rights of patients

sharkdiver · Sep 27, 2009

Amy,

It's even more basic than local laws - it starts with portions of the 1st, 4th, 5th, 9th and 14th ammendments to the constitution. In short, every person has a legal right to self determination.

There is also an abundance of case law dating back to the early 1900's that addresses the issue, usually in conjunction with the principle of informed consent. The following article published in the Iowa Orthopaedic Journal might be of interest - lots of good info and references:

THE HISTORY OF INFORMED CONSENT

Peter M. Murray, M.D.

University of Iowa

Department of Orthopaedics

Iowa City, Iowa

The bottom line is a competent person has the absolute right to refuse any medical care, even if the consequences of refusal may be life threatening. Anyone that attempts to force care on a patient that has refused is committing a criminal act for which they could be arrested and prosecuted.

Some other interesting tidbits about competency (or capacity):

A patient is assumed to be competent until proven otherwise

Only a court of law can determine competency

A patient's refusal of care or treatment may not be used as grounds to challenge their competency

Hope this helps.......

elkpark · Sep 27, 2009

Actually, there are public health laws about which communicable diseases are considered "reportable" diseases and which diseases public health officials can legally require you to be treated for (or you go to jail if you refuse). The laws vary from state to state, however. Also, every state has a mechanism for forcing people into psychiatric treatment against their will. There are some legal limits on individuals' right to refuse treatment.

sharkdiver · Sep 27, 2009

elkpark,

Yes there are some extremely limited exceptions as you cited, but they still require action by a court of law. Only a judge can order someone to be jailed - same for involuntary commitment beyond a very short period - typically 72 hours.

elkpark · Sep 27, 2009

The bottom line is a competent person has the absolute right to refuse any medical care, even if the consequences of refusal may be life threatening. Anyone that attempts to force care on a patient that has refused is committing a criminal act for which they could be arrested and prosecuted.

elkpark,
Yes there are some extremely limited exceptions as you cited, but they still require action by a court of law. Only a judge can order someone to be jailed - same for involuntary commitment beyond a very short period - typically 72 hours.

Yes, that's true. I was just attempting to clarify because your initial response made it sound (in fact, you used the words "absolute right") like the only reason anyone could legally have treatment forced on them was incompetence, and that's not the case. While there aren't many exceptions, it's not accurate to say that there is an "absolute right to refuse any medical care." I'm not trying to be argumentative, just complete -- it's a tricky and complicated subject, and the exceptions are exactly what the OP was asking about. :)

diane227, LPN, RN · Sep 30, 2009

Remember that competency is something that is established in a court of law, not at the bedside. But as a practical every day, on the spot, gotta make a decision now problem, this is the criteria I have always used. If the patient is an adult and their thinking is not altered by a substance (ETOH, drugs) then they can decide what they want to do. You cannot hold them against their will and you cannot force them to do something that they do not want to do, even when you know that the decision they make may result in their death. I did a case in Texas (as a legal nurse consultant) where a nurse allowed a patient to leave the ED after she had been given pain medication. The patient had assured the nurse that her husband was there to drive her home although the nurse never saw the husband. This patient was a frequent flyer to the ED and it was written all over the chart that she was told that she could not drive herself home. Well, her husband was not in her car, she tried to drive her self, had an accident and received a terrible head injury which caused her to die just before we went to trial. The nurse was found 50% at fault and the patient 50% at fault. The patient insisted on leaving. What should the nurse have done? Seen the husband. In some ED's no pain meds until you see the person who is going to be driving the patient home.

Now when I have a patient who is very drunk on on drugs, I have no issue with placing these patients in restraints or with a sitter until they sober up because I had rather go to court and tell a jury that yes I did hold this patient against his will because in my professional judgment he was too intoxicated to leave and I feared that he would harm himself or someone else. I guarantee the jury will not rule against you because you are demonstrating a good faith effort to keep the patient safe. Now, can you force medication on him, that is another matter. If he is actively psychotic and a danger to self and others, then I would say yes, again for the same reason. But I would recommend a psych eval ASAP.

Now, as to the patient that is in the hospital, awake, alert, oriented but who just won't take their medication or walk in the halls or what ever they are supposed to do. You cannot force them. All you can do is explain why it is important, document what you did and their refusal and notify the MD (either by writing in the progress notes or calling him/her).

Now, when the doctor is stupid enough to write an order that says "patient may not go off the floor" that is a useless order. You cannot hold an awake, alert patient against their will. If they are on a PCA, you can remove it. Or have a staff member go outside with them. If the doctor is concerned that the patient is going to go into the parking lot and shoot up into their line, then it may have to be removed, but you can't hold them unless someone is willing to document that they are unsafe to self or others. And then I would suggest that you get a psych eval ASAP and put a sitter on them.

It is a very complicated process but remember, they are adults and unfortunately they do not always make the best decisions for themselves. I had a guy walk out of the ED one night, awake, alert, oriented, who had been shot in the head. He is probably still walking around somewhere with that bullet in his head.

We had another guy come in one night who was shot in the gut. He was too drunk to give consent but he absolutely refused to go to the operating room and he was fighting us every time we tried to take him. The gun shot wound had nicked his aorta and he was bleeding. So the doctor sat him straight up on the stretcher and turned his IV to TKO. He dropped his pressure, became unconscious, they three doctor consented him and took him to the OR. Of course the next day when he was sober he was so glad they saved his life. Sometimes you gotta do what you gotta do I guess.