Legal and Ethical Issues Related to Psychiatric Emergencies
California Involuntary Psychiatric Hold Laws
In California, both child and adult psychiatric emergencies are addressed under the state’s involuntary hold laws, primarily through the 5150 and 5250 provisions. A person, whether adult or minor, can be held involuntarily for up to 72 hours under a 5150 hold if they are deemed a danger to themselves or others, or if they are gravely disabled due to a mental health disorder (State of California, n.d.). The hold can be initiated by law enforcement officers or mental health professionals. After the initial 72-hour period, a 5250 hold can be used for up to 14 days if further treatment is needed. The mental health professional overseeing the hold can release the patient if they are no longer deemed a danger or gravely disabled, and if no further treatment is necessary. After a hold is released, the patient can be picked up by a responsible adult, legal guardian, or, in the case of minors, their parents or legal guardians (State of California, n.d.). If the patient is under a 5150 or 5250, a hearing or review process may be available to challenge the hold.
Differences Among Emergency Hospitalization
In California, the differences among emergency hospitalization for evaluation, inpatient commitment, and outpatient commitment are defined by the level of care and the patient’s needs. Emergency hospitalization for evaluation involves a temporary, involuntary psychiatric hold, typically under a 5150 for up to 72 hours, during which a person is evaluated for mental health issues if they are a danger to themselves or others, or are gravely disabled (State of California, n.d.). Following this period, further treatment may lead to inpatient commitment, where a person is hospitalized involuntarily for longer-term care, typically for those requiring intensive psychiatric treatment. Outpatient commitment refers to a court-ordered treatment plan where an individual is required to follow a prescribed course of mental health treatment while living in the community, as opposed to being confined to a psychiatric facility (State of California, n.d.). This option is often used for individuals with chronic conditions who can function in society with ongoing care but require monitoring to ensure adherence to treatment.
Capacity and Competency
In mental health, capacity refers to a person’s ability to understand the nature and consequences of their decisions at a particular moment, typically in relation to making specific choices about their treatment or legal matters (Lyng et al., 2024). A person with capacity can make informed decisions, even if those decisions are not in their best interest. Competency, on the other hand, is a legal term that refers to a person’s ability to stand trial or engage in legal proceedings. It is determined by a court and assesses whether a person can understand the charges against them and assist in their defense (Lyng et al., 2024). While capacity is about decision-making ability in specific situations, competency focuses on a person’s overall ability to participate in legal processes.
Confidentiality
A key legal issue is the requirement to maintain patient confidentiality under laws like HIPAA, while also ensuring patient safety. In psychiatric emergencies, healthcare providers may need to share patient information with other professionals, such as law enforcement or family members, to prevent harm or provide necessary care. Legally, sharing such information without consent may violate the patient’s right to privacy, but exceptions are made when there is a risk of harm to the patient or others, such as during a 5150 hold (State of California, n.d.). Providers must navigate these exceptions carefully to comply with legal requirements while safeguarding patient privacy. The ethical challenge arises when deciding whether to breach confidentiality in the best interest of the patient or others. In psychiatric emergencies, a patient’s condition may impair their ability to make informed decisions, and healthcare providers may need to share sensitive information with family members, law enforcement, or other healthcare providers. Ethically, the dilemma is balancing the patient’s right to privacy with the duty to protect the patient’s well-being and the safety of others. Providers must weigh the potential harm of breaching confidentiality against the potential benefits of sharing information to ensure appropriate care and prevent imminent harm.
Suicide Risk Assessment
One evidence-based suicide risk assessment tool is the Suicide Risk Assessment (SRA), developed by the American Association of Suicidology (AAS). The SRA evaluates critical risk factors such as a history of mental illness, prior suicide attempts, substance abuse, and a family history of suicide. It also examines the patient’s current suicidal ideation, intent, and whether they have a plan to carry out their thoughts. This tool helps mental health professionals identify individuals at high risk for suicide, enabling them to implement appropriate interventions (American Association of Suicidology, 2025). The SRA is widely used in clinical settings and serves as a reliable method for assessing suicide risk, ensuring that patients receive the necessary care and monitoring.
Link: https://suicidology.org/
Violence Risk Assessment
One evidence-based violence risk assessment tool is the Brøset Violence Checklist (BVC). The BVC is a short, structured tool used to assess the risk of imminent violence in psychiatric settings. It evaluates six observable behaviors: confusion, irritability, boisterousness, verbal threats, physical threats, and attacks on objects. Each item is scored as present or absent, and the total score helps predict the likelihood of violent behavior within the next 24 hours (Almvik, n.d.). The BVC is quick to administer, requires no specialized training, and is supported by research as an effective tool for short-term violence prediction.
Link: https://www.risk-assessment.no/
References
Almvik, R. (n.d.). Risk Assessment – Broset Violence Checklist (BVC). Accessed April 17th, 2025 from https://www.risk-assessment.no/
American Association of Suicidology. (2025). American Association of Suicidology. American Association of Suicidology. Accessed April 17th 2025 from https://suicidology.org/
Lyng, H. B., Macrae, C., Guise, V., Haraldseid-Driftland, C., Fagerdal, B., Schibevaag, L., & Wiig, S. (2022). Capacities for resilience in healthcare: A qualitative study across different healthcare contexts. BMC Health Services Research, 22(1), 474. https://doi.org/10.1186/s12913-022-07887-6
State of California. (n.d.). State of California Involuntary Treatment Information. Accessed April 17th 2025 from https://namisantaclara.org/wp-content/uploads/2015/05/Involuntary-Treatment-Page.pdf
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The diagnosis of psychiatric emergencies can include a wide range of problems—from serious drug reactions to abuse and suicidal ideation/behaviors. Regardless of care setting, the PMHNP must know how to address emergencies, coordinate care with other members of the health care team and law enforcement officials (when indicated), and effectively communicate with family members who are often overwhelmed in emergency situations. In their role, PMHNPs can ensure a smooth transition from emergency mental health care to follow-up care, and also bridge the physical–mental health divide in healthcare.
In this week’s Assignment, you explore legal and ethical issues surrounding psychiatric emergencies, and identify evidence-based suicide and violence risk assessments.
The Assignment
In 2–3 pages, address the following:
- Explain your state laws for involuntary psychiatric holds for child and adult psychiatric emergencies.
- Include who can hold a patient and for how long, who can release the emergency hold, and who can pick up the patient after a hold is released.
- Explain the differences among emergency hospitalization for evaluation/psychiatric hold, inpatient commitment, and outpatient commitment in your state.
- Explain the difference between capacity and competency in mental health contexts.
- Select one of the following topics, and explain one legal issue and one ethical issue related to this topic that may apply within the context of treating psychiatric emergencies: patient autonomy, EMTALA, confidentiality, HIPAA privacy rule, HIPAA security rule, protected information, legal gun ownership, career obstacles (security clearances/background checks), and payer source.
- Identify one evidence-based suicide risk assessment that you could use to screen patients.
- Identify one evidence-based violence risk assessment that you could use to screen patients.