I step out of the patient’s room and nod to the security officer in the emergency department. “Danger to self,” I say. The security officer nods back and speaks into a radio, “Patient placed on a 5150 by psychiatry.”
I pull out a packet of legal papers and a blue-ink pen. Avoid black ink, I’ve been told, because people may not be able to tell which forms are originals. This advice seems to predate color copiers, I think to myself. But because I don’t want to mess around with legal documents, I’ve steadily cached a personal supply of blue-ink pens.
Page 1. Patient’s name and address. I write that I was paged to the emergency department as the on-call psychiatrist to evaluate him. A section asks for facts demonstrating that, as a result of a mental-health disorder, he is a danger to himself or others, or gravely disabled (i.e., unable to take care of himself regarding food, clothing or shelter). “Patient endorsed suicidal ideation with intent and plan to overdose,” I write in clinical terms, along with details about his worsening depression and his refusals to consider voluntary hospitalization.
Page 2. I fill out information about the historical course of his mental disorder. I check a box next to “a danger to himself/herself.” I sign my name, title and facility information. Then come two small but crucial boxes: date and time.
Properly documenting the time of the hold is critical. These numbers translate into minutes, hours or even days of a patient’s life. The admitting team will need to know the exact time of this 72-hour hold for treatment. A lawyer might later use mixed-up times to overturn a psychiatric hold and free a patient before it might be safe. Patients or their families could sue for false imprisonment depending on the circumstances.
I always double-check the date and time.
My hand starts hurting as I write, but pages remain. There’s the advisement form, which I’ll give to the patient. I put down my name and title again, the date and time of the hold again. I explain in more familiar language why I’m placing him on a psychiatric hold: “You said you were planning to kill yourself by overdosing.” More boxes for my name and title.
I wonder whether he’ll remember my name, or look me up, or resent me for years to come.
I’ve lost track of how many of these forms I’ve filled out during my residency. There’s the firearms prohibition form, which informs the patient that he cannot own a gun in California for five years because of this hold. There’s a demographics form, where I fill in his eye color, hair color, height and other details. I stretch my fingers. On the last page, I check off that our psychiatric units are full and request a transfer to any open beds.
After a trip to the copier, I’m ready to give the advisement form to the patient. The security officer stands in the hall. I’ve seen these officers threatened, kicked, hit, spit on and bitten, all to keep the hospital a safe place. I’ve worked with this officer before, and I’m glad to see him.
“You want me to come with you, Doc?” he asks.
“I think he’ll be okay,” I reply. “Maybe just stay by the door for now.”
Telling a patient that you’re keeping him in the hospital against his will isn’t easy. Patients often argue with you or insist that there’s been a mistake. Sometimes, they just ignore you or pace silently in their rooms. Then there are the agitated ones. The patients who crumple up the paperwork you just spent 15 minutes filling out and throw it in your face. The patients who shriek at you. The patients who scramble for the door, lunge at you or flip furniture.
“I’m going to sue you and make your life a living hell!”
“What are you, the Gestapo?”
“Is this Guantanamo? Let me out of here!”
Medical school doesn’t prepare you for these kinds of reactions. I know I’m trying to help these patients. I know civil commitment is practiced around the world to care for patients suffering from psychiatric illness who cannot make safe decisions. I’ve seen parents beg for their adult children to be admitted, siblings crying that their brothers or sisters aren’t the same anymore, spouses terrified that their partners are losing their minds.
It’s still hard to be the one carrying the blue-ink pen.
Language shapes our patients’ experiences. The term “hold” might sound like we are bringing patients into our arms, embracing them and keeping them safe. But we usually don’t talk like that. We tend to use cold language like “put him on a hold.” In California, we call it a 5150, referring to the legal code for this type of civil commitment. In Massachusetts, where I was a medical student, we called it a Section 12.
When placing someone on a psychiatric hold, I try to soften the news as best I can. I ask the patient whether he has ever been on a hold. I try to explain what’s happening in clear terms and answer his questions. I emphasize that an initial hold is for only 72 hours and may not last that long. If possible, I talk with any available partners, friends or family.
Am I the Gestapo? Am I another guard at Guantanamo Bay?
No, but I am a young doctor still grappling with these responsibilities. I think about the powers that other residents have assumed and how they come to terms with their new roles. The surgeon who can cut into you. The anesthesiologist who can put you to sleep. The radiologist who can see through you.
I hope never to take lightly the ability to hospitalize people against their will. I want to connect with my patients in ways that comfort them and that start the healing process, even if I’m handing them legal paperwork or explaining the nuances of psychiatric holds. I hope I can help my patients and their families navigate the obscure and sometimes bewildering system of mental-health care in the United States.
I need to remember that the blue ink on the page is not routine for them.
Morris is a resident physician in psychiatry at the Stanford University School of Medicine.