Ethics Question

[Ddestiny, BSN, RN]

I'm a student nurse going to school with the intention of being a Psychiatric Nurse. The other day we were lecturing about something completely unrelated (integumentary system, which eventually came to burns and the psychological impacts thereof) and it brought up some tough ethical questions. Since then I've been considering a lot of similar situations in the Psych setting and was wondering anyone would be willing to offer some insight.

And I will preface by saying that no, this is not homework related. I'm just very interested in mental health issues.

1. Anyway, I know that someone on an inpatient psych unit can not be released if they are still stating that they are a threat to self or others. But how long can you hold someone that is very obviously still depressed (maybe initially brought in for fear of hurting himself, not responding to treatment, but denies suicidal thoughts? Can you keep them without "evidence" that they have intent?

2. Or, what if he was very depressed and is choosing to end his life by not eating? I've seen this in LTC and, other than bringing in family and professional help (pastor, counselor) there wasn't much that was done. Of course we always offered her food, juice, shakes, etc but she never took it. Is there anything different that can be done in a hospital setting?

3. Where does the patient's ability to refuse treatment end? For example, if someone is extremely agitated to the point of violence towards staff or other patients then they may be given a chemical restraint. Does this also apply if he is being violent towards himself? Are there other situations I haven't mentioned?

Depression really interests me but the idea of helping someone that's suicidal makes me feel very powerless. I know that a lot of that is related to lack of education and I'm very anxious to learn about all of it. I can't wait until we finally get to it next Spring!

Thank you for taking the time to read my questions!

[marshmallowstar, BSN, RN]

#1 Each state's commitment laws are different. Here in Pennsylvania our first level of commitment lasts for 120 hours (5 days) at which point there is a new hearing and the pt can be committed for up to 20 more days. There are extensions beyond that but are used in more long term settings. At each hearing there needs to be continued evidence that the pt is a danger to self or others so it is possible that someone is held on the 5 day commitment because of a suicidal gesture then deny once inpatient and released. It's not too often that someone lies to be released and immediately kills themselves. I've only had it happen once (that I know of) When you know the signs to look for suicide with intent you're normally able to intervene and the docs are able to make a case for the commitment.

2. it is possible to get force feeds ordered on someone who is committed. In my experience it's VERY rare. Most antipsychotics increase appetite so that helps. You have to be careful though because many antidepressants can cause anorexia (not anorexia nervosa) I've encountered not eating/drinking related more to psychosis and paranoia or mania than suicide attempts. We've been able to get them to turn around before too much damage is done. The biggest risk tends to be for people are manic and burning thousands of calories and not eating or drinking because it requieres staying still. Not uncommon to see people doing jogging laps in the quite room while eating a PB&J and drinking milk.

3. Yes, we use meds and even physical restraints to prevent harm to self and others. In many cases those who want to harm themselves are in a little more control than those who want to harm others so you're able to deescalate and get them to contract for safety but there are definitely times when we intervine for safety.

Most pt's are able to refuse treatment up to the point of harm to self or others than they loose the ability to refuse. Some psychotic pt's are ordered forced meds (in pennsylvania this requires a second opinion and court order) this has more to do with the inability to care for self d/t psychosis than direct suicidal or homicidal thoughts.

Don't worry you'll learn what you need to know in school and once you start working find a nurse your respect and use them as a mentor. If you can, I suggest working as a mental health tech during school b/c you'll be exposed to more nurses and different styles and you can see what works well and what doesn't.