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"Patient's right to refuse treatment"

By April Davis posted 09-17-2012 08:09 PM

  
Hello fellow APNA members,

My name is April Powers and I'm an Advanced Practice Family Mental Health Nurse Practitioner graduate student. I've worked in the mental health field for the past 12 years. I've encountered patients with different diagnoses. I've dealt with many patients who were psychotic. They would spend several days and sometimes weeks on an inpatient mental health unit. No matter how many times we offered the patients oral medications, they would refuse. Every week, the psychiatrist and court officials would review the cases of these patients and determine if they should be forced to take injectable antipsychotic medications. Many times, these patients were court ordered to receive injectable antipsychotics i.e. haldol, risperdal, if they refused oral medications. I must admit, I was one of the nurses who had to enforce the court order. My question is, do patients have the right to refuse medication treatment when they're psychotic? I tried to put myself in their situation and wonder how I would feel if I was psychotic and someone forced me to take injectable antipsychotic medications. I imagine I would be very upset. As a nurse who want to establish some type of rapport with my patients, this could destroy any chance of that occurring. What are your thoughts? How would you feel if this happened to you? I'm interested in your thoughts/opinions.

Thanks,

April Powers
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Comments

Mark Demetrios
10-06-2012 07:25 AM

April,
Good question. I think opinions will vary based on experience but I have to believe that the system is working in the best interest of the patient. If you are working torwards their best interest I could only hope that these decisions which are difficult are the correct one. From my experience people that have been in that situation usually apologize for their behavior and are thankful that people took action for them. I find the bipolar manic patient bordering on psychosis as much more difficult to treat.
Mark Demetrios

Nicole Robbins
09-29-2012 11:56 AM

April, That is a great question. This topic had a profound impact on me when I did my nursing training back in 1996. I was a nursing student and the patient that I was assigned to follow on the in-patient psychiatric unit was diagnosed with schizophrenia and in the midst of psychosis and exibiting symptoms of catatonia. Every time I or the other nurses providing care for her tried to administer her medications which included haldol, moban and cogentin she would just get up and walk away. She was court ordered to receive her medications via injection. I was given the choice (because I was a student) a to whether I wanted to give these medications or if her primary nurse from the unit would do this. I chose to do it as it would soon be my role when I graduated from school. This experience effected me in a profound way. I didn't understand how one minute security gaurds would come up and hold my patient down so I could administer injections and the next I was supposed to develop a therapeutic relationship with this patient and spend time on the unit daily with her. I wrote a paper about it and the literature at the time was sparse.
Our final rotation of nursing school was management and I applied for a spot on the psychiatric unit. When I was assigned a team of patient's one of the patients I received was the patient that I had medicated over her objection. She was no longer psychotic and she allowed me to talk with her about her experience. She stated that she did not mind that I gave her the medication. She did not like being psychotic. What she did mind was that she was allergic to Moban and was not able at the time to communicate this to anyone. Thankfully for us both Moban was not available in an injectible form.
All of this to say is that medicating over objection is a very important issue. My situation may have been rare, however there are many reasons that patients may want to refuse medications. I wish there was a system in place to track patient's psychiatric medication use, history and allergies to prevent the adverse outcomes to medicating patients over objection and also that psychotropic prescribers can see and accurate history of what has and has not been prescribed in the past to patients. Is there a way to do this without violating patients rights?
Wtih regard to the original question my first thought would be is the patient at risk of harming themselves or others in their psychotic state and are they willing to assume the consequences of their behavior while psychotic if they choose to refuse medications for the psychosis?