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As the prevalence of mental illness increases in the United States, emergency medical services' (EMS) role in the care of the psychiatric patient continues to grow. The goal of EMS systems is safe transport of the psychiatric patient to the hospital for further evaluation and care. The cooperative patient can usually be transported without physical or chemical restraint, or law enforcement assistance. In cases of the extremely violent or agitated patient in whom de-escalation techniques have proved futile, law enforcement may elect to use an electronic control device (ECD) to subdue the patient. Refusal of care in the psychiatric patient poses a challenging dilemma. The violent and agitated patient clearly lacks decision-making capacity. Thus EMS personnel need to determine decision making capacity in the difficult prehospital environment. Organic causes of abnormal behavior, such as hypoglycemia, should always be considered.