Patient rights to refuse?

[wezzie, RN]

I work on a 20 bed, acute inpatient unit at a hospital. We see everyone across the board from depressed and suicidal to psychotic. Substance abuse, malingering and everything in between.

Lately, I see more staff engaging in the hardball approach when patients don't attend groups. Typically, they will lock them out of their room to "encourage" group attendance. Then when I come in, I am expected to continue this practice so as not to "undermine" my fellow nurses or "staff split".

First off, I believe they HAVE A RIGHT TO REFUSE ANY AND ALL TREATMENTS til a court says otherwise.

Secondly, I don't engage in power struggles with my patients unless they are a danger to themselves or others. Period.

Thirdly, I believe the moment you "or else" someone for anything other safety, all hope for a trusting, therapeutic relationship is lost.

Fourthly, I believe this practice to be illegal and a violation of patients right to refuse.

Fively, I refuse to participate in punishing patients for exercising their right to refuse. If I am "undermining your authority" or "staff splitting", too ******* bad. Rethink your approach and learn the law. I will not be bullied into compliance.. I don't like it any more than our patients like it.

What is your opinion of this? Am I wrong? Can patients legally be forced/humiliated/coerced into attending groups? I have yet to see a court order requiring someone to attend groups while being a patient on our unit.

[PMHNP-1]

There are probably many more problems in this unit than this punative illegal treatment of patients who won't go to group. Let me guess. According to this "nurse", most patients are "entitled", or "on the border haha", or "needy". Or they're faking it to stay out of jail, according to her, right? I hate to think of how she treats patients when no one is seeing/hearing.

Groups. Why are patients in the hospital? because they are so acutely ill that they can't tolerate outpatient therapy, can't care for selves or are danger to self/others.

So they come in where they'll be safe and get stabilized via medication. Some treatment will be offered, but the main thing is safety and meds. Those are the two "big gun" interventions. The rest is all gravy.

Why don't people go to groups? Too tired because of insomnia, new meds, psych or physiological disease. Symptoms such as hallucinations, OCD, fear, confusion, disorganization, behavioral issues, memory problems, other cognitive problems........can make groups more like torture for many people. The meds knock them out and make them too groggy to go to group. For others, the disruptive people in groups bother them greatly, making group .........more like torture.

By forcing people to go to groups that are not appropriate for the patient in that moment of time in that place, or by forcing people not appropriate for groups to go to them, one perpetrates torture. Also violation of patient rights. AND it goes against all evidence.

But that's not what this "nurse" cares about, is it. Hers is a nice power trip, lording it over people who are trapped and powerless. she needs to be turned in, reported, and gone.

[Graduatenurse14]

This. 100%. Those RN's are WRONG! I've said this before on here, the gov't/courts do NOT show mercy when vulnerable populations' rights are being violated. Anonymous reporting may very well be the way to go here. I also agree 100% with PMHNP-1, MSN, NP other reply as well.

I worked as a Milieu Therapist at a Child and Adolescent Acute Inpatient Psych Hospital. We had a level system in place where participation in your treatment plan earned you points to get to a higher level with rewards (in theory, anyway.) There were some RN's and MT's who got into power struggles that they really always lost in long run regardless of what the patient wound up doing.

[elkpark]

There are some who need to be made involuntary for their own safety, cannot refuse medications now.

I've practiced in several different states over my career, and I've never known of any state in which being an involuntary admission meant that you lose the right to refuse medication. In my experience, anyone can be medicated against her/his will in a true emergency situation (acutely dangerous to self or others), but, other than that, even those involuntarily committed retain the right to not be medicated against their will. If the facility really feels that someone needs to be medicated involuntarily outside of an emergency situation, there is a legal process for that in every state (as far as I know) that must be followed.

[brownbook]

I think it is quite simple. A patient may refuse to go to group. As wingding (I love that name) said, they stay in their room with the door or curtain opened. They don't get to wander around the unit, get snacks, watch TV, etc. for the hour they should be in group.

[Whispera, MSN, RN]

To threaten a patient to get him or her to go to groups is assault. This is not ok. Patients are not prisoners unless they have come from the jail/prison system for treatment, but that's a whole different thing.

