of a patient who is delirious and encephalopathic. They have a liver disorder, and they have toxins that are affected, their mental state and they're confused. They don't know where they are, when they are, what the heck's going on. Maybe, you know, they are pulling out their IV lines or trying to leave the hospital.

So I will be consulted for the capacity to leave the hospital. So ostensibly, the doctor is recommending you stay in the hospital and you, the patient, are trying to leave the hospital. You have met the first criteria of a capacity evaluation. I want to leave the hospital. That is the decision you are trying to make. So if the patient's gorked out, and by gorked out, I mean, like, in a coma, non-responsive, then they've already not been able to do this, right? They can't demonstrate the capacity. And we'll talk about what happens if you can't demonstrate the capacity to make a decision.

But really, if you're not making a decision, there is no capacity we're evaluating. So I'm very specific to a consulting team is like, what do you want the patient to do? Because that's the thing I'm going to ask them if they want to do. doctor says he wants you to stay in the hospital what do you want to do well i want to leave that's your decision so the next thing they have to demonstrate is they have to understand the relevant medical facts they don't have to understand what the heck encephalopathy means but they need to understand like something's wrong with my liver and i should be here to get it treated and that something is affecting my brain right they need to at least at a lay person's level and and it really depends on on

the decision they're making, we'll talk about that too, but they need to understand a relevant amount of information. I think of the patient who comes into the emergency room after just getting stabbed in the chest, and I'm going to take them to surgery. And I say, you know, we're going to do the surgery. And he says, yes, please do this surgery. They really don't need to understand all of the risks involves in an emergent situation. Right. But if they're saying, I don't want you to do the surgery, they really need to understand what not doing the surgery means, right? So it depends on the decision that they make. A yes or a no or two completely different decisions.

Yes, I want to stay in the hospital. You don't really have to prove to me that you understand your condition that well. You want to leave the hospital. You have to convince me that you understand what's going on here. And then, along with understanding your relevant medical situation, the third thing is you have to appreciate what I'm asking you to do. do and all of the risks and benefits that come with it and the alternative treatments. So a lot of times we as physicians forget that there's alternatives, right?

You know, I want you to stay in this hospital. Well, yeah, but I want to go home and my family can watch me. Well, that is an alternative. It might not be the best alternative, but there might be a situation where, hey, we can agree to disagree. You can sign out against medical advice, right? Because you really do appreciate that by leaving, you are raising your risk. But you need to demonstrate to me that you've thought about this stuff.

Like, this is what the doctor wants. This is why it's good. This is the risk that come with it. This is the risks if I choose the other thing. This is the benefits. You need to go through this process and show me that you've put the effort into it. Yeah. Yeah, that's good.

That's good. And on most capacity evals, the people consulting you, do they do they do this? No, I think this is the one where patients are like, I have no idea what's wrong with me. I have no idea what the doctor really wants me to do. I don't know why they want me to do this thing. I don't know really what's going on. And sometimes I don't even know.

I'm a psychiatrist and I went to medical school. So sometimes I understand like what a, you know, a laparotomy is and a lavage is. And I've seen these things before. But really, this isn't my day-to-day job. So I'll grab the doctor, right, who's the primary doctor. And I'll say, here, stand here while I talk with the patient because, like, I don't think the patient understands these things. and I don't understand these things, you need to tell the patient

what the risk, benefits, and alternatives are, and the patient needs to understand them and repeat them at an appropriate level. And I need you here to do this, because I can't do this. I can't ask the patient to tell me the risk benefits and alternatives of a laparotomy, right?

