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Discussion

Is this true?

working in psych...patient refused medication this morning, no agitation or anxiety, just clearly stated she is within her rights to refuse meds... so I did not give her morning meds. I continuously tried throughout morning, as I'm normally am able to convince pt to take, but not today...she steadfastly refused... Later, supervisor tells me that I must give her PRN meds via IM if she refused because she was hospitalized on a 302.... ... I checked the PRN meds IM and they state give for INCREASED agitation or anxiety--not for refusal of PO meds.... what is the right thing do?

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    I'm assuming you're in PA since you used the term 302. I haven't worked in PA in a couple of years, so unless things have changed commitment (302) and forced meds are separate. Forced meds is a fairly easy process if the pt is clearly psychotic but does require documentation of a second MD's opinion. Once we had the second opinion the standing orders would read something like 5 mg Haldol PO BID, if refused 2 mg Haldol IM, by force if necessary. I worked in a prison setting though so I think we did forced more than standard inpatient. For sure, 302 does not equal forced meds though. I would look for a forced order or contact the MD for clarification. Emergency IMs can be given for imminent danger to self or others, not matter their inpt status, voluntary or committed.

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    I'm not familiar with PA law and procedure, so I'm not sure what 302 is.

    I can tell you that a psych patient, even an involuntary one, retains the legal right to refuse medication both scheduled and PRN. There are two times where that refusal can be overridden.

    First, emergency medications can be administered without patient consent if the patient is an immediate danger to themselves or others. A patient throwing things at staff, trying to assault another person, or who is trying to cut their wrists with a pen cap qualifies for emergency meds. A patient who is agitated or angry but otherwise not hurting themselves or anyone else does not qualify.

    The second time a refusal can be overridden is if there is a court order. This is not an immediate process, as it involves a petition being filed and a court hearing being held. Usually this is the time where orders will say, "if patient refuses PO, administer the medication IM." This court order is not to be confused with a temporary detention order or involuntary hold (we call them 5150s in CA)--such a hold does not mean we have the right to force meds against a patient's well. The court order to force medication is a specific--and not automatic--process.

    As far as your patient goes, as long as she wasn't a danger to anyone, she could refuse the meds. Your supervisor's wrong on this count...in fact, if the meds were forced, the patient would be well within her rights to file a human rights complaint. And trust me, no facility wants to have to deal with that!

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    • Author

    yes I am in Pa, 302 is a involuntary commitment.. it made me feel uncomfortable to have to give PRN IM injection since she was not posing a danger to the unit whatsoever... she was in her room laying in her bed. In addition --my supervisor also told me that oncoming staff would complain that I had not given her meds!! and that part he is right about... it seems that some nurses in at my facility desire to keep pt "snowed" for the slightest thing. I ultimately did not give her that PRN IM... I have seen orders that clearly state give PRN if refusal of PO meds, but this was not the case for her. it simply said increased agitation or anxiety. I really get tired of this battle of being a newer nurse and not rushing to give IM's for small undesirable behaviors. they are in a psych facility for a reason... Granted if the unit safety was compromised then that's totally different... her laying in bed just didn't constitute PRN in my opinion. thank you for your thoughts and thank you for making me realize that forcing meds she could legal file human rights complaints!! that would be MY license, not the supervisors!!! thank you so much for that- I never thought about that!!

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    Just FYI...

    PA doesn't require a court order for forced meds, it requires a second opinion. The process is outlined in Mental Health Bulletin99-85-10: “Administration of Psychotropic Medication to Protesting Patients”, which I can't seem to find online. The order for the forced meds are separate from their PRN orders and will have wording that clearly identifies it as such.

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    • Experts
    Just FYI...

    PA doesn't require a court order for forced meds, it requires a second opinion. The process is outlined in Mental Health Bulletin99-85-10: “Administration of Psychotropic Medication to Protesting Patients”, which I can't seem to find online. The order for the forced meds are separate from their PRN orders and will have wording that clearly identifies it as such.

    I've never heard of not having to go to court to routinely force meds...very interesting! I wonder if other states do the same (in my experience so far, many states require hearings). If you ever find it, let me know: I'm curious to read it.

