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New Jersey Is Sued Over the Forced Medication of Patients at Psychiatric Hospita

Discussion in 'Psychiatry' started by kugel, Aug 9, 2010.

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  1. kugel

    kugel

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    NEW YORK TIMES

    http://www.nytimes.com/2010/08/04/health/policy/04psych.html?_r=1&src=mv

    New Jersey Is Sued Over the Forced Medication of Patients at Psychiatric Hospitals
    By RICHARD PÉREZ-PEÑA
    Published: August 3, 2010

    Patient advocates filed a federal lawsuit on Tuesday charging that New Jersey psychiatric hospitals routinely medicate patients against their will without a review by an outside arbiter, a practice that is banned in most other states.
    Enlarge This Image

    Yana Paskova for The New York Times
    Joseph Cichowski said he would have challenged forced medication if he had the opportunity.
    Enlarge This Image

    Nicole Bengiveno/The New York Times
    Alice Hsia said she submitted to prescriptions at hospitals quietly rather than risk painful injections.
    Twenty-nine states require a judge’s ruling for involuntary medication, according to the suit, including New York, Connecticut and other large states, like California, Florida and Texas. Five other states leave the decision to an individual or panel outside the hospital. Some states also provide an advocate to represent a patient in a hearing on forced medication.

    But in New Jersey, state rules allow a patient in a state hospital to appeal medication decisions only to people in the hospital. The lawsuit contends that the internal appeal process is routinely ignored and that psychiatric patients in private hospitals lack any opportunity to appeal medication regimens at all.

    The suit, filed in Federal District Court in Trenton by the group Disability Rights New Jersey, seeks a court order requiring the state to provide judicial review of involuntary medication. It notes that a prison inmate has more power to contest treatment decisions than a psychiatric patient.

    The drugs forced on patients include powerful medications for conditions like schizophrenia and bipolar disorder. They help many people with those diseases function better, but can have serious side effects, including diabetes, tremors, seizures, high blood pressure, obesity, sedation, aches and impaired mental function.

    “As a patient in a state hospital, it’s your legal right to refuse and go through a process, but you get severely penalized if you try,” said W. Emmett Dwyer, litigation director of Disability Rights New Jersey, a federally financed organization. “They view you as noncompliant with treatment. They give you an injection instead of a pill. And they tell you if you don’t take it, you won’t get out.”

    There are about 1,800 patients at any given time in New Jersey’s five state psychiatric hospitals, and 1,000 in private ones.

    Michael D. Reisman, a lawyer with Kirkland & Ellis, which is helping bring the lawsuit, said recent records from one state hospital showed that fewer than 20 percent of patients contested their medication.

    But the advocates and several former patients said many more objected to their prescriptions but submitted quietly, rather than risk painful injections or a longer hospital stay. Others, they said, are too medicated to object.

    “When I said no, they just shot me up instead, so pretty soon I gave up,” said Alice Hsia, 34, who has been in and out of hospitals for schizophrenia. “The times I was sedated, I would sign anything they wanted.”

    Mr. Reisman said the question often was not whether some medication was needed, but rather one of dosage or a desire to try a “different drug with fewer side effects.” Some hospital psychiatrists do not take such concerns seriously, he said, but “a judicial hearing would give the patient more leverage and force the doctors to listen.”

    The State Department of Human Services, which runs the hospitals, declined to comment on the suit. But among advocates for the mentally ill, there are wide-ranging opinions on involuntary treatment.

    Phil Lubitz, associate director of the National Alliance on Mental Illness of New Jersey, said he did not see forced medication as a major issue, noting that it was extremely difficult to get patients committed in New Jersey, and that most who were presented “a danger to themselves or others.”

    But Robert Davison, executive director of the Mental Health Association of Essex County, called New Jersey’s policy “beneath contempt.”

    “This state is way behind the times,” he said. “It suspends people’s civil rights without due process, and it’s troubled me for years.”

    A few states require that the issue of involuntary medication be addressed when someone is being committed. More than 20 states require a separate hearing on the subject. There is no way to know how many patients in New Jersey would have their medications changed if there were an external review. But the advocates say a fundamental right is at stake.