I don't know what they are. So at this point, you know, you are listening to them, go through this process. You're listening to them, take in information, synthesize it, report it back to you at an appropriate level, weigh these risk benefits and alternatives. And the fourth criteria of a capacity evaluation is your assessment on their ability to do this reasonably and rationally. And those words are used

a little interchangeably. But basically, what is their thought process? Do you agree with their thought process? Could you see how they can come to the conclusion they did based off of, you know, the dots that they were given? So, you know, if they say the voice on my shoulder is telling me to leave the hospital here. They're not really displaying a reasonable thought process versus somebody who says, you know, I've lived a good life. I've written my will and testament. I've talked to my kids about this. I said, I don't want to go through this suffering. I've been in the hospital for three weeks. I am done with this. I told you this yesterday. And now I'm leaving. And I'm going to go home and I'm going to die. And I've thought this through. And here's all the proof that I've thought this through.

You might hear that and say, wow, that's not the decision I would make. But I can understand how you would make that decision. That's the empathy point. So they say to you, Dr. Ard, I don't want your neck surgery. I'm going to go home and use my essential oils for this large fungating mass of a cancer in my neck because my essential oils are going to shrink this tumor because my homeopath has told me that all I need is essential oils for this. That's a good case. I think one thing I would think about is how significant is this illness, how dangerous is the decision they're going to make.

The doctor says if they don't have the surgery, they're never going to speak again. it's really close to their voice box. They're going to lose their ability to speak. And if they don't have the surgery, it may, I don't know, let's make up something like fun. It may embolize and cause a stroke. I mean, these hypothetical situations are, we think of them as ridiculous, but they happen. They happen a lot, right? Where the worldview of your patient might be one that is more in line with these alternative treatments

and they don't weigh the facts like you do. And you're really trying to balance letting them make autonomous decisions versus helping them reach their predefined goals. And I think that that being the fifth criteria of a capacity evaluation is, is the decision you're making consistent with your values? Is it consistent through time? Is it consistent with your stated values and what matters to you? Because in this case, it sounds like, you know,

this patient, wants to go on living. They just think that this decision they're making will get them there. And, I mean, depending on how emergent the case is, they might not be able to demonstrate the capacity to leave and go do these things that you're mentioning. I mean, it depends on the case. I also think of the exasperated patient who wants to stop doing dialysis, right? This is like day 100 of dialysis in the hospital and they're demoralized. The decision they're making today to stop dialysis will kill them in the next few days. Even if they understand that and even if they seemingly appreciate the risk benefits

and alternatives of that decision and they kind of are walking you through a reasonable thought process of why they're choosing to stop dialysis. One question I have is like, is this consistent with your beliefs? Is this something you've talked with anybody about? Or did you come up with this today because today is an especially bad day? If that's the case today, you might not be able to demonstrate the decision that you know might change the course of your life yeah yeah that's really good i think on that one right there right that's the point that you can empathize the most right like those are the cases where

somebody who is exasperated you could come in and say i would feel that way if i had gone through what you have gone through i could just barely understand what you're going through i've been in the hospital a few times for a few days, and it was horrible. And I'm so sorry you have to be going through this extended hospitalization and all of this pain and suffering. To some level, I get it, and to some level, I don't. No, I don't think you can get it. Yeah.

And I think that's an appropriate response if you're trying to empathize a little too much. But I think... No, I mean, I'm trying to be the difficult patient. No, I get it. You can play the doctor, okay? Let's keep doing this. I love this. So, but I think what you should think about in those cases is, is there something I can do to kind of de-escalate this situation?

And a lot of times, this is when psychiatry gets called in, right? A primary team is themselves exasperated, frustrated with a patient who is today not following their commands, right? And they consult psychiatry's a capacity eval this person's refusing treatment. You go in and you talk with them and they're worn out, right? They're tired to their bones. and you talk with them and you empathize with them and then you realize like they just need something like to make them happy today.

They need some good news. They need a as needed medication for their overwhelming anxiety, right? They need something now that gets them back on track and able to demonstrate that level of capacity necessary. And a lot of times we could do that because we're looking for that and we don't have that interpersonal issue of the patient and the provider, almost budding heads in these situations. Yeah, because we're coming from the outside a little bit

and kind of seeing things a little bit more objectively and comparing their symptoms. You know, is this person depressed or super anxious? Which leads me to another question of, can someone lose capacity for being depressed? Yeah, and that's, I mean, that's a decision that we've made. made before, I think you can, right? I think that what we understand about depression is that it warps your ability to see the world as it is and make accurate assessments of your situation and

the future. If that's the case, if that's your mental state, if you are depressed and now you're assessing the situation so poorly that the decisions you're coming to are unrational, unrational and unreasonable, then yeah, I think in those instances, you don't have the capacity to maybe make this decision in front of you. Yeah. So who chooses? Yeah. So then that's the question.

