Forcing Meds

[Kooky Korky, BSN, RN]

Do you ever force meds in Psych setting?

Does pt have to be involuntary and have a guardian who consents to forcing?

Does your facility/state require eval by and agreement of a 2nd physician to use force? (shots; couldn't very well force orals);

What other considerations are there where you work? Like is a Court Order required? Is an attorney appointed for the pt whose meds are being forced?

[That Guy, BSN, RN, EMT-B]

What is this for? It reeks of homework.

[vintagemother, BSN, CNA, LVN, RN]

I work in an inpatient psych facility. Meds can be forced if the doctor writes an order.

Our patients are not at my facility by choice. On one long term unit residents are here because a court has required them to be here. In this long term care setting, if a resident becomes aggressive we can call the MD and get an order for IM and hands on restraints.

In the other unit,which is short term holds (think 5250, etc) some patients are required by law to take meds and we are required to administer them by force.

I've never been personally involved with forcing someone to take meds.

On the long term care setting the residents are "owned" by the county and have a guardian called a conservator who is a county employee who must approve of all psychotropic meds , including those givens against their will. The county appointed guardian/conservator has never gone against MD orders that I've seen.

In the acute care in patient psych unit, a court order is required, called getting RIESED. Once a pt is RIESED, they can't refuse meds. If they do, it's the nursing staffs job to implement the DRs orders, which means giving IMs against a patients will.

All of our residents/ patients are in our facility against their will. It is due to a court order/ police determination that they are a danger to theselves or others that they are there.

[elkpark]

In an emergency situation, in which an individual is an acute danger to her/himself or others, anyone can be medicated without consent.

Outside of that scenario; when people "need" medication to treat their psychiatric disorders and are unwilling to take them voluntarily, but are not immediately dangerous, different states have different legal requirements/protocols that must be met. In some states, you have to get a court order. In some states, a second physician has to examine the individual and agree that forcing the medication is necessary. But every state, AFAIK, has some kind of established, legally required protocol. If you're working in acute psych, it is important for you to be familiar with what the requirements are in your state. I've found a surprising number of psychiatrists (and psychiatric nurses) think that all that has to happen is that the physician writes an order to force meds, in states in which I know that is not the case, and they are violating the law and the individual's legal rights by carrying out those orders.

And, actually, it's entirely possible to force oral medications; the way it's typically done is that, once a legitimate order to force medication is in place, the oral medication is offered first, followed by an injectable form if the oral is refused. Once people figure out this is how it's going to be, they usually go ahead and take the oral medication, and you v. rarely end up repeatedly wrestling people down for shots.

[Meriwhen, ASN, BSN, MSN, RN]

Moving this thread to the Psychiatric Nursing Forum to get more targeted responses.

To answer your question: psychiatric patients, even involuntary ones, have the right to refuse treatment INCLUDING medications. Yes, even when they're psychotic. Yes, even if they're a 5150.

One time that this right may be overridden is if the patient is an immediate danger to themselves and/or others. Then the medication would be considered an emergency medication. This would also be a one-time override of the patient's rights: just because you had to give a patient an emergency medication once doesn't mean you now have carte blanche to medicate them as you desire.

There are clearly obvious instances where emergency medications would be warranted, such as a violent patient or someone in the process of self-harming. But I'll also admit that there's a lot of grey there too, and some providers are a little more broad in their interpretation of "danger." I can't say I always agree with those interpretations...

Anyhow...

Another time that right may be overridden is if there is a court order mandating that the patient receive medications (e.g., Riese). This is separate from the involuntary hold and requires a hearing. An advocate is appointed on behalf of the patient, and the patient may choose to be present as well...and yes, some patients do win their Riese hearings and are not required to take medication.

Also, as elkpark stated, keep in mind that state laws may have other provisions regarding if and when you can force psych meds against their will. So make it point to know the laws of your state. Because what flies with me in California may not fly for a nurse in Pennsylvania.

[Kooky Korky, BSN, RN]

What is this for? It reeks of homework.

It's not homework. But suppose it was. Is that a problem?

[Whispera, MSN, RN]

In my state meds can only be forced if the patient is a safety risk to self or others, or if there's a specific court order to give the meds even if involuntarily. The court order hospitalizing the patient isn't enough to allow meds to be forced.

[MrChicagoRN, RN]

Illinois:

Emergency psych meds can be given if danger to self or others, otherwise has right to refusal. This applies whether voluntary, or involuntary.

Routine daily or long acting meds may be given against patients will only with a court order that will specify the med, dose, frequency, route. It will include a start and a stop date.

[SarahMaria, MSN, RN]

It depends on the state statute.

[LisaNICUrn, BSN]

I work at an inpatient acute psych facility. 90% of our patients are brought here against their will, baker acted is what we call it here in Florida. Every patient has a right to refuse anything and everything they want.

That being said, if they are an immediate threat to themselves or others, we can give what we call an emergency treatment order. We call the doctor and get an order to give them medication. We can, if necessary, put hands on to secure a patient harming themselves or others, but have to wait for an order to give medication.

If a patient is repeatedly refusing psych meds, the doctor will call their guardian advocate and ask for their permission to give injections to a patient if the refuse certain medication. After a few days the patient will either clear up and start taking the medication or get tired of daily injections and start taking the medication. The doctor alone can not make that decision, even if the patient has been deemed incompetent. The patient will have a guardian, who will take responsibility for the care and treatment of the patient. The guardian will have to ok injections being given against the patients will, knowing it's in the best interest of the patient.

[imapsychrn]

Does anyone know where I would find the information for my state?

[MrChicagoRN, RN]

Try googling "mental health law" for your state. I have a print out of the Illinois Mental Health Code, with notes, in my office

often not an easy read, but worth it.