meds over obj/consent for tx-BIG DIfferece??

  1. my background is behavioral health....our unit recently "transitioned" to a gero-psych unit, from ltc psych..... all the pts. remained the same. >90% of the staff remained the same...EXCEPT for the nurse mgr., sws, & pmp. we have a 80yr bi-polar who is refusing meds & rapidly decomensating. in the past a 2pc would be completed...conversion to invol. status w/a forced medication ethics comittee mtg to determine the validity of forcing meds over objection (only after all 2pcs & conversions were complete) if the comittee deemed it just to force meds, they would then review the case q 30,60,90 days to determine the continued need for forced meds, or if the pt has stabilized & is taking po meds willingly now (no longer a danger to self & others, of course also) NOW....that we are geriatrics....this pt had signed a "consent for treatment" form when he was stabilized. MY NM, says that we do not need to follow the "behavioral health rules, because he signed a consent for treatment & that means we can give him injections of his psych meds over his objection.......This isnt right is it????? what if i went in the hospital, signed a consent for treatment & then changed my mind.....the hospital can just hold me down & preform the procedure,meds, what have you...wouldnt there have to be a legal reason, intervention to do this??? i dont get it....what difference does it make if you are on the geriatric side of the house or the behavioral health side.....if something is being forced upon someone after they change their mind (albeit a diseased mind) their are rules & regs for this stuff isnt there???? HELP ME UNDERSTAND!!!!!
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  2. Visit midnitelpn profile page

    About midnitelpn

    Joined: Nov '04; Posts: 40; Likes: 20

    10 Comments

  3. by   elkpark
    Is your new NM new to psych? What she (he?) is advocating would be illegal in my state, and is probably illegal in yours. Gero psych clients don't lose their legal and civil rights just because they are old ... The previous procedure you describe is v. similar to the process I am accustomed to for legally forcing meds in my state. While a signature on a generic consent-to-treat form is a standard part of a voluntary admission, the client retains the right to refuse any medication or treatment once in the hospital (on any unit of the hospital, not just psych!). Once a client does refuse, then the process for legally medicating someone against his/her will can be initiated if necessary.

    This issue came up over and over again when I worked as an acute psych surveyor for my state and the Feds (and psych units got in trouble with the state and the Feds for inappropriately medicating clients against their will). Have you talked with the NM about how she (he?) arrived at this position? (I often find it's helpful to reframe the question in situations like this. You may want to ask your NM whether she feels that, if she were in the hospital, it would be okay with her for hospital staff to give her any medication they wanted to, because she had signed a standard consent form on admission, and would it be okay with her if the hospital staff forcibly medicated her if she refused something ... Does she feel that she has a right to refuse medication?? Then why wouldn't your clients?) What do the medical director of the unit and the higher levels of hospital administration say? The hospital legal department can certainly advise y'all about the legal requirements in your state.

    Best wishes for a difficult situation ...
  4. by   midnitelpn
    Quote from elkpark
    Is your new NM new to psych? What she (he?) is advocating would be illegal in my state, and is probably illegal in yours. Gero psych clients don't lose their legal and civil rights just because they are old ... The previous procedure you describe is v. similar to the process I am accustomed to for legally forcing meds in my state. While a signature on a generic consent-to-treat form is a standard part of a voluntary admission, the client retains the right to refuse any medication or treatment once in the hospital (on any unit of the hospital, not just psych!). Once a client does refuse, then the process for legally medicating someone against his/her will can be initiated if necessary.

    This issue came up over and over again when I worked as an acute psych surveyor for my state and the Feds (and psych units got in trouble with the state and the Feds for inappropriately medicating clients against their will). Have you talked with the NM about how she (he?) arrived at this position? (I often find it's helpful to reframe the question in situations like this. You may want to ask your NM whether she feels that, if she were in the hospital, it would be okay with her for hospital staff to give her any medication they wanted to, because she had signed a standard consent form on admission, and would it be okay with her if the hospital staff forcibly medicated her if she refused something ... Does she feel that she has a right to refuse medication?? Then why wouldn't your clients?) What do the medical director of the unit and the higher levels of hospital administration say? The hospital legal department can certainly advise y'all about the legal requirements in your state.

    Best wishes for a difficult situation ...
    yes he is new to psych, and is not real receptive to ?ing, if you know what i mean....as well as his superiors.....i was told by my nite supr. to "follow the chain of command" blah blah.....did that, got nowhere...... can i anonymously contact my state mental hygien legal svs. & have them look into it????
  5. by   elkpark
    What do the other experienced staff nurses say? Can you address this with him as a group? What about the medical director (you must have one ...)?

    Yes, you can contact your state dept. of mental health (whatever it's called there), and also the state agency that regulates hospitals (or LTC facilities, if that's what we're talking about) and enforces the state and Federal rules/regs that apply (the agency that I worked for in my state). We often got calls from people who wanted an opinion on whether something was within the rules, either calling anonymously (which we didn't like but we talked to them anyway ) or just posing a hypothetical question ('What if we wanted to do such & such? What do the rules say about that? ...") The name of the regulatory agency is different in every state, of course, but it's usually a division of your state Dept. of Health & Human Services (or whatever your state calls it). There's usually an 800 number. Of course, I have no idea whether state personnel in your state are willing to discuss questions like this anonymously or hypothetically, but it can't hurt to try.