A lot of times we think, well, they don't have capacity, knock them out and do the thing, right? And do the surgery. Well, that's not true, right? If you can't choose, and I need to find somebody who knows you and can make the decision on your behalf, a substituted judgment. California follows a flow chart, though it's not essential that they do. Some states actually you have to go in this order.

But generally, you look for the necks of kin, the spouse, the adult children, the parents, the family, friends. Even before that, do they have a durable power of attorney? Have they filled out paperwork in their advance directive? All of these things that they might have done beforehand to indicate what I want to happen if I can't make the decision. So once I've assessed they can't make the decision, I go to these documents or these people. I remember a case where we actually found a bartender who knew a patient who lived by himself, had no family, friends, but he went to the same bar every single day and had talked with a bartender about end-of-life stuff, and the bartender could say, yeah, this is what this guy would have

chosen. Without a doubt, I know we've talked about this. He's talked about his cancer. We went with the bartender's decision. It was a substituted judgment. He spoke on behalf of the patient who at that point could not decide for himself. Okay. Yeah. Are there any other options? Yeah. And the other thing you do is just wait. Right. I think we forget that too. Like, do I need to make the decision right now? Can I let him sleep on it? Can I, like I said, give them an as needed medication for their anxiety? Maybe the decision is like to do a really intensive surgery and they are intoxicated. Can I just wait for the intoxication to clear up and now they're able to demonstrate capacity. So waiting helps. Getting an ethics committee involved, getting that third opinion, getting a team of people

that are going to make decisions on this person's behalf. And then at the end of the day, if all those things don't work, time doesn't permit, you should look to your colleagues, get second opinions as quickly as you can, and you make a best interest decision. Like this is what I would do in this situation because I really don't know what you would do and there's nobody to tell me what you would do. You make a best interest decision. You do, document the heck out of it. That's good. That's good.

Yeah, so where do you want to go from here? I think one thing that's important is what do we do with the patient who's trying to leave? What do you do with the patient who doesn't want this life-saving intervention? Because it becomes a source of contention when we as the psychiatrist or even you as the primary team make this decision and they disagree and the patient is like literally running for the door, what do we do? So if they don't have capacity, you have a few options. You let them discharge against medical advice, which you've already said they don't have capacity to make that decision. So you're inappropriately letting somebody go against medical advice. You request that a psychiatrist

place an involuntary psychiatric hold because, you know, once they're on a 50-150, then I could stop them, right, even though that's not really appropriate. Or you detain the patient, and you have no legal status. There isn't a document to says, I can stop you, and you just do what you can. And so what do you do? So you document the heck out of it, right? You say, yes, an emergency existed. I didn't have the ability to get consent in time, and it was for the patient's benefit.

You document, document, document. Hopefully your hospital has come up with a medical incapacity hold type. protocol that you can point to and that's your institutional defense. But you hold them there. And sometimes that's what you've got to do. Yeah. And I think that that saves lives, you know? Right. Because if someone's like delirious and they want to leave, they're confused, they're post-op. Leaving for them may mean something worse happens. Right. This is the way that I present it to to nurses, to staff members, security guards, primary teams, you're in between a rock and a hard place. You got somebody who's trying to leave. You're saying they're delirious. I remember a patient who,

he was in Vietnam, and he was, turns out he was in alcohol withdrawals. We didn't know it at the time. And he was trying to leave the hospital, and he thought he was on a boat. And he said, I'm getting off this boat. He was very convinced he was on a boat. And we had to stop him. So you're in between a rock and a hard place because at this point, you are going to possibly assault this patient by forcing them back into the room. This gentleman ended up in four-point restraints, getting shots of medication, and ended up being intubated, actually, for his own benefit, right?

