Ethical considerations

First-break psychosis can present with a broad combination of features, such as hallucinations, delusions, disorganized speech, and negative symptoms [7]. Patient presentation typically informs clinical decision-making, including treatment and discharge disposition plans. Under the New York State (NYS) Mental Hygiene Law, patients can be admitted for psychiatric illness under certain conditions: voluntary, informal, emergency, and involuntary [8]. For involuntary hospitalizations, providers can use the two-physician certificate [8]. The two-physician certificate indicates that “a person has a mental illness for which care and treatment in a mental hospital is essential to his/her welfare; person’s judgment is too impaired for them to understand the need for such care and treatment; as a result of their mental illness, the person poses a substantial threat of harm to self or others" [8]. This allows a person to be held involuntarily for up to 60 days, after which reassessment is required [8]. Initially, two medical doctors must evaluate the patient [8]. Before admission, a staff psychiatrist, besides one of the two original certifying MDs, must confirm that the person meets the involuntary standard [8].

For the other involuntary option, a designee applies, indicating “reasonable cause to believe that the person has a mental illness for which immediate observation, care, and treatment in a hospital is appropriate and which is likely to result in serious harm to themself or others" [8]. "Likelihood of serious harm" means a substantial risk of physical harm to the person, evidenced by threats or attempts at suicide or serious bodily harm, or a substantial risk of physical harm to others, evidenced by homicidal or violent behavior [8]. A medical doctor must then confirm that the person meets the emergency standard, allowing the patient to be held for up to 15 days [8]. Further, NYS Mental Hygiene Law Emergency Standard §9.39 holds that individuals may be admitted for emergency hospitalization if they pose a danger to themselves or others or cannot care for their basic needs, putting their health and safety at significant risk. Involuntary hospitalization can then be extended through a court order [9].

These criteria mainly revolve around harm to self and harm to others. In the absence of these, determining the inability to satisfy basic needs for nourishment, personal care, shelter, or self-protection and suffering worsening mental deterioration and functioning can be more complex. Therefore, evaluating psychiatrists must be particularly exhaustive in obtaining collateral information.

Clinical decision-making challenges

In our patient, the standards above may not apply, given that she did not specifically verbalize a substantial threat of harm to herself or others. With her family's financial and social support, she was questionably able to take care of herself. Though it may be likely that she may have become a danger to herself should she lose the support of her parents, it was unclear whether the involuntary standard or the emergency standard was met. This was further complicated by the challenging family dynamic. Recent studies have shown that patients with more social support are less likely to be involuntarily admitted [10]. The ambiguity of her symptoms was also not apparent at first, leading to the question of whether this unrelated admission required further psychiatric intervention once medically stable. The constellation of cardiac symptoms, time outdoors, and psychiatric complaints initially confused the differential, though ultimately, the third-degree heart block appeared to be a "red herring." Therefore, teams must be cautious of anchoring bias. Further complicating the presentation, the patient lacked any insight into her condition and seemed unwilling to seek follow-up cardiac or psychiatric care; however, the patient’s delivery came off more as a “stubborn” or “bothered” young adult who was not interested in listening to guidance from others. The psychiatric team had concerns that the patient would rapidly decompensate into a dangerous state upon discharge, which ultimately occurred in the weeks following discharge. Since the patient was admitted to the cardiac acute care unit, which is a rapid decision-making unit for discharge or admission, the primary cardiac team encouraged a more expeditious discharge timeline than might have been in the patient's best interest from a psychiatric perspective.

Proposed framework

An unbiased approach must be taken during disposition conversations, with the rationale given for decision-making to grow a trusting patient-physician therapeutic alliance [11,12]. Patient and family views and values must also be taken into account in making shared decisions with an emphasis on compassion, care, understanding, and patient safety. Efforts must be taken to sensitively educate patients and families about recognizing the signs and symptoms of psychosis, the multitude of treatment options, and the likely disease progression. With no risk of harm to self or others, a productive conversation can be had with a compassionate and team approach to the illness. However, sometimes, laws that require explicit phrases such as “dangerous to self or others” as criteria are too rigid and can be dangerous to patients and others [13]. Laws differ from state to state and are constantly evolving, and clinicians must familiarize themselves with the specific language in their practice area. Regardless, the definition of danger to oneself and others can be ambiguous, and interpretation of the law may be outside the scope of practicing physicians. One avenue to pursue is to lean into whether a patient can truly care for themselves or participate in the community and whether they have any insight into their condition to assess the danger posed to themselves. This assessment needs to be made independent of consideration of social and familial support. And therefore, in this case, the patient likely should have been admitted for further psychiatric evaluation and treatment.