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    I am in NC and we also can and do force meds if two MD opinions are on the chart. Good for you for standing up for your patient and your license.

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    • Experts

    Forcing medication is an entirely separate process from involuntary commitment. Meriwhen is correct, there is no state in which one loses the right to refuse medication (outside of an emergency situation in which one is acutely dangerous to self or others) just because one is being detained involuntarily.

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    I think states differ on the mechanism whereby a psych patient can be forced to take medication. When I worked inpatient psych in Texas (although this was many, many years ago, things may have changed), you actually had to get a court order to force meds - it had to do with the court's opinion of whether the pt was competent to make an informed decision to choose (I believe). And at least at that time, the patients frequently won those cases. I think there may have been different standards for patients who were an active, present danger to self and/or others (perhaps similar to the "increasing agitation" order you mentioned). I'm fairly certain that court permission did not have to be sought in those cases.

    It was more an issue of ongoing medication (say antipsychotics, or daily tranqs) vs. meds given in emergent situations in order to protect the pt or others. Pts frequently won the right not to take the ongoing meds when hospitals tried to court order meds.

    Just looked it up, and it appears to still be much the same in Texas:

    http://www.dshs.state.tx.us/WorkArea/linkit.aspx?LinkIdentifier=id&ItemID=8589935380

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    I think states differ on the mechanism whereby a psych patient can be forced to take medication. When I worked inpatient psych in Texas (although this was many, many years ago, things may have changed), you actually had to get a court order to force meds - it had to do with the court's opinion of whether the pt was competent to make an informed decision to choose (I believe). And at least at that time, the patients frequently won those cases. I think there may have been different standards for patients who were an active, present danger to self and/or others (perhaps similar to the "increasing agitation" order you mentioned). I'm fairly certain that court permission did not have to be sought in those cases.

    It was more an issue of ongoing medication (say antipsychotics, or daily tranqs) vs. meds given in emergent situations in order to protect the pt or others. Pts frequently won the right not to take the ongoing meds when hospitals tried to court order meds.

    Just looked it up, and it appears to still be much the same in Texas (and as Elkpark stated, this is irrespective of whether or not the commitment is voluntary - at least in Texas):

    http://www.dshs.state.tx.us/WorkArea/linkit.aspx?LinkIdentifier=id&ItemID=8589935380

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    I think states differ on the mechanism whereby a psych patient can be forced to take medication. When I worked inpatient psych in Texas (although this was many, many years ago, things may have changed), you actually had to get a court order to force meds - it had to do with the court's opinion of whether the pt was competent to make an informed decision to choose (I believe). And at least at that time, the patients frequently won those cases. I think there may have been different standards for patients who were an active, present danger to self and/or others (perhaps similar to the "increasing agitation" order you mentioned). I'm fairly certain that court permission did not have to be sought in those cases.

    It was more an issue of ongoing medication (say antipsychotics, or daily tranqs) vs. meds given in emergent situations in order to protect the pt or others. Pts frequently won the right not to take the ongoing meds when hospitals tried to court order meds.

    Just looked it up, and it appears to still be much the same in Texas (and as Elkpark stated, this is irrespective of whether or not the commitment is voluntary - at least in Texas):

    http://www.dshs.state.tx.us/WorkArea/linkit.aspx?LinkIdentifier=id&ItemID=8589935380

    Probably depends on the state and if they are court ordered. In MI if they are involuntary admitted they are required to take medications. If they refused its an IM no questions asked.

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    • Experts
    Probably depends on the state and if they are court ordered. In MI if they are involuntary admitted they are required to take medications. If they refused its an IM no questions asked.

    Wow, I didn't think there were any states that still had that kind of policy. Are you sure it's state law and not just being done by a particular facility? (I've seen it done in violation of state law before in different places.)

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    Wow, I didn't think there were any states that still had that kind of policy. Are you sure it's state law and not just being done by a particular facility? (I've seen it done in violation of state law before in different places.)

    I don't know for sure sorry.

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