So the rock and the hard place is the assault battery and false imprisonment charge or negligence. I always think of, you know, what if this guy got out of the hospital, he got off the boat and he wandered into the parking lot and got hit by a car? So I present this to you, doctor. You have one of two options.

You hold him here, and you might get sued for assault battery and false imprisonment where you let him go and something might happen to him and you get sued for negligence. Now, you should ask a lawyer which one they would rather defend. So it turns out there's a lot of case law for this too, right? You can look at, there's Craig Miller versus Rhode Island Hospital, a patient got in a motorcycle accident, needed a peritoneal lavage to see if there was blood in his abdomen. He refused.

The doctors ended up doing it anyways. and he sued for assault battery false imprisonment, right? And the physicians were found to be right in this case, that they were looking out for the patient's best interest in this emergent situation. I think another one that really stands out, Youngberg versus Romero, right? So this mother institutionalized her adult disabled son, and then turns out she didn't like the treatment that was happening there. And it was very physical.

This gentleman was very violent and needed to be restrained on multiple. occasions. And she actually sued the hospital where he was that said, you know, you can't do this to him. So the court found, right, so yes, the patient retains liberty and safety from bodily restraint, yet, and this is from the court, yet, they're not absolute, right? There are occasions in which it's necessary for the state to restrain the movement of residents to protect them as well as others. And so the penal code, right, says that there is an exception for assault statute for physicians who act in good faith in accordance with the accepted medical therapy. If you're trying to do the right thing, document that and you'll be protected. Yeah. Those are some interesting cases. So it sounds

like that Craig Miller versus Rhode Island, you know, this guy had a pretty bad motorcycle accident and they were afraid he had internal bleeding. And, you know, if someone has internal bleeding, they can die quickly. Yes. Yeah. You know, he could go to bed and then be dead the next morning.

And we need to do this evaluation now to see it. And the lavage is a test, right? It's to see if there's blood next. If there is blood, we've got to open you up and figure out where it's coming from. We had to, you have to hold him down to do this test. This is the same as that delirious patient

who's trying to leave the hospital. I need to act in your best interest in this emergent situation against your will. And I might need to restrain you physically. chemically. I might need to intubate you. I might need to take you into an operating room all against your will in your best interest because I don't have the time to find a surrogate decision maker. And people feel really uncomfortable with this. I have a few articles that kind of cite these

court cases. And I think they're important for doctors to read over and see like, oh, this happens. People get sued for this and they're protected. Like you were trying to do the right thing. And one of the things that bothers me about these consults for a patient trying to leave is everybody knows what to do. Literally, everybody knows what to do. This guy who's withdrawing from alcohol and thinks he's on a boat, everybody knows if he leaves from here something bad will happen. There's nobody here that says, no, let him go. Everybody says if we let him go, something bad's going to happen. But what they worry is, will I get in trouble for it?

So please put him on a 5150. That absolves me. That's not the case, right? you act in the patient's best interest, you document it, and that is your protection. All of your documentation and justification statements, that's what you're going to take to court. And you can ask a lawyer, which, again, which one they want? Do they want to defend you for letting somebody go and getting injured? Do they want to defend you for doing what you thought was best in a very difficult situation?

One thing I appreciate about this topic is, you know, you're using this information to coach the other specialties to coach the people who are consulting you. And through that, you're really empowering them to take care of people how we were trained to take care of people. Some of the most frustrating, aggravating things as doctors that we deal with is when we're basically not allowed to give people needed treatment because of different barriers, insurance companies, you know. resources.

