Can a patient refuse code services?

[wonderbee, BSN, RN]

The paranoid schizophrenic patient's blood pressure dropped dangerously low, within code paramaters and not her baseline. A code was called and the team responded but the patient refused transport to the medical facility. It happened on the night shift when there were no supervisors available. The code team didn't know what to do and neither did the unit RN. Security officers refused to accompany on the transport which is required for all psych patients. She wound up not going. Once the dust cleared, the unit RN got a good chewing out from management on the premise that no one can refuse a code.

I'm curious about this. According to state law, even committed patients can refuse medical treatments. We can force psych meds on forced med protocol, but we cannot force meds or treatments for medical conditions. How is a code situation different? The last thing I would want is to be accused of is battery on a nonconsenting patient.

Has anyone had experience with this or have some insight to share?

[Thornbird]

If the patient is alert and has adequate mentation to understand the consequences, he may refuse any treatment including those which are lifesaving. Psych patients have to be evaluated on a case by case basis to determine if they have the ability to give or withold informed consent. If the patient wasn't actively hallucinating, delusional or suicidal at the time, he probably had the capacity to withold consent. If due to intellectual disability, medication or substance abuse his judgement was impaired, then he did not have the capacity. These situations really require thorough individual assessment.

Of course, if the patient is unconscious, in the absence of a written DNR, consent is implied.

This patient should really have advance directives in place so that there is no confusion if such an episode happens again.

[jmgrn65, RN]

If the patient is alert and has adequate mentation to understand the consequences, he may refuse any treatment including those which are lifesaving. Psych patients have to be evaluated on a case by case basis to determine if they have the ability to give or withold informed consent. If the patient wasn't actively hallucinating, delusional or suicidal at the time, he probably had the capacity to withold consent. If due to intellectual disability, medication or substance abuse his judgement was impaired, then he did not have the capacity. These situations really require thorough individual assessment.

Of course, if the patient is unconscious, in the absence of a written DNR, consent is implied.

This patient should really have advance directives in place so that there is no confusion if such an episode happens again.

I agree

[wonderbee, BSN, RN]

Advance directives aren't given any importance during the admission process. Our patients are pretty sick. Most of them delusional and many paranoid. All of them come in through the ER. I disagree with our upper management that no one can refuse a code. We have patients with passive death wishes who refuse to eat. They don't get tube fed. There are patients who refuse life-saving antiretrovirals and antibiotics. We can't force them to take them under any circumstances regardless of level of commitment. In the absence of altered mentation, I just don't see how we can force the issue unless an advance directive has been signed by someone with power of attorney.

Although many of our clients are committable and unstable, they voluntarily sign in having been brought in by local law enforcement with a choice of a bed in a jail or our facility. Until their hearing within 72 hours, on paper there's no question. They have all of their rights intact. That was the situation here.

There's been a lot in the media lately about psychiatric patients dying waiting for treatment and patients wandering away from our medical facilities, dying of exposure to the elements. This may be a reactionary response by upper management to reduce exposure to further liability. Most nurses don't question what comes down from on high, but I don't feel comfortable with the absoluteness of the response having worked as a critical care nurse. I'm going to ask our unit director to get written clarification. It just doesn't feel right to me.

[DavidLCPCCSADC]

Was the attending MD contacted.....what was his/her's position?

[heron, ASN, RN]

The question hinges on competence ... a tricky determination in a psych setting.

The admin was wrong, however, to assert that, in general, a pt cannot refuse a code.

In fact, if the pt was competent to give consent and refused the code, then forcing it on her would be criminal assault and battery.

[wonderbee, BSN, RN]

This was night shift. We have residents on call for nights. I wasn't there so don't know for sure.

[RochesterRN-BSN, BSN, RN]

yes this is an issue of if the patient could be deemed competant or not. A patient that is refusing medical care that is detrimental to his or her well being can be deemed incompetant if evaluated by TWO physicans--Psych MD's. If they are deemed to be competant then they CAN refuse care of any kind, if deemed not competant the care is provided desite his or her wishes. I work in a Psych ER and our physicians are often called to places all over the hospital--the med ER, ICUs, Pre-op for the OR....you name it....HUGE hospital.....for competancy evaluations. They are called to talk to a patient to see if he or she understands the medical care needed, the benefits and risks of having the medical care and of refusing. If these concepts seem to be understood the patient can make the choice.....if they are not thourougly understood the doc may say the patient is incompetant and get a second doc to eval and if both agree they document, legally, that this patient has been deemed unable to make medical decisions for himself. We had a consult on a guy who was refusing eye surgery that needed to be done emergently or he would go blind. Our doc went and saw him and deemed him able to make this STUPID decision for himself because despite it being a bad choice he seemed to understand the consequences of his choice. --- this is a tough one with the CPMI patients as when they are well they really function okay but when they are bad they are horrible. Its a tough this with psych patients.....I usually document that the patient is unable to make a educated decision about this due to psychosis or severe depression with suicidality....then when they are admitted and get to the floor and take meds for a couple of days and start to clear this is more appropriate to address.........although it should be done--advance directives with the primary MD--psych or medical MD--while the patients condition is STABLE....this way its not having to be addressed when the patient has decompensated.