Patients are involuntarily admitted to a psych unit for one of two reasons: Either they have an altered mental status to the point that they could no longer function adequately, or they are a threat of harm to themselves and/or others.
On the geriatric psych unit, if a patient was diagnosed with a terminal illness and had suicidal ideation, they could, and often would, be admitted involuntarily.
Theoretically speaking, if a patient is diagnosed with a terminal illness and refuses medical treatment that would extend or prolong their life, isn't that a form of self-harm? However, it is known that a patient has the right to refuse treatment.
Unfortunately once capacity is well established as diminished ethics committee actions and state licensing standards drive many of the ways care is implemented across the care team. The care providers as well as family members risk significant consequences if normal standards of care are withdrawn
This is true which is why it is important to have an advanced HC directive and let all your relatives know your wishes while you are still capable.
Specializes in New Critical care NP, Critical care, Med-surg, LTC.
2 hours ago, Daisy4RN said:
This is true which is why it is important to have an advanced HC directive and let all your relatives know your wishes while you are still capable.
It's unfortunate that even for those that think they have planned ahead, things can still be derailed by family members. There is currently a patient in my ICU with a written generalized advanced directive stating she would want NONE of what happened in the past three months. However, the wording was things like "if I am deemed to have a terminal prognosis", care would be withdrawn. Unfortunately, she never had a terminal prognosis, she had an acute event that led to intubation and then she has been unable to be weaned. So the family member is demanding that she was unable to give her wishes for this specific situation so she will remain on a ventilator despite the complete lack of quality of life. A lawyer even looked it over and tried to convince the family member this clearly she intended to avoid this situation, but admitted it was not specifically spelled out.
I hope she comes back and haunts the family member! I hate even walking by the room. Knowing what we know of how vibrant and energetic this woman was even in her advanced years, this has been horrifying.
Specializes in Psych (25 years), Medical (15 years).
Wow! Great information, responses, and perspectives!
Although each post, in and of itself, is worthy of a direct response, I'd like to do my post in an organic way, beginning with heron's.
15 hours ago, heron said:
I realized that the prospect of forcing someone to stay alive against their will was revolting.
It's amazing how much the essence of the medical field has changed in the past 40 some years. When I got into nursing, there was the feeling of physicians still having the final say, and life was to be prolonged no matter what.
I remember having a patient as a student LPN in 1983 who was diagnosed with cancer, but I don't remember seeing the word "terminal" being used or documented. I sought more less to his custodial direct care needs, got to know him and his wife, and he was assigned to me for a week or two or three.
I saw mental capabilities go downhill significantly after treatment episodes. I remember a nurse telling me, "Dr. (so and so) never says die" which I took to mean that chemo and/or radiation treatment would go on no matter what. The patient was cognizant and pleasant when he was first assigned to me but became confused and disoriented in a short time, possibly two to three weeks.
The patient passed away during the weekend when I was not in attendance in the program, after caring for him that Friday, and I've often wondered if it wasn't the cure that killed him.
Specializes in Psych (25 years), Medical (15 years).
On 12/6/2022 at 4:20 PM, DavidFR said:
Fully agree with the poster who said refusing treatment for a terminal illness is not the same as suicide...
...However Davey, are you asking what to do if somebody has an active psychiatric illness and is making a decision they may regret during a "well" phase?
I have known of patients who were involuntarily admitted because they said something along the lines of, "I don't want treatment for my terminal disease. I would rather die".
That "rather die" was a shoe in for an involuntary admission. It sounds ludicrous when it may have just been the phrasing.
The institution and its policy of admitting anybody for any reason comes into play here. At Wrongway Regional Medical Center, assessing staff often asked, after an individual denied being suicidal, "But if you were going to commit suicide, how would you do it?" Whatever action the individual gave became criteria for an involuntary admission.
Crappy, right?
In thinking about things again, most patients diagnosed with a terminal illness admitted to geriatric psych were due to a diagnosis of MDD. They were depressed, perhaps to the point of an altered mental status. That was enough for an admission, voluntarily or not.
Specializes in Psych (25 years), Medical (15 years).
While in the EMT program back in '79, I learned of the "intended permission" of treatment. If an individual is unconscious permission to treat is intended.
I keep a copy of my DNR/DNI in my wallet would such an event occur. My medical nurse/wife Belinda wouldn't let me get DNR tattooed on my chest. Not even DNR/DNI with a "(see wallet)" beneath it.
Back in '08, I bought a preplanned funeral package. This was after my divorce and before I chose Belinda for my POA or we were married. I had no close family members who I would trust to TCB and wanted my wishes to be known.
Speaking of preplanned funerals, I get a rash of telemarketer calls who want to sell me a preplanned funeral package. I inform them the matter has already been taken care of and please put me on their Do Not Call List.
Do telemarketers really believe we sit by the telephone and say, "Hey- I'm at an age where I really should preplan my funeral. I hope a telemarketer calls me with a plan so I can buy one from them"?
Specializes in Psych (25 years), Medical (15 years).
Senior moments seem to have become more regular and longer in length nowadays.
Somehow, I knew "intended permission" wasn't the term I was looking for but could not come up with the word. Then, while lying in bed last night thinking, it hit me:
"Implied permission" to treat.