And sometimes it's patients refusing treatment that if they don't get it, they may die. And this is, I mean, this is an interest for me in psychiatry. I think in most other medical specialties, especially in the outpatient setting, if patient doesn't want a treatment, usually they have the capacity to refuse that treatment

and you agree to disagree. But I think in our field, we deal with mental disorders that really limit somebody's ability to make appropriate decisions. And we get to be in a lot of, involved in these very difficult cases and were trained to be empathetic and caring and compassionate through these moments and hopefully help move them through appropriately. And I think so bringing it all back together, right?

Capacity. All this talk about capacity. We started out talking about holds. I hope that people at the end of this see it as the same thing. If I'm holding you against your will, whether you're delirious trying to wander out of the hospital or you're suicidal and trying to leave, it's the same idea. think that you're demonstrating the capacity to make the decision you're making. Therefore, I have to step in. This took me a lot of time to feel comfortable with. And I think the thing that

helps is, again, recognizing that your day-to-day experience is with people around you that, like, at worst, are really, really tired and making bad decisions, right? Are really stressed out in making bad decisions. Most people do not have interactions with very sick people. Most people in the general public do not have any contact with somebody who is acutely delirious or acutely psychotic. And we know this because most people who have a relative who becomes delirious in a hospital freak out. Right. And it's traumatic and they don't know what to do with it. And it may actually cause a trauma to see their loved one pulling out their lines, screaming belligerently. cussing, doing all the things that they've never seen their level one do.

So that's a really good way to put it because most people don't see one person after another who are post-op day four from a big surgery and they're elderly and they get delirious. They see things, they hear things, they're pulling out their lines. my other thought is most people don't come into contact with the 1% of people in the hospital who this might be an issue to or like a 0.1%. Because like imagine how many beds there are at Loma Linda, how often do we get a competency eval? Right.

You know, so it's like not, this isn't going on for the majority of patients who are in the hospital. You as the hospitalist might ask for a second opinion for capacity once a month. Maybe. Yeah, maybe less. But me as the psychiatric consult team, I mean, we have three or four patients on our list right now that we are consulted for for capacity questions, right? This is a daily for us. And one of the things you said about, you know, educating and discussing with teams, and that's the goal of the liaison part of consultation liaison.

I want to do the things that I as a psychiatrist could do, pick the right medications, you know, do the bedside therapy. That's the consultation part. but the liaison part, if I do my job right, you don't need to utilize me that much, right? You feel empowered as the primary physician to make the decisions that, you know, my expertise has been able to be handed off to you. So that's the hope of this podcast, right, is that you feel empowered with this information to help people that are going through difficult times, maybe placed on involuntary holds, or are unable to make the right decisions for themselves in a hospital because they're incapacitated. that you, the listener now, have some idea of what's going on and communicate that appropriately in your setting.

One thing that comes to my mind, as psychiatrists, I think we could do a better job at, is to understand that the providers that come to us with questions need empathy, need respect, empathy. We need to build a therapeutic alliance with them as well. So I talk a lot about building a therapeutic alliance, you know, reading micro-expressions, understanding how to increase empathy. And we need to see it as we're doing it to everyone, right? We're not just doing it to a patient.

And so when a provider is freaked out and they're in this situation and they're stressed out, you know, listen to them. Say that would be, you know, try to get them on the phone and listen to them, give them some empathy. Before you give them any truth about, you know, like, oh, you could do this yourself, let me beat you over the head with this knowledge here that I've learned from this podcast. So first and foremost, always start with empathy and understanding and then move to, you know, educating. And that will allow you to connect with these people who are in the trenches,

you know, just like we're in the trenches. Yeah, I agree. I like that. Start with that empathy. Get them to connect with you because that really does relieve a lot of the difficulty and the frustration that they're having to feel validated in their frustration. And then you could move towards solution. Yeah. Yeah. And I think the second point on that is if they come at you and the frustration seems to be pointed at you, in the empathy, you know, realize what their goal is. Like, you know, oh, it must be so stressful and frustrating. Hey, help me understand what your goal is. And once they tell you their goal, their goal is, you know, maybe to get this patient out of the hospital, maybe to get them well, maybe to get the capacity eval, maybe to get them to a

psychiatric hospital, affirm the goal. Hey, that's a really good goal. I want to help you accomplish that goal. Or affirm an aspect of the goal that you may agree with. They're like, hey, after I do this eval, I would love to try to help you work towards a goal like that. So that you become aligned with their goal, not an obstacle towards their goal. Because if we're the obstacle, if we're seen as the obstacle, then the anger is rightfully going to be pointed at us. But most of the time, like, we are kind of, consultants are kind of like the helper, you know, in the traditional mythology, right, that you love, I know, there's the hero, the villain, and the guide, right?

