Warning: Wall of text.
Patient who came in from the ambulance bay "allergic reaction" that was an obvious psych patient who desperately needed to be hospitalized and on meds. Patient was of age so the doc could legally decide to get psych involved and have him admitted to an acute inpatient facility on an involuntary, put on meds, the whole shebang. Any of our psych docs would have known this kid needed a 72 hour or longer hold. With the way he behaved we already needed 4 point restraints and he probably would need multiple rounds of sedation.
Pt's mom was there and demanded that her kid not be given a psych eval from front street, before I could even ask her what he was allergic to (surprise, he's not allergic to what he said he was allergic to, he also said he was allergic to every med we could have given him to treat his "allergic reaction"). So obviously mom is not only part of the problem but the entire problem. Mom's also there with her two other kids who exhibit the exact same psychiatric symptoms the "allergic reaction" pt. had. Mom tells patient he has to get healthy so he can "heal the world", in front of me, the attending and resident.
Patient wants to sign out AMA but me, the attending on duty that night, and the patient's assigned resident discuss the case. Patient is having active hallucinations and paranoid delusions that are a result of mom's psychoses but he's not a threat to anyone else or himself at this point in time. He was in 4 points because he kept telling us he was having anaphylaxis symptoms but kept attempting to abscond. He functions well enough to attend college (according to mom) and behave normally enough that this wouldn't have happened unless he had an "allergic reaction".
The other difficulty is that they were from out of town, by a few hours drive so we have nothing on record on them. But we're guessing that by the fact that crazy mom still has custody of her kids and the public school system has never taken them away that she's doing the bare minimum to not have them taken from her by DCF/DCFS or whatever the department is called in their region. All 4 of them reek heavily of BO and unwashed clothes. The kids are a mix of black and white so they all have black curly hair in a variety of shapes that obviously hasn't been properly cared for. But otherwise they weren't gaunt or neglected, covered in filth, or smelled like urine/feces or animal excrement.
The issue became that mom wasn't willing to leave the room for any period of time and mom's very firm, almost combative insistence that her son not receive any psychiatric evaluation or medications (when he's legally of age and that's not her decision at that point in time) threw a wrench in the works of doing the right thing. If we got that kid a psych eval he would definitely be admitted to our very large network of university affiliated hospital's inpatient acute psych facility. Mom would then freak the fuck out then need to be removed by security or LE. LE, infamous for punting anything even slightly related to psych over to us (the hospital I worked at was in one of the top 10 most dangerous cities in the U.S.) would have removed her from the premises, brought her to booking, listened to her crazy tirades then brought her right back to us for admission. Psych would have obviously admitted her and finally got her on the drugs she'd needed to take for quite some time. She was either a very functional paranoid schizoaffective or had been raised the same as she was raising her children, hyper religion, angels and demons. Her son made false accusations that demons had taken a hold of the medics on his way over to the hospital and they had beat him up. That being in the hospital near all those "demons" made him act out whenever he freaked out about the restraints.
The attending I was working with was our medical director as well. So he knew the ins and outs of the legalities of the issue but it was the ethics of the issue that became the biggest difficulty. He discussed the case with another long time attending on duty that night and she told him to pull the trigger on psych, run the risk of her getting arrested, and doing whats right for that kid (he was just barely of legal adult age) and his siblings.
We spoke to SW just to get a low down on what would happen if mom ended up arrested and on an involuntary. The kids would get taken away and put in the system in their state unless they had relatives to take them in. By their condition and behavior we doubt they did as someone sane would have intervened in mom's psychotic behavior a long time ago. Our pt. in question would be admitted to a psych facility, put on meds, then released. Most likely he would just end up right back with mom. Since he's an adult there is no way to legally keep him away from her unless they eventually broke some law and the courts made it a condition of probation.
Knowing that it was going to be ridiculously difficult and borderline futile to do what was ethically proper, especially for this poor young adult and his siblings, we ended up just allowing him to leave AMA and continue to live in the fantasy world his psychotic mom had built up for him. Mom, relieved that she got to keep her little slice of paranoid delusion heaven intact, told me that her son was in town to tour the campus of the Ivy league school my hospital was affiliated with because he'd been accepted.
After telling that last snippet to my attending, an alum of both the undergrad, med school, and residency of that school he told me that there were absolutely no tours for months for incoming freshman who had been accepted to that school.
That was a real rough case to be involved in, knowing that I was willingly allowing three poor kids to be released back into the care of someone who wasn't 100% unfit, but was hurting them with her paranoid delusions, assuring that the cycle would continue and they would have a very small chance of living a normal life.