    And, YES, if the forced medication is actually happening now to this patient who is refusing meds (and anyone else), you can officially complain to the state regulatory agency and they will investigate (I don't know, of course, whether your state's agency will take anonymous complaints -- mine will, and, even when we did know who the complainant was, we did not disclose that to the hospital when we were investigating unless we had specific permission to do so).

    Also, does your facility have a patient advocate/ombudsman office or person? Who does the internal investigations of patient complaints? (I guarantee you there is someone, because CMS regs require it.) Perhaps you could meet with that person (or the head of that office) and talk about how best to approach your NM on this topic.

    I realize this is a v. sticky situation for the staff nurses, but there is strength in numbers. If the new NM is proposing a dramatic change to an established process on the unit (one that is dictated by law!), I would think it would be v. reasonable to ask questions about that. You and the other nurses have an obligation to your patients and your own licenses (!) to pursue this until you get answers. Be careful that you don't get left holding the bag personally, though ... Best wishes.
  6. by   CharlieRN
    Never hurts to seek legal cousel. Do get copies of all the relavent hospital policies.
  7. by   Hukilau
    Do a search for "Protection and Advocacy" in your state. At one time every state was mandated to have such an agency. Things have changed somewhat now but you still might find something. Another thing you can do is search the statutes yourself, although depending on the state it can be difficult to make any sense of the mental health laws.

    As others have said, it sounds like what you describe is illegal anyplace I've worked. There is a recent push to implement "Advance Directives for Psychiatric Patients" in some states, which some healthcare providers interpret as meaning, "Once you sign it, we can do whatever we want to you!" But that's a whole 'nother can of worms!
  8. by   ARNPsomeday
    Hukilau, I don't understand how an "advanced directive for psych patients" would be used to do whatever they want to the patient. I mean, if the advanced directive states exactly what medications are well tolerated by the patient and which ones are to be avoided, then that is the guideline that the health care workers should follow. Or for instance, stating in the document that treating the undersigned in this or that way will make them much more agitated? Maybe I'm just too new at this and don't get it?

    Quote from Hukilau
    Do a search for "Protection and Advocacy" in your state. At one time every state was mandated to have such an agency. Things have changed somewhat now but you still might find something. Another thing you can do is search the statutes yourself, although depending on the state it can be difficult to make any sense of the mental health laws.

    As others have said, it sounds like what you describe is illegal anyplace I've worked. There is a recent push to implement "Advance Directives for Psychiatric Patients" in some states, which some healthcare providers interpret as meaning, "Once you sign it, we can do whatever we want to you!" But that's a whole 'nother can of worms!
    Last edit by ARNPsomeday on Mar 15, '05
  9. by   Hukilau
    Quote from ARNPsomeday
    Hukilau, I don't understand how an "advanced directive for psych patients" would be used to do whatever they want to the patient. I mean, if the advanced directive states exactly what medications are well tolerated by the patient and which ones are to be avoided, then that is the guideline that the health care workers should follow. Or for instance, stating in the document that treating the undersigned in this or that way will make them much more agitated? Maybe I'm just too new at this and don't get it?
    It is really great that you are thinking about these issues!
    I believe most of what you stated above was, indeed, the intended use of the Mental Health Advance Directive. But the patient should still have the right to refuse medications, even if he previously agreed to it. That's the part that has been abused. In one state where I worked, an advocacy group went to another facility and had patients sign the AD, which then came with the patient to my hospital. During the interview, it became apparent that the patient had no idea what he had signed! And yet some staff were trying to say we could medicate him even if we had to restrain him to do so because he had signed a document that listed that medication as OK!
    See the potential for abuse?
    Your basic admission interview should cover what is most and least helpful to the patient when he is out of control.
  10. by   CharlieRN
    Be aware that the rules are different for all restraint/involuntary treatment issues in med/surg. In a medical care setting medical/nursing personel can get away with much more than they can in a psych environment. It is, or was, routine to restrain a confused patient just to protect an IV line. It was a nursing decision and required minimal documentation. The doctor's order, if there was one, was something like, "light restraints prn for safety."
    A geriatric unit is arguably more med/surg than psych.
  11. by   medpsychRN
    Perhaps the rules are different from state to state. Where I work. Gero-psych is psych. Thus, the rules regarding restraints remains the same. In fact, once restraints are in place (any restraint) the patient is automatically 1:1.

    In terms of refusing treatment, I am surprised your hospital does not have a number to call to report abuse/neglect. We have a number we can call and report any complaint. Your hospital must have a legal department. Also, surprised the docs are willing to go along with this practice.
  12. by   connate5
    Quote from midnitelpn
    yes he is new to psych, and is not real receptive to ?ing, if you know what i mean....as well as his superiors.....i was told by my nite supr. to "follow the chain of command" blah blah.....did that, got nowhere...... can i anonymously contact my state mental hygien legal svs. & have them look into it????
    A licensed professional is always responsible for his/hers actions irregardless of instructions from management. I would seek clarification thru policy or written statement and try to work with hospital administration and risk management or the legal department to clarify the issues.

    While sometimes called for, whistle blowing always has a backlash and should be considered as a last option

    Good luck. Would love to hear how this plays out

    Connate5

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