Ethical Decision, need help with resources/info on the matter!!!!

karbyr · Apr 2, 2006

You might be better off looking for this information in the Mental Health forum; I can tell you what I know about Michigan, but it may vary state to state; In Michigan, the route to go would be to have a competency hearing scheduled, in order to show that the patient/client needed protection from himself as he is a danger to self and others. If he is found incompetent, a guardian would be appointed and it would be that person's responsibility to decide if he takes medications or not. If the guardian so decided, he could be given medication, including IM meds if he is not cooperative. This is, obviously, the short answer, but it is a direction you can pursue to see what the laws are in the state where you live; a portion of that research would include the rights of guardians of those deemed incompetent; GOOD LUCK!

Editorial Team / Admin · Apr 2, 2006

Thread moved to the Psychiatric forum for a better response.

MarkRN · May 1, 2006

I suggest you take a look at your state's mental health legislation (i.e. mental hygiene law). In New York state, we have to obtain a court order for meds over objection before we can force patients to take meds other than PRNs that are needed to decrease agitation/harm to self or others.

rys77 · May 1, 2006

I would check state law as well. Where I am in Manitoba,Canada, we can only force meds if 1) we have a doctors order to do so, i.e) give Haldol 5 mg and Lorazepam 2mg if Clt. refuses regular hs dose) and if they are deemed incompetent to make treatment decisions. That requires a Psychiatrist's documentation and a mental health act form to be filled.

Also, in any situation on our unit where the client is deemed by staff to be a threat to themselves or any other person on the unit, we have the right to seclude, restrain and medicate.

Thunderwolf, MSN, RN · May 1, 2006

Good thread. We need to separate ethical from legal, though....two different issues.

Competence is a LEGAL term...not psychiatric. It is a term rendered by a judge, not a lawyer.

rys77 · May 1, 2006

Originally posted by Thunderwolf:

"Good thread. We need to separate ethical from legal, though....two different issues.

Competence is a LEGAL term...not psychiatric. It is a term rendered by a judge, not a lawyer."

I agree with you, but often legal and ethical issues go hand in hand. For us here, competence is a term set forth by the legal system, but can only be deemed to be valid by an attending psychiatrist. Even though it is a legal term, it has explict meaning within our psychiatric system. Basically, it doesn't just serve as a legal explanation.

Red Wing Magnolia · May 1, 2006

I agree that this is a legal decision and you might want to check the laws of your state. In Florida, if a person is determined by the court to be incompetent to stand trial, that person is committed to a forensic facility. It is the role of the forensic facitlity stabilize the person's mental illness and inturn to restore the individual's competency whereby they are returned to the judicial system.

Competency to stand trial is not the same as capacity to make an informed decision regarding one's medication. If the person is asked to sign consent for psychotherapeutic medication and he/she has the capacity to understand the information provided, they can consent to psychotherapeutic medication or they can refuse treatment. If medication is refused, the only way to provide psychotherapeutic medication would be by court order to medicate.

Capacity to understand and provide express and informed consent is a clinical decision. When a person refuses medication that the court has ordered, a long acting antipsychotic injection places less burden on the staff and hopefully less trauma to the patitent.

CharlieRN · May 7, 2006

I agree with Wolfie, there are two issues, legality and ethics.

I find that legality is often at odds with ethics. For example "disclaimer" language in advertizing excuses the illegality of an otherwise fraudulent claim, but is an admission of guilt in terms of the ethics. Clearly the advertizer knows he is doing something wrong, since he has put in a disclaimer.

In this case, legally, the lawyer has no say in what the hospital does, unless he has a power of attorney in health matters. That is, he has been appointed the legal guardian of the patient. This should be decided by a court.

Even if he has legal guardianship in health matters, he still can't practice medicine. He would to need the patient's doctor to order the medication.

Assuming that the lawyer has the necessary guardianship and the md agrees to order medication, then we come to the ethical consideration.

If the nurse who is asked to administer the medication is convinced that taking it is not in the patient's best interest, then he/she should not give it. The principal involved is that of doing no harm. Since it is a legal order he/she may face disiplinary action for refusal. Your ethical judgement offers no protection under the law, for you.

There is a very valid question of it being in the patient's interest to be competent to face a murder charge. Seems that being crazy is his position of safety. Why would his lawyer want him to be competent? Now the procecutor might have a reason to want to force the patient to take meds, but the defense would not want this.

truejewel82 · May 10, 2006

I just got back from my Ethics class..and I will have to also work on a power point presentation for this issue...hopefully all this food for thought will give me excellent insights to present to the class, now back to reading the threads............

StuPer · May 12, 2006

While I can see the issues here re: competency to stand trial etc. surely this is not within the scope of a nurse in the sense our practice should focus on the patients well being and illness. Given the patient has a schizophrenic illness, it should be the focus of the clinical team to resolve the symptoms of that illness to the best of their ability.

Under the Mental Health Act here, if the patient's illness is impacting on their ability to function, and preventing them living their life without being a risk to themselves or others, the treating psychiatrist can enforce treatment. The goal of which is not to prepare the patient for trial, but simply to treat the illness, that it will enable a trial to commence due to improved mental state is and should not be in the minds of the treating team.

Further for those that do commit crimes while mentally unwell, any trial looks at the reasons why the person was unwell, what treatment they had recieved before and compliance. Having said all of that invariably in NSW if you do murder someone while psychotic you get off with a 'not guilty by reason of mental illness', and are transferred to a secure psych facility, with release being at the discretion of the Mental Health Review Tribunal and the Minister of Health.

regards StuPer