MrChance2

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In the USA...

Can blood be drawn on a patient without their consent if their proxy agrees and the tests are in the best interest of the patient (though not life or death) and the patient is actively refusing.

Can IM psychiatric medication be administered to a nonviolent patient in the same circumstances?

How is this different for children if there is a difference?

Does anyone have a good resource that clearly lays these issues out for psychiatrists?
 

hamstergang

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Can blood be drawn on a patient without their consent if their proxy agrees
If someone is deemed to lack capacity for a medical decision and has a proxy, then that proxy makes the medical decisions just as another person who has capacity does for themselves.

I know this doesn't answer everything, but I just needed a short distraction for myself.
 
Oct 13, 2008
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This is all actually very complicated. Somewhat state-law dependent and definitely dependent on the specific facts of the case. Impossible to give a one-size answer to those questions.

In many cases, you'd need a guardianship to overrule patient objection.
 
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splik

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In the USA...

Can blood be drawn on a patient without their consent if their proxy agrees and the tests are in the best interest of the patient (though not life or death) and the patient is actively refusing.
Well, you are presuambly talking about an incapacitated/incompetent patient as a competent person (and competence is presumed) has the right to refuse treatment. In a non-emergent or urgent situation it would not fall to a surrogate decision maker such as NOK to make decisions and may instead require guardianship or conservatorship (depending on the state). Even in those cases, no one is going to routine procedures on a patient who is refusing and where it would be dangerous to do so (for example the patient will assault you if you try to batter them - and it is battery). The patient still needs to ASSENT to treatment, even if they cannot consent. No surgeon in their right mind is going to take a patient to the OR kicking and screaming.

Also these things vary by state. Many states (for example MA) do not have a best interest standard and instead use a substituted judgement standard. In the substituted judgement standard the surrogate decision maker is not acting in the "best interests" but supposed to honor what the patient would have likely done if they were competent (which may be based on expressed wishes when competent). Plenty of competent people may refuse treatments, investigations etc, and it would be wrong to force an incompetent person to have such investigations if we know that were they competent they would have still refused such interventions.

Can IM psychiatric medication be administered to a nonviolent patient in the same circumstances?
It's not a question of violence but dangerousness to self or others. In an emergent situation you can administer medications to a patient if there is an imminent risk of harm to the patient or others (for example an escalatingly agitated and aggressive patient in the hospital). Otherwise one needs to get approval from the court typically. Civilly committed patients are no longer presumed to be incompetent (though they usually are), so being psychiatrically hospitalized does not take away one;s first amendment rights, and there is also the right of due process (i.e. an administrative hearing determining the patient is incompetent to refuse antipsychotics) as enshrined in the 14th amendment.

There is huge variation in laws regarding civil commitment, competency, guardianship/conservatorship, right to refuse treatment etc among the states, but the above parses out the main truisms. For children its more complex. Many states give parents alot of powers (to force interventions, hospitalization etc) on children, whereas others recognize that parents cannot (necessarily) be trusted. However the supreme court has previous ruled that absent abuse or neglect, parents should be given substantial weight in decisions for psychiatric hospitalization. In some states you cant even prescribe psychotropic drugs to consenting, competent, minors without parental approval (which causes problems when the parents are nuts and refuse to allow their children to get treatment)
 
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Armadillos

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I would say the most important thing is look into the laws in your state. In my state for example it is quite easy (as an inpatient) to give medications (or ECT) to someone currently without capacity using a alternative consenter even if the patient is actively resisting.
 

clausewitz2

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I would say the most important thing is look into the laws in your state. In my state for example it is quite easy (as an inpatient) to give medications (or ECT) to someone currently without capacity using a alternative consenter even if the patient is actively resisting.
Whereas in my state it is actually 100% illegal to give ECT to someone who is not able to affirmatively consent without a court order. Catatonic? Doesn't matter, judge needs to say yes. Have a POA that gives 100% decisionmaking to someone for all your medical needs that does not explicitly mention ECT? Judge needs to say yes. There is maybe room in malignant catatonia that is sufficiently advanced as an emergency measure but our legal department at least is very loath to test this.
 

SeniorWrangler

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Every state has their own policy, some states are incredibly restrictive when anything psychiatric is involved.
To make things more complicated, there is also a distinction between primary psychiatric and medical causes of behavioral emergencies, so that agitated delirium is treated differently than agitation in a patient with a major mental disorder.
 

thoffen

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My state has a mechanism to basically treat whomever we want, but we rarely use it. Too often, though, people get in these kinds of cases and look to the law for guidance. Something being legal doesn't make it ethical or appropriate practice.
 
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