    Joseph L. Cichowski Jr., who has a schizophrenia diagnosis and helped prepare the lawsuit, said he had tremors, memory loss and dizziness. He blamed the psychiatric medications given to him involuntarily in the hospital.

    “I didn’t know what they had me on half the time,” said Mr. Cichowski, 55, a Princeton graduate and former stockbroker. “I feel like I’m being slowly medicated to death.”

    Mr. Cichowski, who was released in July to a halfway house, said he had gambled away his paychecks and government benefits and borrowed money, and at times had survived on the coins he found in slot machines.

    “I was hearing voices of the angels telling me places to go or things to do,” he said. Asked if he still heard them, he said, “I won’t admit it.”
  2. heyjack70

    heyjack70 Junior Member

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    What's the commitment law in New Jersey? The article is quite vague about this, and in my opinion this is really a debate about how we should go about infringing on an individual's civil rights. When can you force meds on someone and what process should you have to take to limit abuses.
  3. Manicsleep

    Manicsleep

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    I read this a while ago. I was surprised how opposed the NAMI and MHA views were.
  4. Faebinder

    Faebinder Slow Wave Smurf

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    Not shocked at all... and to be honest, if MHA continues that way, they will be surprised at what happens.

    As it is now, new jersey is doing its BEST to close state hospitals.
  5. whopper

    whopper Former jolly good fellow

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    Civil commitment really isn't the issue with forced medication. They are separate. One could be civilly committed, yet not have to be forced medication, or even have the capacity to refuse medications while civilly committed.

    Depending on the state, each, depending on the determination of various court cases have their own methods of determining when and if forced medications are appropriate.

    In NJ, the landmark case of Rennie v. Klein determined the standard to force medication on patients against their will in the state of NJ and in federal cases. In Rennie v. Klein, the Federal Court ruled that they were not medical experts, and forced medication hearings should be reviewed by doctors, not the Courts. That's why in NJ, for the most part, patients don't get to have their say on forced medications in Court.

    In other states, courts use either the substituted judgment standard (what would the patient have wanted while they had the capacity to decide?), or the case is reviewed in court and decided by the judge.

    Each approach has it's problems.
    1) professional review: Often the doctor that reviews the case is a colleague of the doctor who is treating the patient, creating a conflict of interest. (e.g. "I'll approve this forced med order if you do the same for me when I need one....") Another problem is the doctor doing the review has little to lose by doing a poor review. For all intents and purposes the doctor could spend just a few minutes and then approve the forced meds. A real review in my opinion will take a few hours of work. In the other methods, lawyers have the disincentive of losing a case to fuel them to do what they can for their client.

    2) Substituted judgment: it's very difficult to know what the patient would have wanted when they had capacity, if during the present they do not. Very few people make their intentions known for these circumstances. (E.g. how many of you have advance directives in case you become psychotic?)

    3) Legal review: the problem here is if a patient is actively dangerous, and a court hearing is required for forced meds, it can take weeks before the Court even hears the case. So during the next 1-4 weeks, the dangerous patient will continue to be dangerous. Yes, the patient can be given emergency medication, but that's it. The staff and patients on the unit will have to wait in fear that when the meds wear off, the patient will again do something dangerous until staff members can give emergency medications again. I have seen patients and staff get attacked during this period.

    During the few weeks of wait, it costs the medical system around $1000/day to keep the patient hospitalized. Had the patient been forced medicated early-on, the patient could've likely reached stability much sooner, which is in the patient's interest.

    Another problem is the judge is not a medical expert, and he/she might not understand what truly is at stake. For example, in several of the landmark cases, the Court actually mentioned things to the effect that pre-frontal lobotomies were a perfectly acceptable practice. Do you want someone with a law degree making a medical decision? Yes, they do listen to doctors, but the judge nontheless is still not a medical expert, and the judge makes decisions based on filter of what medical experts say in Court.....which have gone through the filter of being possibly grossly distorted in cross-examination.
    Last edited: Aug 10, 2010
  6. Manicsleep

    Manicsleep

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    Although whopper has the current legal take on the situation, the situation can change. Mental Health in NJ needs to understand that the will of the people ultimately is the law.

