medication refusal

[sweetieann]

Quick question....This is in regards to psych hospitals mostly...it is my understanding that if a patient has a standing PRN medication, say IM ativan for agitation, and they refuse it then you cannot administer it to them against their will. The doc has to write a one time order for the RN to administer it on the basis of emergent danger to self/ others. Now, let's say this patient is on an involuntary commitment. Can the medication THEN be given even if pt refuses? Or would a one time order still need to be written in this case?

Thanks!

[GooeyRN, ADN, BSN, CNA, LPN, RN]

We give IM's when they are violent and won't take a po, they get the shot like it or not. We do sometimes give IM's for routine meds when pts refuse all meds for several days in a row, however, it takes to psychiatrists to write for that.

[elkpark]

We do sometimes give IM's for routine meds when pts refuse all meds for several days in a row, however, it takes to psychiatrists to write for that.

If you're talking about forcing medication on a client who is refusing, you may want to check your state law (or ask your facility's legal department to give you an opinion on that) -- I've run into lots of psychiatrists who believe (where do they get these ideas?) that they have the right to force meds on a client who is refusing on their own say-so just by writing an order to do so, but most states require quite a bit more than that (process- and documentation-wise) for it to be legal. If it ever came to a suit, I doubt the nurses would be protected by having followed a physician's illegal order ...

(I've been saying for decades now that the only way most psych facilities and psychiatrists stay in business is that, luckily for them, most of their clients don't have the presence of mind (and familiarity with the law) to realize they're being mistreated and could easily sue.)

[GooeyRN, ADN, BSN, CNA, LPN, RN]

I believe they get it court ordered somehow. It has never been ordered like that for someone who isn't agitated most of the day, though.

[Jules A, MSN]

We don't force standing order meds but will force PRNs many times without LDS or any type of doctor's order.

[safiyarozz]

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.

This is not true at least by Florida's Mental-health Law;just because one is admitted on an Involuntary-Basis they are not considered to be incompetent until a court-hearing and until that time are considered to be competent.

[patrice meursault]

I think standing orders for agitation will be going by the wayside soon as medication is deemed a form of restraint (by JCAHO) and thus will fall under the same guidelines of restraints---meaning no PRN restraints orders are allowed. Sad but true.

[Whispera, MSN, RN]

Where I've worked we didn't have standing orders. The psychiatrists always gave orders for prns though, and we used them if we needed them on an emergency basis. I agree that it's much better to defuse rather than medicating. We'd use a "show of force," by getting loads of staff to confront the out-of-control patient. Usually this worked. Usually. If it didn't, we'd protect everyone and medicate and/or restrain as needed.

In any case where a patient was medicated or restrained, the doctor would be called and informed of exactly what happened. Whenever a patient was put in a quiet room and/or restrained, a whole set of things had to start happening...1:1 monitoring, in person or by camera, offering of fluids, foods, ROM, bathroom (all IF possible, and documented if not possible). If meds didn't work, we would call the doc for more meds.

A patient who was restrained, by the way, had to be seen by a doctor or "licensed provider" (advanced practice psych nurse or LCSW with some medical training) within an hour, to assess physical issues. They also had to be seen by such a person regularly while they were restrained. Rules on this are much more strict for children than adults, and assessments are much more frequent.

I have rambled....but hope it helps!