ethics: refusing medical care on psych ward

[IceCreamMonster]

Haven't really done inpatient in quite some time but now picking up some weekend shifts, so was just hoping for a bit of guidance. I have one specific scenario that I always seem to get mixed answers about... I'm totally comfortable doing capacity evals for psych patients on medical floors. Also totally comfortable with how to proceed when a patient refuses psych meds on an inpatient psych unit. However, in regards to a patient on an inpatient psych unit, I'm always a bit confused as far as how to proceed when they refuse treatment for a general medical condition. I have heard different answers from different attendings I worked with a few years ago.

Inpatient Attending A's approach: If inpatient psych patients can't demonstrate capacity to make decision regarding their general medical condition, they can't refuse treatment. It was totally ok to restrain and give IM Abx to an elderly patient with a UTI of they wouldn't take PO. We had a severely catatonic patient that was refusing all treatment. We had to petition for forced antipsychotic administration which took several days. However, the attending claimed catatonia was technically a *medical* issue, and stated we were well within our right to force injections of ativan on patient even before getting approval from the court for forced antipsychotics.

Inpatient Attending B's approach: "You can do it if it's necessary. " They felt it was ok to restrain patients to obtain general screening labs on admission if they were refusing. However, say a patient was refusing to give a UDS, it wouldn't be ok to restrain them in that situation as it is not really "necessary."

Outpatient Attending's approach: We had a resident (on call overnight) that was contacted by unit nurse to say that a patient was refusing insulin. Resident informed nurse to restrain pt and force insulin. The outpatient MD (who was part of our residency performance evaluation committee, which is why she provided this feedback) stated that forced treatment of medical conditions on psych wards was NEVER allowed and this was considered battery. Of note, it certainly didn't sound like patient was in a life or death situation.
She stated that patients on inpatient psych wards had more rights to refuse MEDICAL treatment than patients on medical floors, which I've never understood.

A couple of scenarios I was thinking of: What to do if a patient is refusing BP meds and running 195/95 consistently? What to do if a patient has a worsening wound and is refusing any treatment for it?

A bit embarrassed that after years of training this is still a grey area for me, but better late than never.

Appreciate the advice in advance.

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[hamstergang]

If someone lacks capacity to make a certain medical decision, that doesn't mean that you just get to make the decision for them. I haven't actually seen the next steps for how a hospital handles such a situation, however.

 

[AD04]

What I do is think how it will look if the forced medications orders were dissected in trial.

This is how I approach the situation.

1. Determine capacity.

2. If patient has capacity, respect autonomy. If patient lack capacity, contact guardian / POA / next medical decision maker and explain the situation and what you propose. Most likely, he or she will agree. Document that patient lacks capacity and that guardian / POA / next medical decision maker agreed with treatment plan. (If he or she refuses, then honor that.)

3. If you cannot get in contact with guardian / POA / next medical decision maker, document that you reached out but was unsuccessful. Then go with the planned course of action. Document that you attempted to reach out but was unsuccessful and that you decided to pursue treatment as it was for the best interest of the patient.

No court will hold it against you if you act in the best interest of the patient, especially if you took steps to determine autonomy and try to inform those who can make decisions.

 

[Crayola227]

If a decision can be put off until the patient or the next person with legal authority to make decisions on their behalf can do so, then you are to do that. Example would be colonoscopy for cancer prevention.

Otoh, if the patient has BRBPR and is borderline hypotensive, then that changes the situation. This is emergent, but actually not so emergent that you don't look in the chart and attempt to contact someone who might have decision making capacity for the patient, and you document that.

For this kind of thing, I wonder if you could curbside EM because they seem to know how to navigate it best, ie what is emergent and you get to be a cowboy and what will get you sued.

There usually is a point in the law where a physician's judgement can be substituted for a patient or the patient's surrogate. One is you don't have time to reach the surrogate. The other scenarios there is time and so it gets more complicated.

In any case, the patient has to lack capacity. And whatever you decide, it has to be in the best interests of the patient, and anyone making decisions is supposed to be guided by what the patient would likely decide if they had capacity, and there is danger if you delay.
Hyperglycemia probably isn't there unless signs of DKA.

So, if when they had capacity they made it clear they were Jehovah witness and no transfusions, then even in the case where it falls to you to decide, you are not supposed to use the fact they don't have capacity now to go against when they did. Make sense?

I'm more familiar with this on the gen med floor than in psych admittedly, but you are also asking specifically about medical issues.

 

[nexus73]

Consult medicine to get their opinion on urgency of the medical issue and treatment recommendations . If urgent/emergent and patient lacks capacity follow state law on proxy decision makers.

 

[clausewitz2]

Realistic answer: call hospital risk management. They are going to be exquisitely aware of and sensitive to the relevant state regs on this.