    The idea that there should be independent review when taking away someone's rights is an excellent idea. If psychiatry were to advocate for this themselves, they would be able to be the designers. If they wait, it will be done to them. This is the only difference.

    Resistance is futile.
  7. whopper

    whopper Former jolly good fellow

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    In my opinion, a neutral doctor, and a patient advocate with some medical training (M.D., nurse), should be appointed by the Court to review forced medication cases in NJ.

    When I say neutral, I mean neutral. A doctor, who for example, is the treating doctor's buddy, partner attending on the unit, works in the same dept., etc has an obvious conflict of interest.

    A patient advocate is also a good idea because it's hard to find a doctor who may not be a colleague. When there's only a few dozen psychiatrists in a county, if even that, the likelihood of finding a truly neutral doctor is low.

    I'm not against the Court reviewing the appropriateness of forced med hearings with one strong exception--the wait time. When you have to wait 1-4 weeks for a patient who is actively punching other patients, and you have to wait for the patient to make the first attack on another person, waiting that long IMHO is too dangerous for staff and patients.

    I had a patient with hepatitis B & C who smeared her hands in her feces and actively held her hands out as if he was Bruce Lee, threatening to spread it on others. It was a daily issue--several times a day. Her case was not heard for 3 weeks while the staff had to deal with it. During that time, most of the patients hid in their rooms all day long, and only left for meals while they covered their heads in their laundry basket and several layers of clothing as a method of protection. They also filed several complaints saying they did not feel safe on the unit.

    All the while, there really wasn't anything I could do about it other than shoot her up with Thorazine after she attacked or attempted to attack someone--which occurred more than daily.

    I've also had some other ridiculous situations. E.g. the Court allowed forced medications for lithium, but wouldn't allow me to do labs. I'm not going to make someone take lithium if I can't do the labs!

    So I had to put in for the forced medication request AGAIN!, and this time I had to clarify the need for labs. During that time, I had to wait another 3 weeks to get this case moving, on top of the previous request where we waited 3 weeks for it to go to Court.
    Last edited: Aug 10, 2010
  8. nancysinatra

    nancysinatra

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    I agree that the waits are too long but I think it is crucial for patients to always have legal recourse. Doctors are trained to think about what's in the patient's best interest--but we don't get much if any legal education at all.

    I'm often surprised in my own program how different attendings have very different understandings of the commitment and medication laws in our state. If I ask 5 attendings to tell me the exact procedures for committing patients, and the exact procedure that should occur when a patient disputes the commitment, I will get 5 more or less similar but not exactly similar answers, even though there's only 1 law and it is very specific. Same goes for medical capacity and competence laws.

    Plus, in psychiatry we are trained--moreso than other medical specialties--to regard patient safety as the highest priority. For example, in the ER when we are deciding whether to offer a suicidal patient voluntary admission or discharge them, safety is one of the biggest factors. Whereas I never hear psychiatrists debating about whether the patient's "liberty" will be violated by sending them to a locked ward.

    Our assessments aren't always accurate either. For example, every time I have to commit someone, I have to put an Axis I diagnosis on the forms. I'm SURE some percent of patients committed this way in the US actually don't have a true Axis I diagnosis at all, and many others have a diagnosis that is very weak and shouldn't really be grounds for commitment. But I have never met a doctor who argues for releasing patients from psychiatric wards because their commitment was based on a diagnosis that does not meet the standard of the law.

    For example I had a patient who tried to evade jail by shooting himself. The patient emphatically denied every symptom of mental illness. (He also denied shooting himself and denied that the police were looking for him even though both facts were well documented.) I really don't know what to call his behavior other than malingering, which in my state is not grounds for commitment. If you wanted to stretch it you could call it adjustment d/o I guess, but he had no symptoms other than shooting himself. Nonetheless, my attending cooked up a "mood d/o NOS" diagnosis and demanded that we commit him. I've seen the same tendency for patients with primary substance abuse problems. Obviously I think it's good to protect patients' safety--but this tramples their liberty at the same time and sometimes actually violates the law. And no one can prove that we're wrong, because there is no "test" for "mood d/o NOS."

