At what point does patient autonomy and self determination end?


Okay, this question was posed to me hypothetically speaking. Patient is manic and has not responded to psychopharmacological interventions~ECT therapy has been recommended to her and her family~ Pt is fearful that it will enable others to control her mind and is opposed to it. So, in dealing with severely ill psychiatric patients~~what are their rights and at what point does autonomy and selfdetermination end for the SEVERLY ILL????

Thanks for your opinions.....

I'm kind of thinking that due to the patient bill of rights that they may refuse treatment~~but even if they are severely ill?? I'm not sure!?!


142 Posts

Specializes in Psych, ER, OB, M/S, teaching, FNP. Has 10 years experience.

Remember it is not illegal to be mentally ill, but when the person is a danger to themselves or others, then someone can step in and make decisions for the person.

I remember a patient in particular from when I was working just in psych. She believed all of her family had been replaced by androids and would have nothing to do with her adult children or other family members. She was hospitalized and her family was desperate for us to "do something". She refused meds and in our state that meant she went before the Involuntary Medication Review Board. She lived in a trailer house in the mountains of middle of no where Montana, she had no electricity, no running water and only a wood stove for heat.

She was allowed to refuse meds an taken back home because there are lots of people in Mt that have no electricity, heat with wood and pack their water and she never hurt anyone. She was not a danger to herself or others.

However about 2 years later her paranoia got the best of her and she attacked someone at some public pace and was committed to the forensic unit of the same hospital.

So again, if the person is a danger to themselves or others, often that is when their "rights" are removed.

Hope this helps.


44 Posts

I appreciate your reply, thank you! That's is where I was going with it and wasn't sure if I was correct. Thanks again!

Whispera, MSN, RN

3,458 Posts

Specializes in psych, addictions, hospice, education.

Where I live (Indiana), the law says a patient can be forced into treatment if he/she is a danger to self or others or is unable to care for his/herself. The last is a rather grey area since what we may think is an inability to care for self could be appropriate to lots of people. It's not something a nurse can decide though. A doctor has to believe it and it has to go before a judge for a final decision. People can be detained if there's a reason to believe they can't care for themselves, though. Then a hearing has to be scheduled in a short time.


143 Posts

I think I would be right in assuming that the law in regard to when a person is sufficently unwell that it is appropriate to enforce treatment/hospitalisation changes depending on your state or country. They mostly follow the principle of harm to self or others in determining when the patient requires involuntary treatment, in NSW Australia we also have the term 'harm to reputation' this is intended to help with patients who are manic or hypomanic, and who are ruining their standing in the community and in relationships as a result of their illness.


Specializes in Psych. Has 32 years experience.

This is a State to State issue, every law is different. In CT we must have an "involuntary medication hearing" to force a patient to take meds. If they "lose" the hearing, they will be given IM meds if they refuse the prescribed po meds. For something like ECT, we are required to have a hearing with the probate judge vs. a med hearing officer. On an inpatient unit I think it's a lot easier to "force" treatment on a person with a severe psych illness, than it is in the community.

What I have personally found the most painful to learn about, is the person who is in the community, with a treatable illness, whose family cannot get help for. We recently had a woman in for treatment, who was one of those "cat lady" people you read about. Her sister had been trying to get treatment for her for 2 years. ACTIVELY trying. She had (the patient):

*no running water (no flushable toilets)

*no electricity

*no heat

*was being "taken advantage of" by 3 neighbors (ie: $50 for a ride to buy cat food; sex for a ride to buy cat food etc.)

*had maggots in all food in the house

*the house ended up being condemmed, due to dead animals and human waste everywhere.

So how did she finally get treatment available to her? The ASPCA was called by someone, and the authorities brought her in for an evaluation.

What does this tell you? Animals are more important than humans.

That said, I do believe that people have the right to refuse treatment. But in psych, it's a slippery slope. At what cost? It's a fine line, and it is never the same for each person. I also believe that that right has increased our mortality rate. It has increased the HUGE percentage of mentally ill people living on the streets, or if they are lucky-in homeless shelters. As a society, we have failed our 2nd most vunerable population (children being the 1st).

Gotta get off my soapbox before this becomes a 68 page essay.


2 Posts

Hi, new to the forum, but wanted to give my 2 cents - as far as automony goes, in my state (MA) people can be committed to the hospital for inability to care for self/danger to self or others...however we cannot medicate or treat unless they agree. The only way to medicate against their will is 1. go to court and convince a judge to issue a sect 7,8,8B court order or a chemical restraint for risk of imminent danger to self or others. As far as ECT goes, I've never seen a judge ok it on the 8b treatment recommendations, only a variety of meds. If the patient is repeatedly decompensating and/or in the hospital, the family can pursue a Roger's Guardianship in which they have the right to hospitalize the patient and the patient can be medicated against their will (in the community or hospital) without having to go back to court for the 8B order - this is a great tool in theory, but can negatively affect family dynamics.

After 10 years of this, it still breaks my heart when patients lack insight into the need for ongoing treatment, particularly in young psychotic patients.


117 Posts

Specializes in Mental Health/School Nursing/Corrections. Has 22 years experience.

"Falling through the Cracks" of the healthcare system is how I view it.

It's highly dependent on the medical, mental health and legal system and it's professional assessment and opinions. There is a huge need for education and prevention in the community setting. Then comes the ER personnel who are very much in need of "Crisis Intervention Staff" based on premises since many of our vulnerable patients present there.

I'm planning a presentation to our local Sheriff Dept regarding the petitioning process, observation techniques of patient presentation and the significance of early intervention.

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