DHA 722 Week 6 Ethical and Legal Issues in Health Policy Example

Nine Days in a Hallway: Legal Duties and Ethical Choices in Boarding Psychiatric Patients in Rural Emergency Departments

[Student Name]

University of Phoenix

DHA/722: Policy and Regulation in Health Care

Week 6 Assignment

[Instructor Name]

[Date]

The rural hospitals, patients, boarding times, incidents and policy proposals are composites written for a model paper; laws are described in general terms, and research findings come from the sources cited.

A fifteen-year-old girl arrived at the emergency department of one of the region's rural hospitals after an overdose. After medical treatment, a psychiatrist evaluating her by video recommended inpatient care. No adolescent psychiatric bed was available within two hundred miles. She spent nine days in a hallway alcove with a sitter, a mattress and her mother in a chair beside her. The regional vice president was asked how such a thing could happen legally and ethically, and what should change. This paper analyzes that question.

The Scale of Boarding

The girl's case was extreme but not isolated. Across the four rural hospitals, 214 patients waited more than 24 hours for psychiatric placement last year, with a median wait of 51 hours. Children and adolescents waited longest, because the state has few pediatric psychiatric beds. Adults waited too, often for beds at state psychiatric hospitals with long waiting lists. Patients with developmental disabilities or with both substance use and mental illness were the hardest to place, since many facilities decline them. Most boarded patients were covered by Medicaid or uninsured, which some private facilities cited, quietly, when declining referrals.

Federal Legal Duties

Federal emergency care law requires hospitals that participate in Medicare and have emergency departments to examine anyone who comes seeking care closely enough to find out whether an emergency exists and, when one does, either to treat until the condition is stable or to move the patient to a facility that can, under strict transfer rules. Psychiatric emergencies, including suicidal patients, are emergency conditions under the law.

Enforcement Evidence

Enforcement is real. Terp and colleagues examined 230 civil monetary penalty settlements under the law from 2002 to 2018 and found that 44, or 19%, involved psychiatric emergencies; these averaged $85,488 compared with $32,004 for other cases, five of the six largest settlements involved psychiatric cases and failure to provide stabilizing treatment was more common in psychiatric cases, with the Southeast region accounting for 41% of them (Terp et al., 2019).

State Commitment Law

State law adds duties. When a person is believed to be dangerous to self or others because of mental illness, a petition can lead to involuntary custody, examination by a qualified clinician within set time limits and transport to a treatment facility. When no bed exists, the patient remains in the emergency department under legal custody, with time limits that the shortage of beds makes hard to meet. The emergency physician must decide repeatedly whether the patient still meets the criteria for custody, and if the patient improves, whether to release someone who has received little treatment. Law enforcement officers may wait with the patient for hours, taking deputies away from small rural counties with few on duty.

The Operational Toll

Boarding strains emergency departments. Nicks and Manthey studied adult admissions at a North Carolina academic medical center and found that psychiatric patients awaiting inpatient placement stayed in the emergency department 3.2 times longer than other admitted patients, 1,089 minutes compared with 340, preventing 2.2 additional patients from using each bed and costing the department $2,264 per psychiatric patient when lost bed turnover was included (Nicks & Manthey, 2012). In a rural department with eight beds, one boarded patient can occupy an eighth of capacity for days.

Ethical Principles

The framework most clinicians learn comes from Beauchamp and Childress, who ground clinical ethics in four commitments: honoring patients' own choices, doing good for them, avoiding harm and distributing benefits and burdens fairly (Beauchamp & Childress, 2019). All four bear on boarding, and here they pull against one another.

Autonomy

Patients under involuntary custody have lost some of their liberty, often justifiably, because their judgment is impaired and their lives are at risk. But boarding extends that loss without treatment. The girl was held against her will for nine days without the therapy that would justify holding her.

Beneficence

Beneficence asks what helps the patient. Emergency departments are not designed for psychiatric care: they are loud, bright and crowded, and most offer little therapy. Boarding keeps patients safe from immediate harm but provides little of the care they need, and each day without treatment delays recovery.

Nonmaleficence

Boarding can cause harm. Patients may be restrained or sedated to manage agitation in an unsuitable setting, and prolonged waits can worsen symptoms. Staff face assaults and moral distress, and several nurses in the region have cited boarding as a reason for leaving emergency nursing. Keeping a child safe in a hallway for nine days is not the same as caring for her.

Justice

Justice asks about fairness. Each boarded patient occupies a bed another patient needs, delaying care for chest pain, stroke or trauma in a department with few beds to spare. Justice also asks why children in rural counties wait longer than those near cities, and why psychiatric patients wait while medical patients are placed within hours.

Where Law and Ethics Diverge

The hospital can comply with the law, screening and holding the patient safely, while falling short ethically, providing little treatment and restricting liberty for days. Legal compliance sets a floor; ethics asks more. The gap is not the fault of individual clinicians, who often do their best in impossible circumstances, but of a system that lacks beds, crisis services and payment for care delivered in the emergency department. That is why the recommendations address both the organization and the state.

Organizational Recommendations

The region will begin psychiatric treatment in the emergency department, not only evaluation, using telepsychiatry for daily visits, starting medications and offering therapy; create a calm, safe room in each emergency department; train staff in de-escalation to reduce restraint; and escalate any wait over 48 hours to the medical director for placement efforts statewide. For children, the region will arrange daily family meetings with the telepsychiatrist and a school liaison, so that education and family therapy begin while the child waits. A clinical ethics consultation will be offered for any patient held more than five days.

State Policy Recommendations

The region will advocate for more pediatric and adult psychiatric beds in eastern North Carolina, crisis stabilization units as alternatives to emergency departments, expanded mobile crisis teams, a statewide real-time bed registry and payment for treatment delivered to boarded patients. It will share its boarding data with state legislators, since numbers from rural counties are often missing from the debate.

Measures

Measures include boarding hours by age and insurance status, restraint use, time to first psychiatric treatment, staff injuries, patients leaving without being seen and complaints from families.

Conclusion

Psychiatric boarding in rural emergency departments places hospitals under federal and state legal duties that are enforced and costly to fail. It also raises ethical conflicts among liberty, benefit, harm and fairness. Complying with the law is not enough; the region should begin treatment during boarding and press for state policies that end the wait.

References

Beauchamp, T. L., & Childress, J. F. (2019). Principles of biomedical ethics (8th ed.). Oxford University Press.

Nicks, B. A., & Manthey, D. M. (2012). The impact of psychiatric patient boarding in emergency departments. Emergency Medicine International, 2012, Article 360308. https://doi.org/10.1155/2012/360308

Terp, S., Wang, B., Burner, E., Connor, D., Seabury, S. A., & Menchine, M. (2019). Civil monetary penalties resulting from violations of the Emergency Medical Treatment and Labor Act (EMTALA) involving psychiatric emergencies, 2002 to 2018. Academic Emergency Medicine, 26(5), 470-478. https://doi.org/10.1111/acem.13710