Fugue states in sleep and wakefulness: a psychophysiological study

A patient's refusal to participate in recommended treatment is a problem faced in all branches of medicine. However, psychiatry faces special problems because of its authority to impose hospitalization and treatment on unwilling patients. Nowhere is this more poignant than in the treatment of patients exhibiting suicidal behavior where the potential for imminent self-destruction exists. As part of a prospective study to develop utilization review standards for the hospitalization of suicide attempters, cases were identified where there was independent agreement between both the experts' standards and the treating resident psychiatrists that hospitalization was required. Despite this agreement, the patients were not hospitalized because the patients refused. By most criteria, these patients were a high risk group. They had made repeated suicide attempts, used lethal means which eventuated in serious medical consequences, and were still suicidal when referred for treatment. The emergency room psychiatrists reported feeling confused, anxious, and annoyed in dealing with these patients, and the patients signed out against medical advice. A review of these cases indicates that discussions of social control vs. medical responsibility and clear criteria for hospitalization should be incorporated into residency training programs since the emergency room resident faces these tension-producing issues frequently with several different types of patients. Moreover, utilization review criteria may help to set standards which will assist the psychiatrist in making these difficult decisions.