Shafi Lodhi, MD Chief Resident in Psychiatry University of Cincinnati College of Medicine Cincinnati, Ohio
Christopher Marett, MD, MPH Assistant Professor of Clinical Psychiatry Director, Division of Forensic Psychiatry University of Cincinnati College of Medicine Cincinnati, Ohio
Disclosures The authors report no financial relationships with any companies whose products are mentioned in this article, or with manufacturers of competing products.
In Mr. T’s case, the resident physician was asked to make a decision regarding seclusion on the spot. Prudent facilities will set policies and educate clinicians before they need to face this conundrum. The following practical considerations may guide implementation of seclusion as a measure of quarantine on an inpatient psychiatric unit:
given the risk of asymptomatic carriers, all admitted patients should be tested for COVID-19
patients who refuse a test should be evaluated by the psychiatrist on duty to determine if the patient has the capacity to make this decision
if a patient demonstrates capacity to refuse and continues to refuse testing, seclusion orders should then be placed
the facility should create a protocol to ensure consistent application of seclusion orders.
So that they can make an informed decision, patients should be educated about the risks of not undergoing testing. It is important to correctly frame a seclusion decision to the patient. Explain that seclusion is not a punitive measure, but rather a means of respecting the patient’s right to refuse testing while ensuring other patients’ right to be protected from COVID-19 transmission.
It is crucial to not allow psychiatric care to be diminished because a patient is isolated due to COVID-19. Psychiatrists have legal duties to provide care when a patient is admitted to their unit,28-30 and state laws generally outline patients’ rights while they are hospitalized.31 The use of technology can ensure these duties are fulfilled. Patient rounds and group treatment can be conducted through telehealth.10,32 When in-person interaction is required, caretakers should don proper personal protective equipment and interact with the patient as often as they would if the patient were not in seclusion. Table 233-36 summarizes further ethical considerations when implementing quarantine measures on a psychiatry unit.
The contemporary inpatient unit
The ideal design to optimize care and safety is to create designated COVID-19 psychiatric units. Indeed, the US Substance Abuse and Mental Health Services Administration recommends segregating floors based on infection status where possible.37 This minimizes the risk of transmission to other patients while maintaining the same standards of psychiatric treatment, including milieu and group therapy (which may also require adjustments). Such a unit already has precedent.38 Although designated COVID-19 psychiatric units present clinical and administrative hurdles,39 they may become more commonplace as the number of COVID-19–positive inpatients continues to rise.
Bottom Line
The coronavirus disease 2019 (COVID-19) pandemic has created challenges for inpatient psychiatric facilities. Although seclusion is a serious decision and should not be undertaken lightly, there are clear ethical and practical justifications for using it as a means of quarantine for patients who are COVID-19–positive or refuse testing.
Related Resources
Askew L, Fisher P, Beazley P. What are adult psychiatric inpatients’ experience of seclusion: a systematic review of qualitative studies. J Psychiatr Ment Health Nurs. 2019; 26(7-8):274-285.