    If I were a patient I would want both medical and legal experts to be part of the appeal process--doctors to look out for my well-being, and lawyers to protect my rights.
  9. whopper

    whopper Former jolly good fellow

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    Exactly.

    I was one of the only doctors I knew that actually read the NJ psychiatric laws while I was a resident. That's not just the residents, that included attendings. I felt I actually knew more about forensic psychiatry than most of the attendings I trained under, and my knowledge of forensic psychiatry IMHO was not at an acceptable level by the time I graduated from residency. I obtained most of what I learned in residency on my own, having to read books on the issue on my spare time. To recommend that someone be involuntary committed, when one has not even read the laws concerning this issue IMHO is not acceptable.

    Before I graduated, I wrote a residency training manual and I included the NJ laws concerning the management of psychiatric patients. When I put that in the manual, several attendings saw that section and didn't know what it was--tipping me off that they never read those laws.

    I don't think I would've been a "balanced" psychiatrist without the forensic fellowship, even if I didn't do any forensic psychiatric work again, and only stuck to clinical psychiatry.

    As bad as that makes my general residency program seem, I don't think my residency program was dramatically worse than other programs in terms of forensic psychiatry. In fact, I had the opportunity to sit in civil commitment court about 2x per month, about 0-5 cases each time depending on the situation. I probably wrote at least a few hundred reports requesting civil commitment by the time I graduated---yet not one doctor had me read the civil commitment laws, and I suspected many of them didn't even read it themselves.

    Do the laws matter? Yes.

    In Wisconsin for example, you have to have enough evidence that is beyond reasonable doubt (e.g. hard physical evidence, several witnesses, the same level of evidence to have someone convicted of a crime) for someone to be civilly committed.

    In most states, it's only preponderance of the evidence. (It must have some evidence, but it doesn't have to be beyond the 99% range)

    In some states, you can only request civil commitment if the person has what many consider a "severe" mental illness....e.g. psychosis, or a mood disorder.

    In other states, their definitions allow for including of borderline personality disorder (e.g. the person has a disorder of mood, not by the DSM definition but by a layman's definition. Since borderline PD is characterized be unstable moods, that qualifies under the state's commitment laws).

    In a long term psychiatric unit, you will have difficult patients that you believe will likely harm others, but cannot be civilly committed under the laws. In that case, the exact wording of the law matters. You could for example state to the Court that you actually believe the person will be a harm to others, but not within the definition of the wording of the law to be committed. So, if the person does end up murdering someone say 1 year later (in most states, the wording is dangerous in the "immediate" future"), you're still safe because you addressed the concern to the Court and the law was followed.

    I certainly don't expect general psychiatry programs to teach forensic psychiatry on the order of a fellowship, but I do think the current training needs to be better. Training in malingering IMHO should be taught well in general psychiatry because it is a common issue, especially in urban settings with a high amount of crime. Civil commitment should be taught to the degree where the actual laws are stated to the residents, and residents should be given at least a taste of what the laws are in other states because many residents don't end up practicing where they trained. A resident should be able to perform a forced medication request, not just in their own state, but under the auspices of the regulations under other states (e.g. Massachusetts uses the substituted judgment standard, Ohio uses the Court/legal review standard, NJ and Federal Courts uses the professional review standard). A resident should also testify at least a few times by graduation.

    Why do I say that? Because in any long term facility, you will have to do all of the above, whether or not the unit is forensic. To work in a LT facility with no such training is IMHO is not the standard we should have. Even in a short term facility, most of the above scenarios are common. Wouldn't you think that by the time you graduate, you should have the knowledge and training to be able to run an inpatient unit? I don't think anyone should have to testify in front of Court, it being the first time ever for them without a training period, especially when they can possibly get a legal eagle cross-examining them and humiliating the frack out of them. That's ridiculous.
    Last edited: Aug 11, 2010
  10. kugel

    kugel

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    Just my opinion:

    I come down on the side of judicial review.
    Judges aren't medical experts and shouldn't be.
    They aren't there to decide what meds should be given and at what dose.
    This is about whether there is sufficient evidence under the local laws to require that the patient's constitutional rights be suspended.
    A judge is the one to decide that.

