Rights of Psych Patients?

Meriwhen, ASN, BSN, MSN, RN · Feb 25, 2010

If there's no court order mandating otherwise, the patient can refuse treatment (i.e., to give the urine). If she refuses the cath but you cath her anyway, then that's battery, and (again, if there's no court order) in no court of law will her being a possible psych patient get you off the hook for doing that to her.

As far as sneaking a hat into the bathroom, I'd talk to your hospital's legal department. It sounds like the best solution...but then that's also going into a big grey area.

I'm sorry you're in such a rough spot on this. It's often easy to assume that psych patients may not have the same rights as other patients...but they do.

sewingkelli · Feb 25, 2010

no liason, we don't even have a psyc nurse that works in our ED, only social workers and psyc NP's and MD's.

I do feel like it is battery but I will look into my state's laws.

Thanks everyone!!

aura_of_laura · Feb 25, 2010

Sounds weird - I've never heard of an ED that would keep someone over night just because the psych person goes home - don't they have on-call psychiatrists? We always have an on-call admissions person who will do a phone assessment, call the doc, and get the patient transferred to wherever they need to go. Can't imagine tying up a bed that way!

Meriwhen, ASN, BSN, MSN, RN · Feb 25, 2010

Sounds weird - I've never heard of an ED that would keep someone over night just because the psych person goes home - don't they have on-call psychiatrists? We always have an on-call admissions person who will do a phone assessment, call the doc, and get the patient transferred to wherever they need to go. Can't imagine tying up a bed that way!

I agree--unless you have an in-house psych unit, why not get them transferred to a psych facility? A lot of psych places offer telephone/mobile assessment services, so the patient need not show up at their door right away to start the ball rolling.

sewingkelli · Feb 25, 2010

nope no one on call, telephone interview? never heard of that, not even and option, and tying up a bed, LOL we have had psyc patients held in the ED for 2-3 days because there isn't an inpatient bed for them anywhere! This hasn't happened in a while but it has happened.

If the ED doc says they need to see psyc because the patient themself states they are suicidal or homicidal they stay overnight until psyc comes in, in the morning.

pinkiepie_RN · Feb 28, 2010

We schedule patients for U/As when they come up to the floor from the ED all the time when they refuse down there. It's absolutely within their right to refuse something like bloodwork or a tox screen. If they're a danger to themselves or others, then it becomes different and medications can be given against will but there's still alot of red tape around that.

Larry77, RN · Feb 28, 2010

We have this same issue when a patient needs "certification" for admission from the county designated mental health professional...they want a UDS to make sure the patient isn't impaired, we can't make the patient give us a urine (unless they are altered, ie OD).

Thankfully we have 24hr social workers who are very good at tying up loose ends that the county requires and if the patient appears impaired we just place them on a "safety hold" and send them to psych with or without a UDS. It's the voluntary psych patients that we have to worry about but if they are "voluntary" usually they will give us a urine. Sometimes we have to argue with the CDMHP because they think a psych patient is impaired but they can't require a UDS to do their eval.

I think my post may have been more confusing than helpful...sorry about that...these rules are different in every state so I would look for some answers "in-house"...

Meriwhen, ASN, BSN, MSN, RN · Feb 28, 2010

We have this same issue when a patient needs "certification" for admission from the county designated mental health professional...they want a UDS to make sure the patient isn't impaired, we can't make the patient give us a urine (unless they are altered, ie OD).

Well, if the patient is unconscious (sleeping does not count), in most states that implies consent for treatment unless there is a advanced directive/living will on file for the patient stating otherwise. So if a patient who ODed came in and then loses consciousness, then perhaps after the patient is out they could cath for the urine. But then again, big grey area alert.

You're right though: the OP needs to check her state laws as well as hospital policy.

Jules A, MSN · Feb 28, 2010

I might be reading more into this but you really sound hell bent on getting that UA. Your description of "a stubborn young female with obvious psyc issues" makes the tone of your post sound adversarial, imo. We aren't qualified to judge whether or not someone is in the "right state of mind". Right state of mind for what? Maybe she just smoked some MJ and is afraid to supply a sample? Personally when I deal with truly psychotic patients in the psych er urine is the least of my concerns. Let it go.

sewingkelli · Mar 1, 2010

I might be reading more into this but you really sound hell bent on getting that UA. Your description of "a stubborn young female with obvious psyc issues" makes the tone of your post sound adversarial, imo. We aren't qualified to judge whether or not someone is in the "right state of mind". Right state of mind for what? Maybe she just smoked some MJ and is afraid to supply a sample? Personally when I deal with truly psychotic patients in the psych er urine is the least of my concerns. Let it go.

I wasn't "hell bent", she wasn't even my patient, it just bothers me how this patients urine was obtained. I agree that they do have the right to refuse. And yes she was stubborn because when her primary nurse again asked her to provide a urine sample she stomped her feet on the stretcher kind of like a mini temper tantrum. I don't think a urine tox would have made a difference, problem is our psyc people want that urine tox before they evaluate them to verify if they were or are under the influence. Again we do not have 24 hour psyc workers. They leave at 10pm and come back in the morning, so if the ED attending feels they need psyc intervention they sleep the night in the ED.

