Sunday, July 16, 2006

Clinical Judgement And Judicial Clinicians


We've had some discussions on this blog about split-therapy versus single-provider therapy, and over at Trick-Cycling there was a vigorous discussion about the role of nurse-practitioners in mental health care. In the correctional world we have one more practitioner to deal with: the judge.

In most cases the role of the judge is limited to sending the patient to our facility or getting him or her out. We do get referrals for treatment from the court, and for the most part these are appropriate. It can never hurt to have an extra pair of external eyes watching out for my patients. The problem happens when the role of the judge extends beyond identification and referral and into the realm of imposing treatment. I don't mean ordering that the patient participate in treatment, I mean ordering the treatment itself.

The usual way this comes up is at the bail review hearing. Inmate X appears in court and says to the judge, "I'm not getting my (insert sedating psychiatric medication here)." Inmate X does not mention that he was not participating in treatment at the time of arrest, or that the only time he takes medication is when he's locked up. Nevertheless, an order gets written that Inmate X must be evaluated for medication. Well and good, this is appropriate although not totally necessary. Provided that Inmate X was honest with the intake nurse and gave a history of mental health treatment, he would have been referred to see the psychiatrist anyway. We now have two duplicate referrals, one from the court and one from the intake nurse. Subtract one point for inefficiency.

But back to the court-ordered treatment. Occasionally Inmate X will tell the judge that he wants to be on the mental health tier. We do provide some special housing for inmates with chronic mental illnesses who have trouble in general population. No problem. But if the inmate gets into trouble or starts fights or otherwise acts up on this tier, he might not be accepted back there. Thus, the court-ordered jail hospitalization. Not because he needs to be in the hospital, but because the judge wants him out of general population. Subtract one point for losing an inpatient bed.

Some judges order that the inmate "be provided with medication"; usually the implicit understanding is that the medication is provided if clinically indicated. Rarely, you'll get a judge who orders that an inmate should get medication, even if the inmate has already been seen and found to have no Axis I disorder. I've also seen orders specifying the name, dose and frequency of medication to be given. This creates an interesting situation when the patient then tells me he has a history of an adverse reaction to that same medication. Subtract one point for creating a legal conundrum.

So far I haven't heard of any correctional physician who has been found in contempt of court for using sound clinical judgement, or who can document the reasoning behind a clinical decision and can explain it coherently to the court if asked. The real downside is that doing this takes time which could be spent providing clinical care. That's where I see a need for sound judgement.


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Disclaimer: The opinions expressed in this blog are my own, expressed while off-duty, and do not represent those of my employer or the state government. Please don't make me listen to Barry Manilow.