medication refusal

Flare, ASN, BSN · Dec 21, 2009

if a patient is committed on an involuntary basis, that means that a court of law has declared them unable to make decisions for themselves (among other reasons) and they do not have the right to refuse - especially if they are a danger to self or others. Of course this also does not mean that we can drug them into next week because we don't like the sound of their voice.

sweetieann · Dec 21, 2009

thanks for your response! So, say they are on an involuntary commitment and have standing PRN meds---you could give them IM without consulting psychiatrist first or having them write one time order? Just making sure I understand. Thanks!

pattymac · Dec 21, 2009

It's not something I would do personally. Seems like assaut to me. Of course, if they really don't want it and you try to force it on them, I doubt they would let you anyway. Surely, there must a policy for that at your place of employment?

bill4745, RN · Dec 21, 2009

You really need to check with your administration about this to see what the official policy and state law says.

maxthecat · Dec 21, 2009

Just because someone is committed involuntarily, they do not lose their right to refuse medication or to make decisons concerning their care. Involuntary commitment is not the same as being declared incompetent. Incompetency is decided in a court of law and a guardian must be appointed to make decisions. Otherwise, the patient can make their own decisions, even if you think they are poor ones. The only time you can administer meds against their will is if they are an imminent danger to self or others (hence the one-time order). Another time is if a judge orders mandatory medication given when they hand down their ruling at the mental health hearing--usually comes with mandation to a treatment facility for 3, 6, 9 months, etc. The other time would be if your state has something like an advance directive for mental health, which lets patients who know they will refuse meds when they are at their sickest give a directive when they are in good mental health to allow medication to be administered when they are ill. Anything else opens you up to charges of assault and battery.

elkpark · Dec 21, 2009

Just because someone is commited involuntarily, they do not lose their right to refuse medication or to make decisons concerning their care. Involuntary commitment is not the same as being declared incompetent. Incompetency is decided in a court of law and a guardian must be appointed to make decisions. Otherwise, the patient can make their own decisions, even if you think they are poor ones. The only time you can administer meds against their will is if they are an imminent danger to self or others (hence the one-time order). Another time is if a judge orders mandatory medication given when they hand down their ruling at the mental health hearing--usually comes with mandation to a treatment facility for 3, 6, 9 months, etc. The other time would be if your state has something like an advance directive for mental health, which lets patients who know they will refuse meds when they are at their sickest give a directive when they are in good mental health to allow medication to be administered when they are ill. Anything else opens you up to charges of assault and battery.

:yeahthat:

I know that, in the states in which I've practiced (and there is some variation among states, so it's important to know the law where you're practicing), involuntary admission only gives a facility the right to hold someone against their will and assess them, not to treat them against their will. They retain the right to refuse medication or any other form/modality of treatment, except for the two exceptions noted by maxthe cat -- an emergent situation in which the client is an immediate danger to self or others (and you can medicate voluntary clients against their will in the same circumstances) or if the legal requirements in the state have been met to legally force medication on someone.

Most every state does now have some mechanism for forcing medication on psych clients outside of a judge issuing an order, but the process is usually pretty involved. In my state, two different physicians (the attending and the chief of psychiatry) have to certify in the record that this is the only possible hope the client has to improve or stabilize her/his acute psychiatric condition, and the client is not able at present to make rational decisions for him/herself -- and they have to recertify this every two weeks or stop forcing the meds.

Jules A, MSN · Dec 22, 2009

I answered this in the psych section also and I'm still not sure I'm understanding the question because I certainly do give IM PRNs against a patient's will. We can't force a standing order on a patient just because they are there on a cert but if they become a danger to self or others while on the unit we do restrain them and give IMs if they refuse PO medication. This has nothing to do with our med panel process for standing orders. :confused:

Whispera, MSN, RN · Dec 22, 2009

where i've worked (two different psych facilities) we could only give medications against a patient's will if they were dangerous to self or others or unable to quit destroying property. this went for all patients, not just those who were hospitalized involuntarily. then it was documented in detail.

as for the involuntarily hospitalized ones, they had the right to refuse any and all medications unless the above was going on, or unless the court said medications could be given against their will.

sweetieann · Dec 22, 2009

whispera-

could you give a standing IM med against refusal if they were danger to self? Or did you need to get one time emergency order?

thanks!

elkpark · Dec 22, 2009

whispera-
could you give a standing IM med against refusal if they were danger to self? Or did you need to get one time emergency order?
thanks!

In my experience, in many cases, when you gather up the extra staff and really make it clear to the client that this is going to happen, one way or the other (and I'm speaking specifically of situations where the client is acutely, emergently dangerous to self or others), the client often "gives up" and agrees to take the medication voluntarily rather then go through the wrestling-down-to-the-floor process. If that's not the case, and you end up having to hold them down to administer the medication against their will, holding them down to give the med is a restraint per the CMS rules (and, probably, your state rules, also), so you're going to have to call the physician anyway, to get the restraint order/initiate the 1:1 LIP eval/etc.

AngelfireRN, MSN, RN, APRN · Dec 22, 2009

Where I worked, if a patient was going berserk, we would attempt to defuse them, then get the meds. If they refused to take the meds by mouth or take a shot willingly (and we did give them the option and the explanation of what would happen if they refused), then we took them down and gave them the shot anyway. The safety of other patients and of staff comes before the right to refuse if a patient is being a turkey.

As an aside, I ran into an old co-worker from that facility a few days back, and he proceeds to tell the unit he was precepting in (he's in nsg school now) that the hospital still talked about how amazing it was that no bigger than I was, I could take down full-grown men without breaking a sweat. Another friend that worked there was a 3rd degree black belt in tae-kwon-do, and we used to spar with each other in the gym when we took the patients to play. Once they saw what we did to EACH OTHER, we usually did not have any problems that night, lol.