Psychiatrists' duties in discharging sicker and potentially violent inpatients in the managed care era

Psychiatrists have certain clinical responsibilities and legal duties to patients treated in managed care settings. They include disclosure of all treatment options, the exercise of rights of appeal for any care they believe will materially benefit patients regardless of allocation guidelines or gatekeeper directives, continuance of emergency treatment, and reasonable cooperation with utilization reviewers. An additional duty--to warn and protect endangered third parties--will likely increase as cost-containment measures curtail the length of hospitalization. The author discusses these duties in the context of sicker and potentially violent patients. He cautions psychiatrists to be careful not to prematurely discharge these patients because of pressures from managed care organizations. The policies of such organizations can place psychiatrists and patients in a precarious position by limiting the time and resources for diagnosis and the assessment of the risk of potential violence. These responsibilities and duties often can be turned into clinical opportunities that enhance the therapeutic alliance with patients.