wezzie, RN

Indeed.. safety first.. always.. Im's, seclusion, restraints.. whatever needs to be done when all the least restrictive measures have been exhausted..

Very well said. Not just what I quoted, but your entire post. Thanks for taking the time to reply.

The law in my state as it's written.. Subd. 12.Right to refuse care. Competent patients and residents shall have the right to refuse treatment based on the information required in subdivision 9. Residents who refuse treatment, medication, or dietary restrictions shall be informed of the likely medical or major psychological results of the refusal, with documentation in the individual medical record. In cases where a patient or resident is incapable of understanding the circumstances but has not been adjudicated incompetent, or when legal requirements limit the right to refuse treatment, the conditions and circumstances shall be fully documented by the attending physician in the patient's or resident's medical record. Subd. 9.Information about treatment. Patients and residents shall be given by their physicians complete and current information concerning their diagnosis, treatment, alternatives, risks, and prognosis as required by the physician's legal duty to disclose. This information shall be in terms and language the patients or residents can reasonably be expected to understand. Patients and residents may be accompanied by a family member or other chosen representative, or both. This information shall include the likely medical or major psychological results of the treatment and its alternatives. In cases where it is medically inadvisable, as documented by the attending physician in a patient's or resident's medical record, the information shall be given to the patient's or resident's guardian or other person designated by the patient or resident as a representative. Individuals have the right to refuse this information. ____________________________________________________________ Looks to me like the only legally acceptable way to deal with refusal of anything outside of an emergency is providing information and teaching. Unless of course, the person has been deemed incompetent to refuse groups by a court of law. Personally, I don't think our local county courts with their backlog of cases would appreciate our doctors taking patients to court to force them to attend groups.. or else. Although, for "frequent flyers" who refuse or "need extra encouragement", I believe it would be prudent and legal for doctors to say, "ya know, we really aren't doing anything beneficial for you. I'm going to discharge you immediately".

I understand that, and that is often the case on our unit too. I understand the frustration with "frequent flyers" as well. But, as I understand patient rights and the law, patients have a right to refuse and decide for themselves what's "in their best interest" til a court says otherwise. For instance, in many cases, the treatment team would certainly decide that taking anti-psychotics are "in the best interest" of the patient.. however, the treatment team does not have the right to impose their will through any form of "encouragement" outside of an emergency situation beyond verbal encouragement and teaching. As I understand the law, the second an "or else" is uttered to a patient exercising their legal right to refuse, maltreatment of a vulnerable adult has occurred. What happens on your unit when acutely psychotic people refuse meds? Why should group attendance be any different, even if the person is frequent flying? Why do they not have the right to refuse without fear of threats/punishment? I believe the law says they do.. Maybe people wouldn't frequently fly if proper services/treatments were available and we didn't have laws that tie doctors/hospitals hands to admit people that should never be admitted in the first place.

Not very therapeutic I reckon.. it's unfortunate the system is still lumping so many diverse, unique illnesses experienced by diverse, unique human beings all under one banner of "mental health". One size definitely does not fit all.. every individual has unique needs and too many people fall through the cracks and don't get the care they deserve in my opinion. Like I said in an earlier post.. always about the money.. our society for the most part has been ignoring mental illness since the dawn of time. Not to mention shedding mental health beds and services for decades as the need grows exponentially. It's a broken heap of a mess.. The stigma is slowly but surely getting better I think but we still have a long way to go.

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..

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..

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..

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

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.. :)

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.

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.

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.

Thanks Twoyearnurse.. :) Oddly enough, I think the experience made me a much better psych nurse..

I'm guessing they will eventually refer you to a state monitoring program. I think they'll be more concerned about the overdose and depression rather than the + marijuana screen, but I'd expect that would be part of the monitoring contract. Frequent, random drug screens. Possibly medication administration restrictions. My personal experience.. depressed > hospitalized> (-) drug screen = 2 years monitoring. I was required to meet with a therapist at a minimum twice per month, meet with a psychiatrist or psych NP once per quarter for "medication management" (50 mg Zoloft daily), and have a "workplace monitor". Thankfully, drug screens were not part of the contract as I would have had to call a # every day to see if I needed to go do a test, all at my expense. Myself, the therapist, NP, and workplace monitor all had to submit quarterly reports on how things were going. Things went great. I went above and beyond expectations. I completed a partial program and 7 months of weekly DBT classes. After 1 year, I requested to have my case closed and my case manager obliged. My experience was a positive one. The irony.. I'm a psych nurse.. :) .. and first and foremost, human.. funny thing, when I was in the partial program, 25% of the people there were nurses. Four out 12.. So glad to hear you're doing well. You just keep doing the best you can and don't sweat what you can't control.. let the chips fall where they may.. The important thing is.. you woke up breathing this morning.. *hug*