    It's a judge who decides if there is sufficient cause to suspend the 4th amendment and search someone's home against his will (unless it is an emergency defined by "exigent circumstances"), and it's a judge who should decide whether there's probable cause to suspend patients' constitutional protections against battery.

    In fact, I don't like our practice here of having a semi-professional Patients' Rights advocate rather than a lawyer. I preferred the New Mexico system, where a State's Attorney and a Defense Attorney argued the case, on the record with a court reporter - and that kept the Special Commissioner on the straight and narrow.

    The wait is a separate issue.
    And shouldn't be solved by taking judges out of the loop.
  11. Faebinder

    Faebinder Slow Wave Smurf

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    Again i state... I await the pendulum swinging.
  12. Manicsleep

    Manicsleep

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    I would agree with Kugel to a degree and I also notice the pendulum swinging.
    I think that the judicial system should have oversight but should allow governance by independent experts in the interm. The patient should be allowed to have access to counsel and appeal to the courts to intervene. The primary goal should be to treat the patient while avoiding paternalism.

    I notice that many psychiatrists who work in the legal/correctional system have very harsh views on the way patients should be treated and often seem to be trying to find ways/excuses to take away patient rights. This blase attitute that develops after overexposure to a combination of severely mentally ill and a legal/correctional mindset is a serious problem with psychiatry. Not only does it go against the very fundamentals of medicine, it contributes to the stigma associated with psychiatry as well as the anti-psychiatry movement.
  13. Molls

    Molls

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    Is the knowledge of the laws helping to protect yourself or does it make you a better doctor? It is interesting that you say the forensic fellowship made you more balanced. Is that good or bad?

    We all have ethics and morals, these are taught to us in medical school and presumably residency. However, laws and ethics are 2 different things, a statement attorneys are loathe to endorse but nonetheless accurate. So do we really want to play juggler and be both lawyer and doctor. I am not blind to the reality of being forced to know the law in todays litigious society. However, I would argue that this unbalances a physician rather than making them more whole.
  14. whopper

    whopper Former jolly good fellow

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    Both.

    Defensive medicine is only unethical if an action regarding the patient is done to protect onself against a lawsuit (or other problematic occurrences) that is against the patient's interest.

    Example of defensive practice against the patient's interest: holding a patient on a psychiatric unit for several extra days even though there is no reason to believe the patient will be immdiately dangerous due to mental illness.

    Example of defensive practice for the patient: keeping a clear and concise log of all the medications that were tried on a patient before one decided to recommend the patient for Clozaril.

    If, for example, I do extra documentation for defensive purposes, often times that actually makes for a more complete record that is often in the patient's interest.

    Most of the laws are there for good reasons. To follow practice standards based on the law...that are there for good reasons is a good thing. It certainly is better to practice at or over the legal standard than below it.

    I do not advocate defensive medicine against the patient's interest.
  15. Manicsleep

    Manicsleep

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    I think you missed my point.
    We are taught to follow ethics and morals as well as to what is best for the patient.

    Keeping medication logs is medically sound practice whether for clozaril or any other medication.

    Laws often have good intentions but it is not the law that determines how we practice but medical judgement. If medical judgement (after appropriately consulting my colleagues for their medical opinions) was completely against the law, I would hope I have the fortitude to break the law.
  16. Ibid

    Ibid

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    Could you give a hypothetical example out of interest. The law is not always clear and medical opinion is often divided. In the UK high court judges are loathe to hand down judgements that impinge on medical decision making but sometimes they are best placed to be the ultimate decision makers. These decisions are the law. Presumably you would always accept the decision of a court.

    As an aside where I am the "reasonable other", in this case other psychiatrists would have, until recently, constituted a defense for a course of action. This is no longer the case. A reasonable course of action is now what a high court judge says is reasonable is now the test. A moveable feast and somewhat uncomfortable but the point is that again the law is the ultimate arbiter.
  17. toothless rufus

    toothless rufus

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    I don't understand why there is even an issue. If a trained medical professional deems that such treatment is merited: done. Waiting weeks and having to deal with threatening behavior is BS. These people making these decisions are out of the loop and have no idea what patients and staff have to endure.

