Forced IM meds...always ethical??

[Abbyrose]

I work on an acute adult inpatient unit. We have an extremely aggressive patient who is involuntarily committed. He is child like and becomes aggressive when he is told no or doesn't get his way. Otherwise, he is actually pretty likable. He has a behavioral plan in place that says to offer his meds PRN meds PO twice when he is in need, and if he refuses force an IM. this is after trying other options to de-escalate. I understand and agree with this, but the other night staff disagreed while he was being held down and waiting for the nurse to draw up his meds...

His meds were taking a while to be prepared, about 5-7 minutes, which seemed like a while since he was in a physical restraint. The hospital supervisor and security were able to verbally de-escalate him during the time. He was no longer being restrained and had calmed down. He said he would take the meds PO. He began crying and saying "I'm sorry". The director of nursing and the treatment team were the ones who impressed upon staff that the behavioral plan must be followed by everyone. This incident occurred on a weekend and they were not present to clarify the plan at the time.

The charge nurse said "no, it's too late. He's getting the IMs". The charge nurse was in the nursing office during all of this and the supervisor was with the patient. The supervisor disagreed and gave them PO without incident. We had no problems with him after that. Her rational was "...he is agreeable. Not only would it be unethical, but it risks him escalating and disturbing the mileu again".

This caused staff to turn on each other, and everyone was interpreting the behavioral plan differently. We have not heard anything from the DON or treatment team regarding this. Both sides of the argument emailed their perception of the incident to the DON.

My question is:

If a patient becomes agreeable to take PRN meds PO, after originally refusing, can they be forced with an IM? Is that ethical and following least restrictive/invasive treatment?

[Jules A, MSN]

Good question and imo not always cut and dry. My preference is to evaluate every instance and patient for the best individualized approach. I tend to be of the mindset where if they are agreeable to take PO I would in most cases just give the PO as I usually kept them in my pocket anyway. I have worked with experienced nurses I respect who say absolutely NO and if it escalates to the point where we have to go hands on they are getting the IM. There is something to that because I have seen on more than one occasion where the hold is released so the patient can take the PO meds and they start swinging again which is very unsafe and requires another attempt at restraint. Its psych so of course there are no easy answers and that is why in a crisis there should be one person controlling the scene with a debriefing after.

What is the most concerning to me about the scenario is WTH it took so long for the IMs to be drawn up? That is a big problem and a safety issue for the patient and staff. Hopefully someone is checking into that aspect.

[Abbyrose]

Thanks, I agree with everything you said!!

The code was called in the middle of shift report. I was receiving report, and the evening shift charge nurse was giving report to all of night shift staff. Typically it is more organized, but we had a lot of seasoned nurses leave recently. Literally all of evening shift that day is relatively new to the facility and psych (less than 1 year!). The night shift supervisor was the one who took the lead and made the decision. She has many years of experience, and new the patient well and had good rapport.

I think it took so long because someone not sure who called the code over the radio to have security and anyone available in the hospital assist. He was restrained so quickly and without warning no one had time to prepare meds or a plan. The charge nurse usually directs the situation but she learned of the code as it was announced. She entered the scene once he was already restrained. She then want out to the nurses station and stayed there for the entire code. It was so unorganized! My biggest complaint is, the next day she went and complained to management about the supervisor, and she was the only one willing to take the lead.

Also, he was just banging doors and swearing loudly, which his plan does say that warrants a code....had he been posturing toward someone, or violent, I'm sure he would have had the IM without question by the supervisor.

[Meriwhen, ASN, BSN, MSN, RN]

That is a tough one. I'm personally of the mindset that if they decide at the last minute to take the PO and I have it ready to give that moment, I'll give it over a shot. However, if the patient is particularly violent/aggressive/psychotic, have a known history of cheeking or spitting out/vomiting up meds, and the shot is immediately there, the shot may be the better choice.

One thing about giving POs while the patient is in 4 points: you have to release/reposition the patient to an upright position for taking oral meds because if they try to take it while flat on their back, it's an aspiration risk. And you HAVE to be sure that this patient isn't going to knock you senseless once you free them from a restraint--it's not uncommon for patients to say whatever they think will get them unrestrained.

And I agree with Jules: 5-7 minutes to draw up IMs is WAY too long, especially in an emergent situation.

[Jules A, MSN]

I know geodon takes a bit to mix, but that does seem excessive.

Unless the only choice due to allergies I don't order Geodon IM for emergencies. Like you said it takes so long to mix when your staff is getting pummeled and part of their selling point was that it isn't as sedating. I had a sales rep at one of the drug dinners tell me this and I was like "Really? Well sedation is often at least part of my intention in an emergency situation with an aggressive, psychotic patient."

[ella69, RN]

In the scene you described above, I think it was appropriate for the pt to have received the PO meds, since, as you indicated, he had calmed with verbal de-escalation. I question the validity of the behavioral plan utilizing IMs. If the pt has been med paneled & lost, that's the only time I can think of when we can force IMs if POs are refused in the absence of imminent dangerousness. When talking about those behavioral emergencies, the order for the IM must be obtained at the time of the incident. At least that's what CMS told our hospital when we were forced to d/c all IM PRNs for behavioral emergencies. The fact that the behavior plan is being interpreted so differently by the direct care staff, along with what I wrote above, tells me it needs to be rewritten.

[Abbyrose]

Very good point about four-points! ...he was in a physical restraint, and before any meds, IM or PO, prepared he was released for the hold.

[Abbyrose]

I wish I could fix my typos and spelling! Lol I can't edit it...

[UTHSC_Bound, BSN]

I think the charges response was unprofessionally emotionally charged with a desire to punish the pt for the hassle of the behavior. absolutely give the pt the dignity of taking the PO meds if he is agreeable. its not a one way road is it? The mere fact that de-escalating is a part of the plan proves that its not!

[Here.I.Stand, BSN, RN]

I'd be concerned about the legality of that, not just the ethics. Of course if a pt is a danger to self or others, that supersedes his right to autonomy...but if he was deescalated and agreeing to take the PO meds? To hold him down and force a needle into him sounds like battery and false imprisonment.

[SarahMaria, MSN, RN]

Is this patient involuntarily committed to your facility for treatment, or for medication? Does he have a conservator? Just because he is committed, does not give you the right to medicate him against his will unless he is a danger to himself or others. In this situation, he had calmed down and was willing to take meds PO, so IMs would be illegal unless there was a special-limited conservator authorizing meds against will or the patient was committed by the court for meds.

That's how it works in my state.

[Whispera, MSN, RN]

The point of the medication was to help him calm down. He was calming down already!

I think the forced IM in this situation smacks of punishment. He is a patient, not a prisoner. In most states a court order is required to allow forced medication, an order that's separate from the order to be hospitalized. I see the problems with him acting out once you try to give him the PO meds, but still... He was calming down already. Maybe the PO meds wouldn't even be needed!