CASE STUDY I: A “NO-ADMIT” LIST: A graduate student asked about the use of a no-admit list and described the following situation. A 29-year-old male patient with diagnoses of bipolar disorder,...

CASE STUDY I: A “NO-ADMIT” LIST: A graduate student asked about the use of a no-admit list and described the following situation.  A 29-year-old male patient with diagnoses of bipolar disorder, substance use disorder, and antisocial personality disorder comes to the emergency department (ED) one midnight shift under the law enforcement Baker Act.  This law permits a 72-hour involuntary placement for psychiatric assessment.  The law says the patient is to be admitted to the nearest Baker Act receiving facility.  The ED staff provided me with the following unsolicited information: “Get rid of this guy fast; he’s trouble”; the patient is an “abuser of the system,” they say, and he has assaulted several health care workers.  He is a drain on overextended resources because his behavior requires constant intervention to maintain safety. I find in our assessment office that the patient is on a “do not admit” list.  The unit nursing staff on duty that night provides me with the information that this patient assaulted a nurse on one of the adult psychiatric units and was jailed and charged for this offense.  The nurse sustained permanent damage to her knee and currently has a restraining order against this patient.  At this time, the patient is calm and cooperative during my assessment – other than making continuous, aggressive requests to smoke and several attempts to leave the ED without an escort to do so.  The psychiatrist on call was new to this facility, as was I at the time, so we were unaware of the patient’s history and past treatment record.  In addition, the psychiatrist and I had previous positive professional relationship at another facility, and I knew that he respected my recommendations.. Before calling him, I make inquiries at area psychiatric units and find out that earlier in the day this patient left treatment at a facility 70 miles away and is now welcome back because of his aggressive behavior.  The local community mental health facility also is not amendable to a referral because this patient assaulted personnel there in the past.  My colleague at the community center says that this patient has “burned all his bridges in a hundred mile radius.”I now have a great deal of information from various sources about this patient.  To pose this question realistically and succinctly, do I say, “Doc, this guy is bad news, and the unit will have your head and mine if we admit him” or “Doc, this patient is suicidal with a plan and we have the closest bed”?  What about the Law*?  How legal is a “do not admit” list, and what are my ethical obligations particularly when administration is aware of this patient’s situation and has opted not to address options that might break the cycle of continued abuse of acute services and the abuse of resources this facilitates?