    It's frustratingly annoying and potentially often dangerous or violent. People get hurt! I think those who make these imbecilic decisions should first have to do a one-on-one sitter with the patients in question, and see if they see things a little more clearly. "Oh...I see..uh, please snowball that dude into never-never-land as I find this situation replete with suckitude" (I imagine them saying in enlightened wonderment)
  18. Suenya

    Suenya Hail Eris

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    If a trained police officer thinks that someone might commit a crime, why would you need anyone to review that before throwing them in jail?

    People get touchy with their freedom for some reason. Beats me why.
  19. toothless rufus

    toothless rufus

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    It's all good in theory but when your in that situation: not so much. Reality is what counts.Stuff does go down. I'm not talking about if they're just psychotic and keeping to themselves. I'm all for treating people with the utmost respect and acknowledging and supporting their rights. But its ubfortunately not a land of milk and honey.

  20. Suenya

    Suenya Hail Eris

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    Really, I'm at least theoretically okay with involuntary treatment if needed, but there is far from a uniform decision making. You can see it change by resident and by attending, and even by which nurses are working. People have very different limits in when they are willing to take away someone's freedom to not be medicated (especially with a psychoactive substance). You can talk about a trained medical professional's view, but that is far from something that all people will agree on in the same situation. Having a legal framework to guide and protect the rights of patients is important to try to make up for the fact that medical professionals can disagree (perhaps only in practice, if not in theory too) on when it is necessary.

    Put yourself in your patient's shoes. Their circumstances are often pretty rough. Having no recourse when people are forcing meds on you (and, if you are a frequent visitor to the psych ER or floor, often somewhat inconsistently) that you don't want or think you need. You might even think that people are forcing meds on you just to make their life easier. Even having the option of having someone that is more likely to be objective will help.

    If you think it's unlikely that people medicate patients to make their life easier, with some pretty good justifications for the medication, rather than with strict, strict need and respect for a patient's freedom and (even limited) autonomy, I think you're missing something. We owe it to our patients to do our best to respect their rights, and this is one way to help that.
  21. whopper

    whopper Former jolly good fellow

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    Depends. When this becomes an issue, often a judge has to figure this out.
  22. nancysinatra

    nancysinatra

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    Let's say it was against the law to treat uninsured patients, or to prescribe certain medications. Then I could see your point about going against the law to provide treatment. But that is not the subject here. The issue here is that patients sometimes don't WANT our treatments, no matter how appropriate they may seem in terms of "medical judgment." Psych meds aren't the only treatments that patients refuse--patients are known to refuse surgeries, heart medications, blood transfusions and many other things. The reason we have judges involved is because sometimes what the doctor wants is different from what the patient wants. I'm pretty sure that if forced medication decisions were left to doctors only (or worse yet nurses) then every patient who ever walks into a psych er or inpatient unit would be promptly and continuously medicated despite their objection. Emergency medications are done that way--and there are definitely cases wher they are misused.

    When judges release a patient or deny forced medications, the courts are taking on the liability for any harm that patient might cause. If you go against that judment and medicate the patient, that is battery, for which you can go to jail.

    I doubt anyone here would say that laws against police brutality should not be observed--similar with medical battery. Which is what the NJ lawsuit is getting at. The issue here isn't about the laws trying to regulate medical judgment.
  23. kugel

    kugel

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    This is precisely when laws and policies protecting the patients' rights are MOST important. When it is frustrating, annoying and even dangerous is when the patients' basic constitutional rights are most in jeopardy. Several times per week, I see patients on other wards held down and given involuntary medications for behaviors that do not meet any reasonable standard of "immediate danger of severe injury."

    It is not terribly uncommon for staff to demand (and the physician to order) restraint and involuntary medication because someone is loud, obnoxious, or smacked his hand on the wall or counter. It's fairly common for nurses demand involuntary medication for a patient who is loud and cursing, justifying it by stating that he is bothering the other patients. When I ask if the patient has been offered the PRN P.O. medications already on record, they tell me, "He's too agitated. He needs a shot," which I interpret as A) "I want to be rid of this problem now and I don't want to wait 30-40 minutes for PO meds to work", and B) "I want him punished."