 

[comp1]

For something non-emergent, sure contact risk management. That could take days or at the very least hours to get a response, however. I'm surprised at the number of people who assume there is a surrogate decision maker. For my inpatient psych population, that is a tiny, tiny minority of patients who have anyone who cares about them. If they did, there might have been something less drastic possible than an involuntary psychiatric admission. I think it's very normal to have a wide variation in attending responses to this question. It's going to have to do with what exactly is going on with the patient in specific, not a general guideline. You are correct in your belief that it's going to relate heavily to the acuity of the situation. If a patient is going to be risking life or limb due to inaction urgently, do the action. If it's a chronic condition or something not likely to result in harm over several days, the risk of physically retraining or sedating a patient to administer treatment may outweigh the benefit. One of my risk management people once asked "Who exactly is going to sue you for this?" It's a good thought to keep in mind when you're getting particularly rigid with processes and rules....often there isn't anyone. Do what's right for the patient.

 

[clausewitz2]

For something non-emergent, sure contact risk management. That could take days or at the very least hours to get a response, however. I'm surprised at the number of people who assume there is a surrogate decision maker. For my inpatient psych population, that is a tiny, tiny minority of patients who have anyone who cares about them. If they did, there might have been something less drastic possible than an involuntary psychiatric admission. I think it's very normal to have a wide variation in attending responses to this question. It's going to have to do with what exactly is going on with the patient in specific, not a general guideline. You are correct in your belief that it's going to relate heavily to the acuity of the situation. If a patient is going to be risking life or limb due to inaction urgently, do the action. If it's a chronic condition or something not likely to result in harm over several days, the risk of physically retraining or sedating a patient to administer treatment may outweigh the benefit. One of my risk management people once asked "Who exactly is going to sue you for this?" It's a good thought to keep in mind when you're getting particularly rigid with processes and rules....often there isn't anyone. Do what's right for the patient.

I definitely agree with you. Even if they don't answer the phone, giving them a ring before plowing ahead with your decision makes it much harder for anyone later to argue you were being negligent. No you weren't, you clearly took appropriate steps to ensure things were being done properly but you had to act with the information that was available at the time due to the medical urgency.

If you genuinely think, though, beyond a shadow of a doubt, that someone has a good chance of dying or being serious injured unless you act right away, who cares about the legal implications? I know my conscience wouldn't really be much assuaged at 3 AM by the thought I followed policy if I just let them knowingly die in a way that would have been 100% preventable by a simple action I could have taken. I don't care what the law says if a bear is about to maul a toddler, I am going to snatch up the toddler or shoot the bear.

 

[NickNaylor]

The actual answer will probably depend on your state statutes regarding this type of situation. In my state, for example, surrogate decision-makers are clearly defined in statute. If a decision-maker cannot be found, a "member of the clergy" can serve as a decision-maker, so we will ask our chaplain service to function in that role, which they are variably comfortable doing. In emergency situations, our state allows for the administration of treatment without explicit consent if there is documentation that the medical condition is an emergency and two physicians attest that the treatment is medically necessary.

As others have mentioned, I don't think you will be faulted for doing what is in the best interest of the patient as long as you have made attempts to follow whatever is outlined in statute in your jurisdiction. The real question is how far you're going to push it; ordering antihypertensives/antibiotics that the patient takes without explicit consent - or even against consent (e.g., "I'm not going to take that") - that they then take probably isn't a big deal. Holding a patient and giving medications IM is a bit more dubious.

I work at a med/surg hospital, so if there was an acute medical issue that necessitated urgent treatment and they refused that treatment, I would simply transfer the patient to a medicine service, get whatever the issue is treated, and transfer back to the psychiatric floor once the issue has been addressed. Had this issue recently with an elderly patient with a UTI that was contributing to a delirium - so much so that the patient was unable to meaningfully engage in psychiatric care and was refusing PO antibiotics. The patient was transferred to the medicine team for work-up/treatment and returned to the unit once she was successfully treated and her mental status improved.

I imagine this would be more difficult if you don't have access to those resources.

 

[robellis]

I wouldn’t make any of these decisions, why would I be determining when to force blood pressure meds or even giving blood pressure meds to a very hypertensive patient? Call internal medicine (who is consulted on most of my patients anyway) and have them decide what they want to do whether that’s transfer to medical floor or keep on the psych unit and try to convince the patient or whatever they want

 

[Merovinge]

The outpatient attending is almost certainly wrong, they certainly would be in the state's I have been. I would be shocked to see a state that ALWAYS blocks involuntary medical treatment on a psychiatric floor (this would assuredly cause people to die).

