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Behavioral Medicine > Legal - Forensic Psychiatry > Flashcards

Legal - Forensic Psychiatry Flashcards

1
Q

Define civil commitment

A

Being court ordered into mental health treatment (inpatient or outpatient; different from criminal court)

(terms and procedures vary by state)

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2
Q

Legal 2000 “L2K”

A

Nevada’s version of civil commitment - inpatient

(Oregon = hospital hold; California = 5150)

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3
Q

In addition to atttempting suicide or homicide attempt, what are 2 other reasons to put a patient on a legal hold (Legal 2000; L2K)?

A
  • Causing bodily harm to self or others (i.e. extreme pain, disfiguring)
  • Incurring serious injury to self or others by not giving basic needs (can’t care for self)
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4
Q

Who can fill out an L2K (5)?

A
  1. Physician (or their PA)
  2. RN (w/psych training)
  3. Social Worker (w/psych training)
  4. MFT
  5. Police officer
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5
Q

Involuntary outpatient civil commitment is delivered in ________

A

the community

(for 6 months, then reassess)

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6
Q

What qualifies a patient as having a mental health crisis?

A
  1. mental illness
  2. capacity impaired
  3. great liklihood of them hurting others/self

(NOT someone who has epilepsy, cog deficits→impulsivity/behavioral issue, dementia, delerium, substance)

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7
Q

Pros of outpatient civil commitment (4)

(in NV, its 6 months)

A
  1. less restrictive environment
  2. facilitates independence
  3. better delivery of rehab services (ex: OT)
  4. proactive

(if they don’t comply→inpatient)

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8
Q

Cons of outpatient civil commitment (2)

A
  1. Intrusive / coercive (population is already vulnerable)
  2. No true consequences for non-adherence
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9
Q

Define competency. Who determines this?

A
  • Ability to decide about a specific issue or action
  • Legal judgement, determined by court

(capacity is medical judgement, determined by physician)

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10
Q

All adults are presumed competent and less _______

A

A judge deems otherwise

(determined by the court system. Legal judgment, not Medical)

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11
Q

Define capacity. Who determines this?

A
  1. Ability to make informed, rational decisions
  2. Assessment of psychological ability to understand, appreciate and manipulate information
  3. Medical judgment, determined by physician (competency is legal judgement, determined by judge)
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12
Q

Common reason for Psychiatry consult

A

Help decide if patient has clarity to decline procedures

(capacity: answers question about specific fxn or condition)

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13
Q

Capacity is task-specific. When Consulting on whether or not a patient has capacity, ask questions for “_____”.

A

WHAT - it is specific

(ex: do they have the capacity to refuse a lumbar puncture? Accept / refused chemotherapy?, can’t answer the general q: “Do they have capaciy to make medical decisions?” - too broad)

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14
Q

If a person lacks capacity to make informed decisions or give consent they may need referral for _____

A

Competency hearing

(If they are found incompetent, a decision-makers appointed by the court → family or public guardian)

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15
Q

If a person is found to be incompetent to make informed decisions or give consent they are appointed a decision maker. Who does this job?

A

Family member (if unavailable→ public guardian)

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16
Q

Define Guardian

A

Court-appointed person who provides services for those legally determined unable to care for themselves

(maybe public or private)

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17
Q

Define advance directive (what is it? what is included?)

A
  • Document giving instructions when/if a person becomes incapacitated
  • Instructions regarding power of attorney, health care proxy, end-of-life-care
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18
Q

Define power of attorney

A

Authorized to act on another person’s behalf in legal matters

(must be specified for healthcare, but it can extend to other areas such as finances)

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19
Q

Define surrogate decision-maker

A
  • “Healthcare proxy” who acts as an advocate for incompetent person
  • Can be guardian or individual with power of attorney
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20
Q

Mn: CRAM

A
  • Communication of a stable choice
  • Relevant information is understood
  • Apprehension of the situation
  • Manipulation of information in a rational manner

(conducting in that evaluation for capacity)

21
Q

What does “Communication of a stable choice” mean when conducting a capacity evaluation?

(Mn: CRAM)

A

Do the history and physical exam confirm the patient can communicate a choice

22
Q

If a patient can NOT communicate a stable choice, then what?

A

Defer to an advance directive or surrogate decision-maker for further direction

23
Q

What happens if a patient is unable to express any choice?

A

Lack of capacity is assumed

(paralyzed w/indecision)

24
Q

In what situation would a patient be deemed “lacks capacity” to make choice if they are able to communicate one?

A

If their choices are inconsistent, they can change their mind, but if the decision shift so often that treatment can’t be delivered → they lack capacity to make the choice

25
Q

Consistency in communicating a stable choice can be affected by (4)

A
  1. Delirium: impaired consciousness
  2. Psychosis: thought distortion
  3. Dementia: disrupts short-term memory
  4. Severe ambivalence (severe depression)
26
Q

“Relevant information is understood” (Mn: CRAM - conducting capacity evaluation)

A
  1. Understand what their medical condition is
  2. Worst part & what can be done to fix it
  3. To answer these questions, pertinent facts MUST be explained to the patient by the physician
  4. Must be able to receive & retain facts given
27
Q

“Appreciation for the situation” (Mn: CRAM - conducting capacity evaluation)

A
  1. Understand facts & know the implications and consequences
  2. Significance of possible medical outcomes
  3. Implication of their decision on their future
28
Q

“Manipulation of information in a rational manner” (Mn: CRAM - conducting capacity evaluation)

A
  1. Able to assess facts → Use in a logical manner → come to a decision
  2. Is their decision affected by a mental disorder (depression/psychosis)?