If an individual is unconscious, the permission to treat is implied.
While my last hospital wasn't a psychiatric hospital, we did have a similar situation. In this case, it was a younger man who had a serious chronic illness. He knew his quality of life wouldn't be the same no matter what treatment he got and that the treatment would lead to increased pain and exhaustion. He would rather die than live like that. Our hospital used a consulting service, a bunch of psych APRN's with varying levels of competence and professional etiquette. The first one noted that he wasn't sure whether or not the patient was suicidal. When a different psych APRN was on call, the MD requested a re-evaluation. The second psych APRN made it clear the patient was not suicidal and pretty much confirmed what we all already knew.
The patient ended up discharging on hospice.
As long as a person is determined to have capacity, they have the right to refuse treatment.
Specializes in CCU, SICU, CVSICU, Precepting & Teaching.
On 12/6/2022 at 10:52 AM, Davey Do said:
On the geriatric psych unit, if a patient was diagnosed with a terminal illness and had suicidal ideation, they could, and often would, be admitted involuntarily.
Theoretically speaking, if a patient is diagnosed with a terminal illness and refuses medical treatment that would extend or prolong their life, isn't that a form of self-harm? However, it is known that a patient has the right to refuse treatment.
Really: What do you think?
Speaking as someone whose mother was involuntarily admitted to geri-pysch, I'm thinking that refusing treatment is not the same brand of self-harm as suicidal ideation.
Mom had Alzheimer's. Her special brand of crazy at that point in her Alzheimer's was to try to harm others. I am grateful to the LEOs who risked evisceration with broken water glasses to restrain her and take her to geri-psych for an evaluation and titration of her meds.
Suicidal ideation is someone who is actively self-harming or plans to. Refusing treatment -- especially for someone who understands the risks and benefits of said treatment -- is nature 'taking its course.' We survivors tend to have less of an issue with, say, a multiple myeloma patient refusing dialysis because it won't change the underlying condition, or an end stage cardiomyopathy patient refusing a feeding tube and an LVAD than we do with someone jumping off the top of a six story parking garage or hanging themselves. I think there are many reasons for that -- refusing treatment may be self harm in the loosest interpretation. But unlike active suicide, it doesn't harm others. Active suicide usually harms people other than the 'victim.' Like the guy who jumped off an overpass into traffic or the ones committing 'suicide by cop' or the guy whose 9 year old discovered his body hanging in the two story staircase or . . . the list goes on.
People have a right to die as they choose, but I don't think they have the right to involve others. Perhaps my perspective is somewhat skewed because my father used to pull out the Smith & Wesson and threaten suicide whenever he had to have a biopsy or was faced with legal consequences to his own (usually poor) choices. As a teenager, I witnessed more than one of those S&W dramas, and I heartily wish some adult would have intervened and involuntarily admitted him for evaluation.
Specializes in Physiology, CM, consulting, nsg edu, LNC, COB.
Famous case in med-legal circles (https://casetext.com/case/lane-v-candura). Mrs. Candura was an old lady with diabetes whose hypoperfused leg became gangrenous, as they do. She had been ill a long time and when the physicians told her the leg would have to come off or it would kill her, she refused. She understood she would die, she was ready to die, and she made her wishes very, very clear to everyone who would listen. As she deteriorated, she becamse less oriented but continued to refuse surgery, and eventually became unresponsive.
Her daughter did not want her mother to die. She asked the court to have her mother declared incompetent so she, the daughter, could consent to the surgery. Long story made short, the court refused, opining that it would be unconscionable to sit in wait on someone who had made her wishes abundantly clear to become unable to speak, and then to override her expressed wishes. Mrs. Candura died peaceably.
Whenever this comes up on AN, it's my experience that many people respond like my students used to when presented with this case study, something along the lines of "She's disoriented, she doesn't know where she is or who the president is, she's not able to decide for herself, this is awful, the doctor has to DO something!" You don't have to know that Eisenhower isn't in the White House to know what you want in terms of your own care. We're not talking about somebody who is institutionalized because she is hearing the voices and hallucinating in the throes of schizophrenia; that's incompetence (and it still needs to be determined by a court; a physician cannot declare incompetence and then proceed to act on that). We're talking about somebody who has been clear and rational in expressing her wishes and everybody knew it.
One of my colleagues was asked to consult on the Teri Schiavo case. Unfortunately, Teri did not have anything in writing but had told her husband she didn't want to live "as a vegetable," which, alas, she was. He wanted her feeding tube d/c'd so she could die peacefully as she wished (which, given her condition, was perfectly possible). Her parents disagreed, and spent a long time with legal efforts to get custody of her so they could continue her care. They lost, because they did not have standing in the case. There were inflammatory photos on the net allegedly showing her smiling and responding; as anyone who has ever cared for people like this, these fleeting expressions are no more meaningful than the same ones a newborn makes. My friend is a neurologist who specializes in brain injury and said there was no purposeful movement or reaction there. Eventually, her tube was withdrawn and she died in about two weeks.
Both of these cases were before hospice was as well-known and used as it is now. But the principle of pt autonomy stands.
Daisy4RN
2,238 Posts
This is true which is why it is important to have an advanced HC directive and let all your relatives know your wishes while you are still capable.