Patient rights to refuse?

ScudderRN31 · Jan 6, 2015

Touchy subject. I agree with your thoughts in most part. The only thing I would question is if these are psych patients do they hold the mental capacity to make decisions for themselves? Is adult protective services involved? I am by no means a psych nurse but I can see why some feel the need to push the issue. There won't be any improvement without treatment right? However punishing a patient..absolutely not. That would cause more issues I would think. These people need strong individuals to guide them, not more people who shun them. Are there other options available for them? 1 on 1 therapy, videos..something they can do on their own to help them open up. I view this similar to elderly who refuse to take pills, eat, shower..they absolutely have the right to refuse But when it causes them more harm to refuse things one must push harder for their corporation. They don't refuse because they want to die, they refuse because of their mental capacity to make appropriate decisions for themselves is poor. In such case we as nurses won't just stand back and allow them to starve to death. Different view to look at things but essentially the same type of situation. There are many ways to address these type of people and as a nurse it's our responsibility to find what works for each individual patient to ensure they receive the treatment the are entitled to, we wouldn't be doing our job if we didn't.

wezzie, RN · Jan 6, 2015

Indeed, I prefer to talk to them, find out what they want, encourage them, explore alternatives, etc. When someone needs antipsychotics and refuses, physicians are required by law to submit a commitment/Jarvis petition to the county courts. If it's deemed a necessary medical procedure such as Electro-convulsant therapy, (ECT), a Price/Shepherd petition must be filed. Patients have rights and these are measures for their protection.

I don't think groups are ever life threatening or otherwise "necessary". Sure, we want them to go but quite frankly, not everyone is even appropriate for groups or will ever benefit from them. I think certain staff jump to "go to group or I'm going to lock your door" out of frustration.

I had one RN tell me last week at shift change regarding the power struggle she chose to create by locking someones door that if I let her back into her room, "she wins" because "all she wants to do is stay in her room". This patient then became behavioral and pulled another patients hair. She then went to seclusion where they continued to lock her room door and make her stand for hours on end, or lay on floor that has been pee'd on, pooped on, spit on, ect, more times than I can count.

When I got there, she was already in seclusion, locked out of her room in the seclusion area with a small common area to be in. Staff is behind a locked door and thick glass in this area. She was a danger to no one, including herself. I opened her door. Later, the charge nurse goes back, kicks her out of her room, and tells me "I just don't want you to undermine what the day nurse did". At this point, groups are not even an option.

After a heated debate, she agreed with me and I re-opened her door. The next day when I come in, she is again locked out. This time it was because "we want her to sleep at night and not during the day". This lady is almost 70 years old. I didn't have her that night as I was floated to adolescent, but still knew what was going on.

I may be wrong, but I believe that a court is needed to determine mental capacity to lose their right to refuse. Until then, the patient is the boss as far as I'm concerned.

amoLucia · Jan 6, 2015

I'm not trying to be a smarty pants and I don't want to sound snippy when I say this but your question sounded familiar. I remember because I, myself, answered to this question at the time. Looked it up as a thread on 10/17/2014 - lots of good answers as I read through them again.

Like you, I don't agree with locking out the residents. Lots of other respondents didn't either.

And BTW, there are some precedents re same issue.

wezzie, RN · Jan 6, 2015

Thanks! .. I'll check it out..

Just to clarify too.. this is a short term, acute unit. We are designed for stabilization, nothing more. We really don't have "residents", although with the shortage of available services, unfortunately some people can linger for several weeks, even months.

mariebailey, MSN, RN · Jan 6, 2015

Right on, OP. Just how much can someone benefit from group therapy if they're forced to participate? Also, I suspect a lot of the people who do refuse do have the "mental capacity" to make that choice. I would never force a med on a patient that refused it; the same logic applies to this situation.

elkpark · Jan 7, 2015

Touchy subject. I agree with your thoughts in most part. The only thing I would question is if these are psych patients do they hold the mental capacity to make decisions for themselves? Is adult protective services involved? I am by no means a psych nurse but I can see why some feel the need to push the issue. There won't be any improvement without treatment right?

In my experience (almost 30 yrs in psych nursing), the vast majority of inpatient psychiatric clients do have the mental capacity to make decisions for themselves.

wezzie, RN · Jan 7, 2015

For sure, the vast majority of our patients have the capacity to be their own boss and the ones that may not, we, well, at least, I, wouldn't even encourage group attendance.

They may not always make what someone else would consider a good decision, but who am I to judge? If they are not a danger to themselves or others, I have zero problems taking no for an answer and I will continue to treat them with nothing but kindness and respect.

We do see a lot of involuntary patients.. commitments.. extended stays.. histories of violence.. like I said, we see everyone across the board. We see them at the point of crisis.

Ya know, been thinking.. It's really unfortunate that mental health has not specialized as much as medical in the acute setting.. at least a little bit..

Lets take 20 people. Some are actively psychotic and hallucinating. Some are depressed and suicidal. Some have just attempted suicide in myriad ways. Some are manic, grandiose and delusional. Add a dash of malingering, demanding, and entitled. Toss in all the CD/MI, ETOH, and chronic pain patients. Don't forget all the behavioral patients. Sometimes we get dementia, alzheimers, severely mentally disabled. Then we put them in a confined, locked unit. I'm sure I'm forgetting many others, but, you get the picture.. It's all "mental health"..

Yeah yeah.. too much money.. always the money.. whatever.. human beings shouldn't have to walk around with a price tag on their life in my opinion..

Feels good to rant a bit.. :)

wezzie, RN · Jan 7, 2015

Right on, OP. Just how much can someone benefit from group therapy if they're forced to participate?

Exactly.. if it was me, I'd do the opposite out of principle alone.

LakeEmerald · Jan 7, 2015

I am not in psych nursing, but it seems it would be more appropriate to offer a reward system to all patients for attending group and meeting goals; rather than a punishment system that creates anger and eliminates a patient's opportunity for privacy.

In addition, with the myriad types of patients in the unit - suicide, violence, chronic pain, dementia, etc., how productive can these groups be? Hopefully the participants are selected for specific groups and don't just walk into a group because they can't go to their room?

My hat is off to all psych nurses, BTW. I deal with psych patients in the ED occasionally and I'd rather work 1000 criticals than be subjected to the intricacies of working with the human psyche. So many layers, and it's horrible when they are violent or unpredictable. It takes a lot of time and energy to give proper psychiatric care.

wingding · Jan 7, 2015

My unit is small, sometimes a patient refuses, however, we have to take each case on an individual basis - what is the pt. affect & behavior? Voluntary admit - refuses medications, refuses groups, refuses to get out of bed except for meds & meals --- then I start wondering why pt. is here? 3 hots & a cot - we are not a homeless shelter!!! There are some who need to be made involuntary for their own safety, cannot refuse medications now. Our encouragement to those who don't go to group is ALL curtains opened, ALL doors opened & you are encouraged & asked to attend SEVERAL times a day - again, this is a psych unit, not a homeless shelter & we discourage malingering!

PMHNP-1 · Jan 7, 2015

Based on what you just wrote, it's time for 2 things: write up a report on the violation of patient rights, and file that with the rights coordinator. Two, call the state board and report. This is serious, this is illegal at state and fed levels. And of course, it's punative, it's not based on evidence (actually it is anti-evidence), and it's something people could get a hospital SHUT DOWN for.