( “Bad” judgement is a right!)

29
Q

In general, defendant may be found incapacitated if, as a result of mental disease or defect, the defendant is unable to (3):

A
  1. understand the nature of the proceedings against the defendant; or
  2. assist and cooperate with the counsel of the defendant; or
  3. participate in the defense of the defendant
30
Q

Who is referred for a competency evaluation?

A

Defendant

(sometimes inappropriate → competency restoration)

31
Q

In general, defendant may be found incapacitated if, as a result of mental disease or defect, the defendant is unable to (3):

A
  1. Understand the nature of the proceedings against the defendant; or
  2. Cooperate with the counsel of the defendant; or
  3. Participate in the defense of the defendant
32
Q

What is included in a basic psychiatric evaluation for competency evaluation?

A

Legal knowledge:

  1. Understand the nature of the proceedings against the defendant; or
  2. Cooperate with the counsel of the defendant; or
  3. Participate in the defense of the defendant

(doctor writes recommendation; judge makes the decision)

33
Q

Why would a defendant be referred for competency evaluation (3)?

A

Strategy of attorney for their client:

  1. delay, avoid proceedings
  2. seek resources (otherwise unavailable)
  3. mental health rec. for insanity plea

(doctor writes the eval, the judge makes the determination)

34
Q

Pre-commitment evaluations occur (often in jail) → 2 outcomes

A
  1. Court finds defendant competent to continue → Trial proceedings resume
  2. Court finds defendant not competent to continue → Trial proceedings suspended; defendant goes to a forensic facility
35
Q

Goal of competency restoration

A

restore competency (not cure mental illness)

36
Q

Restoration to competency treatment (4):

A
  1. Meds
  2. Behavioral interventions
  3. Programming/activities
  4. Legal education!

Patient re-evaluated for competency; has new hearing→ Judge again makes determination

37
Q

Competency restoration outcomes:

A
  1. Competent → Back to jail
  2. Not competent, with probability of restoration in foreseeable future → Competency restoration treatment continues (6 more months)
  3. Not competent, without probability of restoration in the foreseeable future→charges may be dismissed → hospitalization
38
Q

What if a defendant is determined not competent to stand trial without probability of restoration?

A
  1. Proceedings are dismissed
  2. But, certain crimes cannot be dismissed; these defendants are committed for 10 years under NRS 178.461 (patients are “461’s”)

(may be conditionally released)

39
Q

Determination of incompetence to stand trial is a _________.

Not Guilty by Reason of Insanity (NGRI) is a legal defense, a ______.

A
  • court-determined legal fact
  • plea (like guilty, not guilty, etc.)

(remeber: must be competent to enter NGRI)

40
Q

The insanity plea is used in _____% of cases, with a ______% success rate.

A
  • <1%
  • 26%

(most all were previously dx w/mental illness)

41
Q

NGRI (not guilty by reason of insanity) defense is NOT a free pass. Defendants will likely have to ______.

A

spend more time institutionalized than if convicted & jailed (possibly 2xs more)

(high probability of loosing; defendants may reject mental illness label)

42
Q

Define irresistible impulse

A

loss of behavioral control is more pronounced than cognitive impairment

43
Q

Model Penal Code (1972): new rule for insanity

A

“A person is not responsible for criminal conduct if at the time of crime as a result of mental illness or defect he lacks substantial capacity to appreciate the criminality (wrongfulness) of his conduct or to conform his conduct to the requirements of the law.”

44
Q

Congress passed Insanity Defense Reform Act (1984)

A
  • Burden of proof shifted from prosecution to defense
  • Standard of evidence in federal trial increased from “preponderance of evidence” (51% sure) to “clear and convincing evidence.” (75% sure)
45
Q

Insanity defenses bystaet

A
  • ALI test discarded in favor of new test more closely resembling McNaughton
  • Only perpetrators suffering from severe mental illnesses at time of crime could successfully employ the insanity defense
  • Defendant’s ability to control self no longer a consider
46
Q

HIPAA

A

Health Insurance Portability & Accountability Act 1996

47
Q

Purpose of HIPAA

A

give patients control over the use of their health info

(violation of privacy → criminal or civil penality)

48
Q

What type of communication is not a violation of HIPAA

A

one-way communication. you may receive info about pt w/o disclosing their info

49
Q

What are the 4 elements to establish malpractice?

(civil tort related to neglicence of duty: omission/commission)

A
  1. Duty
  2. Breach of duty
  3. Damage
  4. Causation

(suicide is the MC reason for Psychiatrist malpractice suits)

Behavioral Medicine (35 decks)

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