PC Hearings in California

This is an Introduction to PC Hearings conducted in the psychiatric inpatient setting. This guide is primarily for medical student/resident rotators and/or Psychiatry Interns beginning their residency. Note this applies to the state of California. The process may or may not deviate significantly in other states and/or countries.
72 Hour Involuntary Hold (5150):

• Goal: Legal document written by a qualified clinician or officer to place a patient on an involuntary hold due to suspected mental health disorder under the premise of Danger to Self (DTS), Danger to Others (DTO), and/or Grave Disability (GD) in the state of California
  • Allows for a time period to conduct a thorough initial psychiatric evaluation and follow-up to determine whether patient needs further inpatient admission vs can be safely discharged to a lower level of care
  • No hearings are conducted while a patient is on a 5150

14D Hold (5250):

• Goal: Provide evidence for continuation of involuntary hold in the acute inpatient psychiatric setting
• Before attending the hearing:
  • Bring Patient’s Paper Medical Chart with you
  • Check to see that both the 72 hour hold (5150) and 14 day hold (5250) are in the chart
  • Be familiar with the circumstances that brought the patient into the hospital
  • You may bring Progress Notes/Initial Evaluations with you for reference
• During the hearing:
  • Begin by reading the 5150 hold: include date, time and reason for patient being placed on the hold verbatim
    • “Per 5150 beginning February 20^th, 2018 at 1100, ‘Client was endorsing thoughts of harming self…’”
  • Next read the 5250 hold: include date initiated and reason for patient being placed on current hold verbatim
    • “Per 5250 initiated February 24^th, 2018, ‘Client remains acutely psychotic and cannot provide a viable plan for self care…’”
  • Allow time for Court Hearing Officer to write down the information
  • Now begin crafting the story and providing evidence
    • How has the patient been since arriving on the unit?
    • Has the patient required behavioral PRNs (IM or PO) since being here? If so, what were they? (Give medication, dose, and frequency) and what was the reason? (Agitation, depression/anxiety, suicidality, etc)
      • Ex: “Pt was acutely agitated, attempting to assault staff, requiring 5 haldol / 2 ativan / 50 benadryl injection last night”
    • Has the patient been placed into seclusion/restraints? If so, why and how long?
    • Has the patient continued to endorse SI/HI/AVH vs when presenting in the ED?
    • How has the patient behaved with nursing and other members of the team? (verbally abusive vs calm/cooperative/behaving appropriately?)
    • For GD: Can the patient provide a viable plan for self-care outside the hospital?
      • Can patient provide him/herself food, clothing, shelter, and other basic needs (eating/showering/sleeping) under the premise of mental illness?
    • List all psychotropic medications including medication name (trade name or generic), include dose and frequency
      • Example: “Haldol 5mg twice a day, Depakote 500mg twice a day, Prozac 20mg daily”
      • Do not include non-psychiatric medications (don’t need to know pt is on insulin)
    • What is the current disposition plan? (Home, B&C, FSP, Shelter, etc)
    • Finally, what is the patient’s current working diagnosis?
      • It is okay to say “unspecified mood/psychosis” if we aren’t sure
    • At the end of the hearing:
      • If you win: Patient’s Advocate will provide patient with option to File a Writ of habeas corpus and have a second hearing that can be done in Downtown Superior Court in LA
        • If the patient says he wishes to pursue this, then you must inform the resident/attending as the second court hearing must be done by them in DTLA
        • If the patient wishes to cooperate with treatment team, then you are done, notify resident/attending about the result of the hearing
        • If patient did not attend the hearing, you are done, notify resident/attending about result of the hearing
      • If you lose: notify resident/attending ASAP!
      • Take the chart back to the nurse station

30D (5270) Hold:

• Goal: Provide evidence for continuation of involuntary hold in the acute inpatient psychiatric setting on grounds of ONLY grave disability
  • Read the 72 hour (5150) hold as above
  • Read the 14 day (5250) hold as above
  • Read the 30 day (5270) hold including date initiated and reason for placing patient on hold
  • General guidelines similar as 14 day (5250) hearings, but must provide strong enough evidence for Grave Disability to justify continued hospitalization

RIESE Hearings: Only residents/attendings can attend these

• Goal: Provide evidence to determine whether patient has the right to refuse psychiatric medications
• Information considered:
  • Has the patient been >50% compliant with his/her medications? (Number of refusals / Number of total doses offered)
  • Has the patient been refusing consistently for x amount of days?
  • What is the current mental state of the patient?
  • What medications will we be forcing the patient to take?
  • Has the patient been informed about the Risks/Benefits/Alternatives/Side Effects of the refused medications?
  • Why do we think Riesing the patient will benefit him/her?
  • What will happen if patient does not improve? What is the long term plan?

LPS Conservatorship (5350):

• Above all legal holds, if patient is on LPS conservatorship, then there is no need for 5150/5250/5270 assuming paperwork and legal documents are obtained and placed in patient’s medical chart
• What is the difference between LPS Conservatorship and Probate Conservatorship?
  • Under a Probate Conservatorship, the conservator may not place the conservatee in a locked mental institution against his or her will
    • Deemed unable to care for self or his/her own finances due to medical condition (Ex: Dementia)
  • Under a LPS Conservatorship, a person who has been found to be “gravely disabled” due to a severe mental illness and can be involuntarily committed to a mental institution.

**Final Points**:

• Assume the hearing officer doesn’t have background in psychiatry or medicine
  • Use layman terms as much as possible (instead of “PO BID,” say “twice a day by mouth”) with the exception of the working diagnosis (Ex: Schizophrenia) and medication names
• Do not provide false information, be honest, but convincing and state intentions of why you feel strongly to keep patient in the hospital
• If a patient has a combination PC hearing & Riese hearing, please notify the resident/attending as both must be done together and thus medical students cannot do these
• If a patient attends the hearing or is contesting the hearing, there should always be a Nurse attending the hearing for safety of everyone in the room
• It’s okay if you lose the hearing (it happens), if you do lose, please notify your resident/attending ASAP to discuss plan going forward