1. Maya Prabhu, MD, LLB Yale Department of Psychiatry maya.prabhu@yale.edu Everything You Need to Know about PECs (and other legal matters)

2. Topics How to write a PEC How to write a PEC PECs vs. Conservatorship PECs vs. Conservatorship Understanding the Yale Psychiatric CL Service Understanding the Yale Psychiatric CL Service Collaborating between Primary Care and Psychiatry Collaborating between Primary Care and Psychiatry

3. Famous Forensic Patients (and Evaluators)

4. Issues at Nexus of Medicine, HIV, and Psychiatry Right to Treatment Right to Refuse Treatment Right to Die Involuntary Examination Involuntary Civil Commitment Capacity vs. Competency

5. Mental Health Law They are intended to provide security from harm or restraint and the exercise of mental health powers when are exercised arbitrarily, in a discriminatory manner, or in the absence of a fair process. Russia: Political dissidents were confined to psychiatric hospitals Political dissidents were confined to psychiatric hospitals Use of “emergency hospitalization” laws which allowed detention in psychiatric hospitals without going through the judicial process. Use of “emergency hospitalization” laws which allowed detention in psychiatric hospitals without going through the judicial process. Diagnoses such as “depressive paranoid syndrome” or “sluggish schizophrenia” were the basis for continued hospitalization Diagnoses such as “depressive paranoid syndrome” or “sluggish schizophrenia” were the basis for continued hospitalization Injections with Sulphazine Injections with Sulphazine The treatment of political dissidents led to the USSR being forced out of the World Psychiatric Association in 1983 The treatment of political dissidents led to the USSR being forced out of the World Psychiatric Association in 1983 China: In 2002, the WPA voted to send a delegation to China to investigate charges that dissidents were being imprisoned and maltreated as "political maniacs" both in regular mental hospitals and in police- run psychiatric custodial institutions known as the Ankang In 2002, the WPA voted to send a delegation to China to investigate charges that dissidents were being imprisoned and maltreated as "political maniacs" both in regular mental hospitals and in police- run psychiatric custodial institutions known as the Ankang Diagnoses made in both the political dissident and Falun Gong cases, ranging from "delusions of reform" to "paranoid psychosis” Diagnoses made in both the political dissident and Falun Gong cases, ranging from "delusions of reform" to "paranoid psychosis” There is evidence of punitive interventions such as ECT, IV administration of psychotropics. There is evidence of punitive interventions such as ECT, IV administration of psychotropics.

6. How to Get to a Psychiatric Hospital Voluntarily Voluntarily Involuntarily Involuntarily PEC PEC Civil Commitment/Probate Court Civil Commitment/Probate Court

7. Voluntary Admission If a pt is 16 years or older, they may enter a hospital willingly for diagnosis, observation or treatment. An informal request means you have requested admission for hospital treatment without submitting a written request. A formal request, called a “voluntary paper” is a written request for treatment (C.G.S. 17a-495).

8. Sec. 17a-502: Commitment under Emergency Certificate

9. An individual may be sent to a hospital involuntarily by a medical doctor. The doctor must examine the individual and sign an emergency certificate. In order to send the patient to the hospital the doctor must certify three things: That the patient is mentally ill. This means that there is a mental or emotional condition which substantially limits ability to function. This specifically excludes a person whose sole disability is alcohol or drug dependency as defined in Connecticut General Statutes §17a-680 The patient is either dangerous to himself or others The patient is "gravely disabled" - this means that they are in danger of serious harm because they cannot provide for your basic needs such as food, clothing, shelter, or safety because of mental illness There is immediate treatment for mental illness What does examine mean? When does the examination take place? To be valid, a physician with a valid Connecticut license must have examined the patient within 72 hours before signing the paper

10. Sec. 17a-502: Commitment under Emergency Certificate When an emergency certificate is issued, a hospital may keep a pt for treatment against their will for up to 15 days (C.G.S. 17a-502(a)). The hospital must release the pt after fifteen days unless an application for civil commitment has been filed with the probate court. If a civil commitment application has been filed, the hospital may keep the pt for up to 15 more days until the civil commitment hearing is held in probate court (C.G.S. 17a-502(a)). The hospital may not continue to hold the pt involuntarily if the probate judge rules that the pt does not meet the standards for civil commitment ( C.G.S. 17a-502(a)).

