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Psychiatric emergencies, capacity and involuntary admission
In agitation always start with verbal de-escalation and the exclusion of a medical cause, then medication — orally if possible — and restraint only as a last resort; capacity to decide is assessed for a specific decision, with four components, and any doctor can assess it.
Why it matters in the exam
Exam questions present an agitated person in the emergency department and ask for the first step: safety of staff and patient, an attempt at verbal de-escalation, and a quick check for a physical cause — low glucose, hypoxia, intoxication, withdrawal and delirium. If medication is needed, an oral drug is offered first; by injection an antipsychotic (haloperidol or olanzapine) or a benzodiazepine (lorazepam or midazolam) is given according to the cause — a benzodiazepine in alcohol withdrawal, an antipsychotic in psychosis. Injected olanzapine is not combined with an injected benzodiazepine because of respiratory depression. Restraint is a last resort, documented, with observation and repeated review.
Capacity to decide on treatment has four components: understanding the information, appreciating what it means for my situation, weighing the alternatives, and expressing a choice. It is assessed for each decision separately, a psychiatric diagnosis alone does not remove it, and refusal of treatment is not proof of incapacity. In Israel, the Patient's Rights Law requires informed consent, and allows urgent treatment without consent only under defined conditions of serious danger. The Treatment of Mentally Ill Persons Law allows the district psychiatrist to order an urgent psychiatric examination and involuntary admission when a mental illness impairs judgement or reality testing and the person poses an immediate danger to self or others; the decision is later reviewed by a district psychiatric board.
Key points
- Agitation: safety, words, exclude a medical cause, and only then drugs.
- Oral first; injected according to the cause; restraint as a last resort.
- Capacity: understand, appreciate, weigh, express a choice — for each decision separately.
- Patient's Rights Law: informed consent; urgent treatment under defined conditions.
- Treatment of Mentally Ill Persons Law: the district psychiatrist orders examination or involuntary admission.
Summary table
| Situation | Principle | Action | Exam notes |
|---|---|---|---|
| Agitation in the emergency department | Safety, verbal de-escalation, exclude a medical cause | Glucose, oxygen, intoxication, withdrawal, delirium | Do not jump straight to drugs |
| Drugs for agitation | Oral first; injected according to the cause | Haloperidol or olanzapine; lorazepam or midazolam | No injected olanzapine together with an injected benzodiazepine |
| Restraint | Last resort | Documentation, close observation, repeated review | Release as early as possible |
| Capacity to decide | Four components: understand, appreciate, weigh, express a choice | Assessed for a specific decision, by any doctor | A psychiatric diagnosis does not remove capacity |
| Urgent treatment without consent | Serious danger, under the Patient's Rights Law | According to the conditions in the law, with documentation | Not every refusal is incapacity |
| Involuntary examination and admission | Mental illness impairing judgement and reality testing, and immediate danger to self or others | Order of the district psychiatrist; review by a district psychiatric board | Treatment of Mentally Ill Persons Law |
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Sources
- Project BETA consensus (Western Journal of Emergency Medicine), 2012 — Verbal de-escalation and psychopharmacology of agitation
- Israel Patient's Rights Law, 1996 — Informed consent; treatment in an emergency
- Israel Treatment of Mentally Ill Persons Law, 1991 — Emergency psychiatric examination and involuntary admission
- Appelbaum PS, New England Journal of Medicine, 2007 — Assessment of patients' competence to consent to treatment
Sources are given for further reading; the text is written afresh and not copied from them.
Reviewed by the Examqo AI Professor · 2026-11-02. The text may contain errors; when in doubt, check the source.