Catatonia absolutely can be treated as a medical emergency if it is a medical emergency (that is, it is malignant, or the lack of PO intake has caused demonstrable changes that threaten life or limb).

 

[Crayola227]

Haven't really done inpatient in quite some time but now picking up some weekend shifts, so was just hoping for a bit of guidance. I have one specific scenario that I always seem to get mixed answers about... I'm totally comfortable doing capacity evals for psych patients on medical floors. Also totally comfortable with how to proceed when a patient refuses psych meds on an inpatient psych unit. However, in regards to a patient on an inpatient psych unit, I'm always a bit confused as far as how to proceed when they refuse treatment for a general medical condition. I have heard different answers from different attendings I worked with a few years ago.

Inpatient Attending A's approach: If inpatient psych patients can't demonstrate capacity to make decision regarding their general medical condition, they can't refuse treatment. It was totally ok to restrain and give IM Abx to an elderly patient with a UTI of they wouldn't take PO. We had a severely catatonic patient that was refusing all treatment. We had to petition for forced antipsychotic administration which took several days. However, the attending claimed catatonia was technically a *medical* issue, and stated we were well within our right to force injections of ativan on patient even before getting approval from the court for forced antipsychotics.

Inpatient Attending B's approach: "You can do it if it's necessary. " They felt it was ok to restrain patients to obtain general screening labs on admission if they were refusing. However, say a patient was refusing to give a UDS, it wouldn't be ok to restrain them in that situation as it is not really "necessary."

Outpatient Attending's approach: We had a resident (on call overnight) that was contacted by unit nurse to say that a patient was refusing insulin. Resident informed nurse to restrain pt and force insulin. The outpatient MD (who was part of our residency performance evaluation committee, which is why she provided this feedback) stated that forced treatment of medical conditions on psych wards was NEVER allowed and this was considered battery. Of note, it certainly didn't sound like patient was in a life or death situation.
She stated that patients on inpatient psych wards had more rights to refuse MEDICAL treatment than patients on medical floors, which I've never understood.

A couple of scenarios I was thinking of: What to do if a patient is refusing BP meds and running 195/95 consistently? What to do if a patient has a worsening wound and is refusing any treatment for it?

A bit embarrassed that after years of training this is still a grey area for me, but better late than never.

Appreciate the advice in advance.

Wanted to come back and address the scenarios.

Again, you want to document capacity and attempt to reach out to a surrogate. As was pointed out, some of these people have no one. Regardless, you want to still document an attempt (you looked up in chart emergency contact. You asked emergency contact if reached if they know of someone with POA. You want to be aware of laws in your state. Sometimes it spelled out for example that legal spouse automatically can make decisions if no one else is designated)

Attending A is correct only that they cannot refuse *emergent* treatment when they lack capacity, there is no documentation of their wishes from when they had capacity (and there are caveats to when that has to be followed vs when it is reasonable to set aside. Jehovah's witness 20 years ago, present day collateral suggests they no longer hold to those beliefs might be an example), and you can't reach surrogate in time.

The elderly patient with UTI and AMS, you can certainly make a case this is emergent, especially if the UTI or AMS puts them at high risk of serious consequences (sepsis, falls). The catatonia as someone pointed out can fall under the umbrella of emergent. What is missing from this Attending's formulation of the issues is identifying the issue as being emergent and threatening to life limb or organ. The issue isn't that with lack of capacity the person loses right to refuse treatment. They can still refuse non-emergent treatment. For example, removal of a precancerous mole or colon cancer screening. That isn't to say in a patient lacking capacity and refusing these things there is no mechanism for overriding and the decision and treatment being made. But there is time for a surrogate to be appointed so these things have to wait until then.

As for Attending B and getting initial screening labs on admit, the case can be made with the patient lacking capacity, and it will depend on a few things. Assume this is not a case of the person who chronically lacks capacity and for a known cause presenting in their usual state of health. That is not the situation that you have sure footing to force a test being refused. But usually that will not buy someone from the community a trip to the ED or the psych ward. Usually there is AMS or other symptoms. If you cannot rule out an emergent cause without doing testing.... They could have an ingestion, head injury, stroke, and on and on. This is the same rationale for why the unconscious person presenting to the ED gets a battery of tests with no consent from anyone needing to be obtained.

Lastly, the situation with insulin is potentially more complex and again it will depend on whether or not the refused insulin and resultant hyperglycemia is approaching the level of an emergent issue.

Once you sort of understand the principle that needs to be in place, and especially laws in your state, it becomes somewhat easier to navigate the issues at least in the immediate short term.

If you are acting to protect life limb or organ acutely, generally this is OK. If the treatment or decision can wait, then despite lacking capacity it needs to wait until the appropriate surrogate can make the call.