When Should Inpatient Psychiatric Care Include Access to the Outdoors, Despite Elopement or Other Risks?

Abstract

This commentary on a case considers consequences of a so-called "zerorisk" paradigm now common in psychiatric inpatient decision making. Iatrogenic harms of this approach must be balanced against promoting patients' safety and well-being. This article suggests how to collaboratively assess risk and draw on recovery-oriented goals of care.The American Medical Association designates this journal-based CME activity for a maximum of 1 AMA PRA Category 1 Credit™ available through the AMA Ed Hub TM . Physicians should claim only the credit commensurate with the extent of their participation in the activity.Case LH is a 29-year-old woman hospitalized, so far for 11 days, for a severe episode of depression. Dr Psych estimates she will be hospitalized for another week and is working with risk managers to find a way to allow LH to leave the unit with a staff member to walk in the hospital's garden, which LH can see from the unit's windows. LH feels distressed about not having access to fresh air. Dr Psych makes a case to a risk manager for LH's accompanied access to the garden: it will make her feel better, probably diminish her length of stay, and remove LH's feeling "imprisoned" as an obstacle to trust and healing in their patient-physician relationship. The risk manager, however, states: "I'm sorry; we just can't. Two years ago, a patient eloped after being allowed to walk in that garden." Dr Psych considers how to respond. CommentaryHealth care systems, particularly psychiatric care settings, are currently dominated by a zero-risk paradigm: an approach to ethical decision making that upholds elimination of risk as a shared goal and moral imperative. 1,2 The widespread adoption of the zero-risk approach has given rise to dedicated roles for risk managers and a range of interventions and technologies, including, in inpatient psychiatric settings, the use of surveillance, locked doors, and seclusion rooms, all aiming to eliminate risks associated with people experiencing mental health challenges. 3,4 Yet growing empirical evidence demonstrates that the zero-risk paradigm and its associated strategies fail to effectively eliminate or even reduce risks associated with self-harm, interpersonal violence, or absconding and instead threaten therapeutic relationships between health care professionals and patients. 5,6 Furthermore, zero-risk approaches introduce iatrogenic