A Medical Incapacity Hold Policy Reduces Inappropriate Use of Involuntary Psychiatric Holds While Protecting Patients From Harm

Psychosomatics. 2019 Jan-Feb;60(1):37-46. doi: 10.1016/j.psym.2018.06.002. Epub 2018 Jun 14.


Background: The use of involuntary psychiatric holds (IPH) to detain patients who lack the capacity to make health care decisions due to nonpsychiatric conditions is common. While this practice prevents patient harm, it also deprives civil liberties, risks liability for false imprisonment, and may hinder disposition. Medical incapacity hold (MIH) policies, which establish institutional criteria and processes for detaining patients who lack capacity but do not meet criteria for an IPH, provide a potential solution.

Methods: A retrospective chart review was conducted on adult medical/surgical inpatients placed on an IPH or MIH over the 1-year periods before and after implementation of a MIH policy at an academic medical center. The primary outcome was frequency of IPH utilization in patients who did not qualify for an IPH as determined by 2 independent physician reviewers. A Cohen's kappa was calculated to determine inter-rater reliability. Differences in patient demographics and outcomes were compared using a Student's t-test, Wilcoxon rank-sum test, and Pearson chi-square test (α = 0.05).

Results: The Cohen's kappa was 0.72 indicating substantial agreement. Seventy MIHs were placed after implementation (mean duration 4.3 days). Before MIH implementation, 17.6% of IPHs were placed on non-qualifying patients, which decreased to 3.9% following MIH implementation (p < 0.01). The average length of stay for patients on an IPH or MIH did not change following MIH implementation. No instances of patient elopement, grievances, or litigation were found.

Conclusion: MIH policies benefit both patients lacking capacity and the health care systems seeking to protect them while avoiding inappropriate use of IPHs.

Keywords: capacity; commitment of mentally Ill [MeSH]; involuntary hospitalization; medical incapacity hold; mentally Ill persons/legislation & jurisprudence [MeSH]; public policy [MeSH]; treatment refusal [MeSH].

MeSH terms

  • Academic Medical Centers
  • Craniocerebral Trauma
  • Female
  • Hepatic Encephalopathy
  • Humans
  • Infections
  • Intracranial Hemorrhages
  • Involuntary Treatment / methods*
  • Involuntary Treatment, Psychiatric / statistics & numerical data*
  • Male
  • Mental Competency*
  • Middle Aged
  • Organizational Policy
  • Renal Insufficiency
  • Retrospective Studies
  • Sepsis
  • Treatment Refusal