    If you think, "Well, a good physician wouldn't fall for that," I have to say you are wrong. I know very good physicians who have told me, "You have to do what the nurses on the floor want, or they won't go along with what you want," and, "the nurses are in charge of deciding who gets secluded or restrained. I just write the order to back them up." And when I refuse to strap down or inject a patient who has not met the "immediate danger" standard, I'm often told, "the next shift doctors won't put up with this. They'll medicate a patient when I tell them to." And they are not wrong.

    When a disturbance erupts and I have to stop my current interview or write-up to go deal with that, I'm often met with a scene of an impulsive (often manic and/or intoxicated) patient yelling and demanding something immediately, and several staff standing around blankly staring at the patient. When I ask what he wants, it is often something relatively reasonable. When I ask why the nursing staff hasn't allowed him to use the phone (or get him a snack, or allow the patients a break out on the patio, or be discharged since the order was written an hour ago and no one has given him back his shoes so he can leave), I'm usually told that they couldn't do so because the staff are stretched so thin that they have no one available to do that. When I point out that they currently have 4-5 staff standing around watching the patient, so it would be more efficient to have one accomplish what he wants so that the other 4 can get back to work, they are incredulous. Then when I ask who has explained the situation to the patient and tried to help him understand that things cannot necessarily happen exactly when he wants, I'm told that they did tell him to stop yelling. Not exactly the same thing.

    When I order "Now" PO medications, I'll still have 3-4 staff come tell me that the patient needs medications. When I point out to each one in turn that the meds have been ordered but I need a nurse to administer them, each nurse tells me that giving those medications to that patient is not his job. Sometimes I have to remind the charge nurse that the medications have been ordered and if failure to give the meds on a "Now" order results in an incident, it may require additional paperwork - an incident report. "I'm not sure, but I think that would require an incident report, wouldn't it? I'd rather that we give the meds now and avoid the incident report.

    Now don't get me wrong. The vast majority of the staff I work with are wonderful 90% of the time. However, they often look to medications to solve a problem that solid patient interaction could have resolved.

    Running the floor of an acute psychiatric ward or PES is frustrating and nerve-wracking. The best of us can get overwhelmed and turn to involuntary medications and 4-point restraints as a way to resolve problems that could be more properly handled by staffing and professional interactions that are calm and clear. It is precisely those times that strict adherence to laws and policies are needed to protect patients' rights and their safety. Being jumped by multiple staff and forcibly strapped down and then injected is NOT a safe maneuver and it is not uncommon for it to result in injury to patients and staff. We can't be afraid to use these measures when it is truly necessary, but we can't allow our own impatience or anger to cause us to jump to these measures until all the less restrictive measures have been tried.

    When a medical patient needs an increased level of care or staffing, we don't consider it the patient's fault, and then respond by punishing the patient so that he will "learn to stop being so sick."
    But that is what happens in psychiatry WAY too often. Not all the time, but much more often than it should.

    Now before you start thinking that this is all way too easy for me to say from the comfort of my doctor's office, you should know a few things:
    1) I have no office. All my work is done in the patients' area or in the nurses' station. I'm never "off the unit" except for bathroom and meal breaks - and I take less breaks than the nurses.
    2) I'm a former Psych Tech. Managing the floor was my responsibility, and most of the time a 12-18 bed unit was mine alone. My nurse was trapped in the nursing station doing paperwork and meds and phone calls, etc. It was just the two of us - and we watched out for each other.
    3) I'm very often the first one through the door, the first one approaching a dangerous patient, and the first one with hands on when that is necessary. Only yesterday, I responded to a code on another unit and when the two agitated patients started to fight, I was the only one holding onto the one trying to throw punches as 3 other staff yelled at him (thus unable to hear my instructions. - and not watching my back for attack from others.)

    Seclusion and restraint are Not treatment measures.
    They are a failure of our treatment plan.
  24. Manicsleep

    Manicsleep

    Joined:
    Jul 9, 2009
    Messages:
    888
    Status:
    Attending Physician
    SDN 2+ Year Member
    The problem with forced medications isn't when the answer is obvious.

    The ones you need oversight are the ones that are in the middle. These are the cases that the data is right at that clear and convincing mark but could go either way based on several factors. This is where a third party is needed.

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