11. Who Else Can Send a Patient Involuntarily to the Hospital? The police (C.G.S. 17a-503(a)) on a PEER They may be held involuntarily until evaluation is finished, though not for more than 72 hours without signing in voluntarily or being placed on a PEC. A psychologist may also request that the police pick up a patient and take you to a hospital for an examination. Family or friends must apply to the probate court. The probate judge may then order the police to bring the individual before the judge to determine whether there should be an examination by a doctor (C.G.S. 17a- 503(b)).

12. Obtaining Information It is best have a patient's consent when seeking (or releasing) information about a patient. However, Section 52-146f of the Connecticut statutes allows communication for the purpose of emergency evaluation and treatment without consent. And, much of what we need to check is not confidential; i.e. details a patient’s behavior leading their family to call 911 and have them sent to us.

13. Appealing a PEC Probable Cause Hearing: Probable Cause Hearing: Patients can submit in writing a request for a hearing within 3 business days Patients can submit in writing a request for a hearing within 3 business days Patients have a right to a lawyer Patients have a right to a lawyer If the judge rules that there is not a probable cause, the patient must be released from the hospital immediately If the judge rules that there is not a probable cause, the patient must be released from the hospital immediately Probable Cause is not the same as a Civil Commitment Probable Cause is not the same as a Civil Commitment If you are not released, the hospital may not hold you longer than 15 days from the PEC unless they file for civil commitment. If you are not released, the hospital may not hold you longer than 15 days from the PEC unless they file for civil commitment.

14. Sec: 17a-498: Civil Commitment Defn: A judge may send a pt to the hospital by a judge following a hearing in probate court. Defn: A judge may send a pt to the hospital by a judge following a hearing in probate court. Who can Apply for Civil Commitment? Hospital: PEC  Civil Commitment Hospital: PEC  Civil Commitment Hospital: Voluntarily wanting to Leave  Civil Commitment Hospital: Voluntarily wanting to Leave  Civil Commitment Any interested party: Moves for Probate Court Hearing Any interested party: Moves for Probate Court Hearing

15. Leaving after Voluntary Admission The request to leave must be made in writing. The hospital can keep pt for 5 days after a request to leave (C.G.S. 17a-506(a)). During this time the hospital may file an application for civil commitment with the probate court. The hospital may then keep the patient for up to 10 more days commitment with the probate court.

16. Minors People age 16 and older are effectively adults. They can be evaluated and treated without parental consent, though you’ll probably wish to notify parents of minors age 16 or 17. A parent or guardian cannot sign a 16 year old in against his/her will (PEC is required). People age 14 and older can sign themselves into a psychiatric hospital. Below age 14, a child may be signed-in by their parents or guardian. (A PEC may be used if hospitalization is necessary, but parents or guardian are unwilling.) Minors or their parents or guardians may request a Probable Cause Hearing.

17. Capacity vs. Competency “Is Mr. Smith competent to refuse treatment?” Capacity is defined as an individual's ability to make an informed decision. Any licensed physician may make a determination of capacity. Psychiatrists are often called upon to assess a person's mental status and its potential for interfering with specific areas of functioning.’ Competence is a legal state, not a medical one. Competence refers to the degree of mental soundness necessary to make decisions about a specific issue or to carry out a specific act. All adults are presumed to be competent unless adjudicated otherwise by a court. Incompetence is defined by one's functional deficits (e.g., due to mental illness, mental retardation or other mental condition), which are judged to be sufficiently great that the person cannot meet the demands of a specific decision-making situation, weighed in light of its potential consequences. Only a court can make a determination of incompetence.

18. Conservatorship

19. Online Resources http://www.jud.ct.gov/lawlib/law/mentalhealth.htm