Someone who is acutely psychotic or actively suicidal is not likely to benefit from groups in many cases. People with mental illnesses need sleep too. They are recovering from an illness that wears a person down! Dragging them (figuratively) out of their rooms inhibits that.

Encouragement of group attendance is lovely. Trying to force it is illegal. I've NEVER seen a doctor order that the staff to require group attendance, EVER.

And, the voluntary, cognizant patient that refuses everything gets discharged because he or she can do nothing at home just as well as in the hospital.

[MrChicagoRN, RN]

I've practiced in several different states over my career, and I've never known of any state in which being an involuntary admission meant that you lose the right to refuse medication. In my experience, anyone can be medicated against her/his will in a true emergency situation (acutely dangerous to self or others), but, other than that, even those involuntarily committed retain the right to not be medicated against their will. If the facility really feels that someone needs to be medicated involuntarily outside of an emergency situation, there is a legal process for that in every state (as far as I know) that must be followed.

^yes!

in Illinois, a patient may refuse non emergency medications, regardless of legal status (vol or invol).

in order to administer non-emergency meds, a separate hearing and a very specific court order is required. Even then only those meds, at the specified dosages and frequencies may be given.

[wezzie, RN]

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!

Sounds rigid.. and elkpark is right. Voluntary or not, I don't think there's any states that allow medicating outside of emergencies without a specific hearing and orders. My state, Antipsychotics are the ONLY class of medication that courts have jurisdiction over. Not sure if that's the case everywhere.

I'm not a fan of malingering, but I treat them as I would treat anyone. I'm not going to punish an individual for a broken system. I'm a nurse, I don't admit, I don't discharge, I take care of people the best I can regardless of why they're there. That's the docs job and unfortunately, their hands are usually tied by laws that people know how to exploit. It's a conundrum, but I'm not going to treat people like crap..

[wezzie, RN]

Thanks for all the perspectives! .. Much appreciated.. I've talked to my unit educator about adding some mandatory education on patient rights.. I'm not going to be silent about it..

[wingding]

Wow Wezzie - didn't think our policy was treating people like crap because we "encourage & ask people to attend groups" - we don't lock their doors, we don't force medications. And I don't call opening curtains & doors treating malingering people like crap --- My opinion is that the bed could be open for someone who really needs it. The nurses run 3 educational groups a day + admits; discharges; flash meeting; treatment team meetings along with covering for techs if we are short; the nurses (all female) participate in non violent take downs & restraints if needed - (we have limited male staff available within the hospital so it is on us) & we advocate for our patients every day. At no time is any medications given to pt. that is not necessary for their well being. We work hard at trying to reach our patients & make a difference in their lives. If that is what you call treating a pt. like crap - then so be it.

[wezzie, RN]

My apologies wingding.. I meant no offense towards you or your unit.. I have seen people treated like crap on my unit. At least as I perceive and believe.. Peace..

[Fuzzy]

I've been on the other side of this door so to speak. I've been a patient. An involuntary patient. If you didn't attend groups, you didn't get to leave as a rule. So I attended groups. This facility (private) offered only one group that was a one size fits all type of thing. At first I didn't recognize it. What opened my eyes was when the facilitator said that we needed to chose new friends and not hang around with our old friends. It was like WHAT? My friends are a big part of my support system. When I asked for a clarification on the comment. She said that I needed to stay away from my drunk and druggie friends. I countered that I was there for a bipolar crisis and that I was not there for an addiction of any kind. In fact I have not been much of a drinker and I certainly don't do drugs. Unfortunately, the group never changed. It was still focused on substance abuse. I was in between a rock and a hard place on that one.

Fuzzy

[Mandychelle79, ASN, RN]

At times the TREATMENT team decides that it is in the patients best interest to be locked out of the room between certain hours. It is part of the patients individual treatment plan. The treatment plan usually says if x does not attend 3 groups x will be locked out of his/her room the following day. Not something we use a lot and those who we do use it on... most of the time frequent flyers who we all know very well and need the extra encouragement to go.