I also don't want to let it go because it isn't right, I need to find a tactful way to address this so not to create huge waves with management.

Thanks for responding to my post, I want to find answers for this issue.

rn/writer, RN · Mar 1, 2010

Couple of questions. How did this young woman come to the ER? On her own? Brought in by family/friends? Escorted by police? I ask because this could be a clue to her state of mind/level of impairment.

If she came of her own accord or with other people, what were the concerns that made the trip seem necessary? Had she expressed SI/HI or shown any leaning in that direction? Just having psych issues in general is not a reason to detain someone against their will. Nor is it grounds for badgering them to provide a UA or have any other type of procedure.

Even if the police brought her in, unless she was acting in a way that was dangerous to herself or others, you probably can't hold her overnight without a darn good reason. Not having psych staff available or on call does NOT qualify. In fact, I don't understand how she could be admitted to a facility for psych needs if there isn't round-the-clock psych staff to care for her.

I'd go further to say that holding a homicidal or suicidal patient in an ED without anyone trained to meet these very serious psych needs is an invitation to disaster. ED folks are great, but unless they have some psych background, they don't have the situational awareness to deal with a patient who is determined to cause harm. ED rooms are full of potential weapons. Someone who is obsessed could tear a cot sheet and hang themselves, cut themselves with broken plastic, or break open the sharps container and start quite the ruckus.

I think it is a serious mistake for your facility to accept a patient it isn't equipped to treat during the duration of that person's stay. Makes me wonder if risk management is aware of the current practice.

As for the UA, just because someone has psych issues, that doesn't mean they lose their rights as a patient. I can't think of a time when straight cathing under restraints would be acceptable. It isn't even a practical idea as cathing can be a challenging under normal circumstance and that difficulty would certainly increase with a patient who is bucking and twisting. Besides, all they have to do is just "let go" and pee all over the place. Not a pretty picture.

As others have mentioned, I'd suggest looking into your state and county regulations. And you might want to check around and see what other facilities in your area do.

It just seems really risky for your ED to take psych patients and then not have psych staff to handle them. It's a danger to everyone involved and could be a horrendous lawsuit if anything were to happen to this patient while waiting for the psych folks to show up.

sewingkelli · Mar 1, 2010

Couple of questions. How did this young woman come to the ER? On her own? Brought in by family/friends? Escorted by police? I ask because this could be a clue to her state of mind/level of impairment.
If she came of her own accord or with other people, what were the concerns that made the trip seem necessary? Had she expressed SI/HI or shown any leaning in that direction? Just having psych issues in general is not a reason to detain someone against their will. Nor is it grounds for badgering them to provide a UA or have any other type of procedure.
Even if the police brought her in, unless she was acting in a way that was dangerous to herself or others, you probably can't hold her overnight without a darn good reason. Not having psych staff available or on call does NOT qualify. In fact, I don't understand how she could be admitted to a facility for psych needs if there isn't round-the-clock psych staff to care for her.
I'd go further to say that holding a homicidal or suicidal patient in an ED without anyone trained to meet these very serious psych needs is an invitation to disaster. ED folks are great, but unless they have some psych background, they don't have the situational awareness to deal with a patient who is determined to cause harm. ED rooms are full of potential weapons. Someone who is obsessed could tear a cot sheet and hang themselves, cut themselves with broken plastic, or break open the sharps container and start quite the ruckus.
I think it is a serious mistake for your facility to accept a patient it isn't equipped to treat during the duration of that person's stay. Makes me wonder if risk management is aware of the current practice.
As for the UA, just because someone has psych issues, that doesn't mean they lose their rights as a patient. I can't think of a time when straight cathing under restraints would be acceptable. It isn't even a practical idea as cathing can be a challenging under normal circumstance and that difficulty would certainly increase with a patient who is bucking and twisting. Besides, all they have to do is just "let go" and pee all over the place. Not a pretty picture.
As others have mentioned, I'd suggest looking into your state and county regulations. And you might want to check around and see what other facilities in your area do.
It just seems really risky for your ED to take psych patients and then not have psych staff to handle them. It's a danger to everyone involved and could be a horrendous lawsuit if anything were to happen to this patient while waiting for the psych folks to show up.

If I remember correctly, I think her father brought her in for bizarre behavior and she did already have a known psyc illness in her history. She was young, 20 y.o, and she was post pardom, which makes it all the more complicated.

I say we keep them in the ED, yes we do, we have a specific area for psyc patients and are on constant observation w/ a sitter. They are in rooms w/ nothing but a stretcher and of course sheets. So yes safety is a concern but it isn't as bad as I guess I made it sound.

If the ED attending doesn't feel there is a psyc issue going on they will discharge them, if they feel they need psyc to "clear them" they have to wait until the morning. We do tell these patient right up front that they will have to stay overnight and usually they are ok with it, because they are usually the same patients and kind of know how it works at our hospital. Not that I agree with it.

I do want to dig further and will probably have to consult our legal dept at the hospital, I just don't want to create this huge issue and have myself named as a trouble maker, and it wasn't even my patient in the first place!

Thanks again for responding.