Although the federal law to protect patients’ confidentiality, Health Insurance Portability and Accountability Act (HIPAA), can appear excessive when it interferes with providing ideal care to psychiatric patients in emergency services, it presents even more challenges in inpatient work. In emergency services, releases of confidentiality documents are unnecessary when involuntary holds are in place. No release of confidentiality document has to be signed by patients to talk with their legal guardians or physician invoked health care proxies.
I’ve had the privilege of working in both inpatient and emergency psychiatry as a licensed independent clinical social worker. Inpatient cases typically last longer and involve more clinical exploration than emergency services cases. Inpatient units are designed to plan for discharges and aftercare much more than emergency services are.
It can be nearly impossible to obtain reliable information from a patient who is so disorganized that he or she can barely form a sentence, is highly agitated, is not wanting to be there, and is paranoid. As a social worker on inpatient, I obtained background information from family members or friends of the patients, updated them on progress, and gauged readiness for discharge based on their impression of patients’ progress. Some patients refused to allow me to provide information to anyone on the outside who cared for them.
I knew family members were concerned about patients on my caseload because of the desperation I sensed in their voices and frequency of calls. A young woman in her early twenties was admitted to inpatient because the police found her attempting to stop traffic on the highway. She couldn’t logically explain the reason for doing this after she adamantly denied that she was suicidal. She believed that her admission to the unit was all a misunderstanding and that if only I called the police to clear it up, she could be released. She wasn’t in any ongoing outpatient treatment because she didn’t believe that she was ill.
Still, on an involuntary hold, the patient refused to sign the documentation that would have rendered her voluntarily there. She also refused to tell us the name and phone number of any family or friend. Apparently no next of kin knew that she was there and there was no family member listed in her chart. Despite her thought process and behaviors being disorganized, the psychiatrist didn’t believe this patient qualified for an extended involuntary commitment and discharged her accordingly.
Just hours later, this patient’s mother called the unit. The call was transferred to me because I was the social worker and expected to manage most family interactions. After telling me that she’d been calling all local hospitals and police stations, the mother asked me if her daughter was there. During the uncomfortable silence as I struggled to find something to say, she began to cry and said that she'd thought about calling morgues, too.
I felt horrible. Who was responsible for leaving this mother sick with desperation? Who allowed the psychotic patient to fend for herself without any care? Who dropped the ball? The police officer who authorized the involuntary hold either didn’t care enough to find a next of kin to inform or found it impossible to do so. The hospital emergency department staff couldn’t locate a family member. The patient probably didn’t give them any clue about this.
Perhaps, if the psychiatrist had asked more questions of the patient and looked more closely at her, she would have understood that she wasn’t ready to be safely discharged. She’d probably have remained on the inpatient unit if her mother had been able to share her concerns early on. But now, there was nothing anyone could do to make things better.
Aside from speaking in “code” to families, which I've done, there’s not much any of us can do besides advocate and put pressure on the government to make changes. In my forthcoming book, Breakdown: A Clinician’s Experience in a Broken System of Emergency Psychiatry, I offer a simple solution to alleviate HIPAA constraints.
Lynn Nanos