So we want to be the guide and we want the consultant to be the hero. to be the hero and the patient is not the bad guy, right? So the patient is also a hero of sorts. So we don't want to be the bad guy. We don't want the consultant to be the bad guy. We want to place herself as the Yoda and to help guide the situation. Yeah, you mean you get to be the intercessor and align everybody's goals, right? When somebody consults you, you're really trying to align that.

the patient's goals and the consultant's goals to achieve success. And sometimes you can see a way that they might not. And that's your role. Yeah, I like that. I mean, you're the helper in these situations. I don't place orders on a consultation service, right? You're the one that's responsible for all those orders. I'm just trying to help you out.

And I would say the same thing is true for like placing someone on an involuntary hold. When we talk to them about it, we want to find out what their goals are. beyond just going home, right? People have goals like I want to spend time with my family and I want to, you know, get back to work. And like I think coming alongside those goals and saying, hey, those are great goals. You know, I want you to have this time be

where you can hopefully get to a place where when you spend time with your family, you're even more present, you know, because it's really hard to be present when you're suicidal. So finding the goals, aligning yourself with the goals, empathizing with the distress, and then giving them the information, like, hey, I just want to let you know where I'm at as a professional. You know, sometimes I have to make these tough decisions to advocate for patients

and just kind of explain your thought process. And then you watch them. And then something else will come up and you empathize with the distress, answer questions, empathize with the distress. and remember in the how to work with a violent and potentially violent patient or person really in that episode i did with gillian friedman amazing episode by the way she is one of the best inpatient psychiatrists i know she talked about repeating the cycle 10 times we talked about that and like so sometimes you'll empathize listen empathize and then tell them

some information and then you'll repeat that cycle 10 times. And that could be a five-minute conversation, but it's an aligning conversation and it allows you to maintain a therapeutic alliance or build a therapeutic alliance in the midst of this really, really difficult situation. Any final concluding remarks? You mentioned this guy at UCLA has like a medical hold. Yeah. Actually, I was at a bioethics conference where I heard.

heard Dr. Chung at UCLA give this talk. And I remember my, my jaw hitting the floor because I heard him talk about something that I felt like we only dealt with. And like, he's like, no, we deal with this too. Like, we surveyed hospitals in the area. They deal with this. This is what we came up with. And yeah, if you get a chance, and we could put it in the notes. So what is the, but the idea is, yeah, the big pearl is, what do you do with the delirious patient that wants to leave? And you think the reason that they're trying to leave is their medical condition. UCLA has developed a policy that can be instituted by a physician to hold the patient there that gets security involved, and it protects patient safety, right? And there's a lot of safeguards built into it,

second opinions and renewal processes. And I encourage, you know, if you're at a hospital that does not have a process to deal with these, and I'm guessing there's somebody hearing this that's like, oh my gosh, I deal with this too. I thought I was alone. Because I felt that way about Loma Linda. Read the article and work with your, you know, your ethics team and build policy to try to replicate it. I mean, it's good. We're working on it.

We need something to deal with this. It happens a lot. I'll put that stuff in the resource library. And, you know, if you have any questions, as always, you know, shoot me an email, a direct message through my Instagram, Facebook, Twitter, Markard. It was a pleasure having you. I appreciate the opportunity. And we'll have Mark Ard back, hopefully, many times after he chooses to go away to a wonderful C&L place and then come back here to spend the rest of his life at Loma Linda University.

All right, man.