When a patient is admitted to a hospital or other residential setting, the patient's legal status should be promptly clarified to establish whether the admission is voluntary or involuntary, whether the patient gives or withholds consent to evaluation and recommended treatment, whether the patient appears able to make treatment-related decisions, and whether an advance directive is in place. If there is a potential legal impediment to necessary treatment, action should be taken to resolve the issue.

The decision to hospitalize a patient involuntarily will depend on multiple factors, including the estimated level of risk to the patient and others, the patient's level of insight and willingness to seek care, and the legal criteria in that jurisdiction. In general, patients at risk for causing harm to themselves or others will satisfy the criteria for involuntary admission; however, the specific requirements vary from state to state (201), and in some states, willingness to enter a hospital voluntarily may preclude involuntary admission. To that end, psychiatrists need to be familiar with their specific state statutes regarding involuntary hospitalization.

Advance directives are attempts to ensure that individuals' wishes about treatment will be honored. Such directives may relate to wishes about treatment at the end of life (202) but may also relate to wishes about psychiatric treatment (203) or assignment of a durable power of attorney or health care proxy to make decisions in the event that the individual lacks capacity to do so (204). Although the specifics of advance directive regulations vary by jurisdiction, psychiatrists should include in their evaluation whether the patient has executed an advance directive—and, if so, the nature of the advance directive should be determined.

In every institution, whether public or private, fiscal and administrative considerations limit treatment options. Usually there are constraints on length of stay and on the intensity of services available. Further constraints can arise from the absence or inadequate funding of aftercare services or of a full continuum of care. The initial assessment of treatment needs should not be confounded unduly with concerns about financing or availability of services, although the actual treatment may represent a balancing of optimal treatment and external constraints. A common example is the situation in which a patient's safety requires a level of supervision not available in a given facility. Another example is when a patient requires a general medical evaluation that cannot be carried out in a free-standing psychiatric facility and requires the patient's transfer to a general hospital. If such issues result in a major negative effect on patient care, efforts should be made to find alternatives, and the patient, family, and/or third-party payer should be informed of the limitations of the current treatment setting and/or resources.