Refusal of medical monitoring (labs, ekg's, etc) in patients on court compelled medications

[esob]

I just finished a sub-acute rotation, which has been my favorite inpatient experience by far. However, the one unresolved issue that bothered me was the number of pts that we have on court-compelled medication who refuse essential monitoring. The classic case is a pt on an SGA who doesn't have an FLP, CMP, EKG, A1C, or even vitals due to refusing these items.

I brought this up to one attending (not on that service), who said the best we can do is document the refusal and note that the pt needs these things, but that the benefits of continuing to give the medications without monitoring outweigh the risks.

My question is, are there studies to back that up? We certainly use lab refusal as justification to not initiate medications that require routine monitoring (Depakote, lithium, etc). Does the fact that the court compelled those meds absolve the physician of liability when the pt goes into torsades, gets metabolic syndrome, gets hyponatremia, etc?

I'm sure there are state and institution-specific policies that vary widely, but it seems that if the state compels a medication, they are implicitly compelling the standard of care that accompanies that medication, such as an annual CMP.

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[Bartelby]

I agree with your attending, but the compelled part isn't (to me) the key. It comes down to risks/benefits. If the benefits of continuing the antipsychotic outweigh the risk based on the data you do have, then continue it. If the risks outweigh the benefits stop the medication and notify the court (or notify them ahead of time of the noncompliance depending on the standard in your area). Basically do the right thing medically.

Consistent documentation of good medical judgment is the best way forward, but I doubt there is any study specifically addressing liability outcomes with different strategies in this situation.

 

[ClosetCentrist]

EKGs for most psychiatric medications are basically gotten for superstitious reasons. The effect of the medications we prescribe on QTc is vanishingly small and not clinically relevant outside of some very idiosyncratic cases.

A good essay on the topic: Stop Twisting Yourself Into Knots About QTc

 

[Merovinge]

You are going to be horrified when you find out the percentage of patient's who are on those medications who actually get that lab work done even in high functioning/affluent ambulatory practice settings.

 

[comp1]

The OP's question is absolutely ADORABLE! This is why I work with medical students. The lack of jade gets me through the day. Concur with above. It's a risk/benefit issue and it's one you will manage with both voluntary and involuntary patients. Yes, they will probably get diabetes, but if it stops them from assaulting people on the unit or at their care home, it's worth it. DEFINITELY concur with EKGs being based on superstition. The people who need EKGs are on IV haldol and they probably had one. And regardless of whether the court is compelling lab draws (which it may or may not based on state case law) , you have to balance whether actually collecting that is worth the risk to staff to get it. It's almost certainly not if you're worried about long term things like diabetes or extremely rare things like electrolyte abnormalities.

 

[ClosetCentrist]

The people who need EKGs are on IV haldol and they probably had one.

Actually, not really: https://www.sciencedirect.com/science/article/abs/pii/S0163834320301213

 

[comp1]

Look, I'm liberal as can be with avoiding EKGs, but even the article says that you need to know their QTc is under 500 ms and for that you need an EKG. It only says you don't need telemetry if it is under 500 ms, which I strongly agree with.

 

[ClosetCentrist]

Look, I'm liberal as can be with avoiding EKGs, but even the article says that you need to know their QTc is under 500 ms and for that you need an EKG. It only says you don't need telemetry if it is under 500 ms, which I strongly agree with.

I mean that's what they say, sure, but it seems like they're saying that just because nobody wants to say "don't worry about it." It's totally at odds with the conclusion of the article which is that Haldol doesn't prolong the QTc interval relative to placebo. If that's true, why would it matter if it's over or under 500ms? This is just the authors hedging their bets.

500ms is a silly threshold to choose, past which there is still basically no clinically relevant risk - a roughly 1 in 22,000 chance for a serious ventricular arrhythmia. The risk of SJS/TEN (roughly just as deadly as TdP) with lamotrigine is 1 in 2500 - even with slow up-titration - and yet we prescribe it with just some words of caution.

Again, see the blog post above for a more thorough (and more well cited) discussion

 

[whopper]

Some meds are 100% NO if they don't do the labs. E.g. Lithium, Clozapine, Valproic Acid.

Other meds I'd be willing to do, but only if the patient was warned of the risks, and the discussion was documented.

For this very reason, whenever I did court-order medication requests, I always included the required labs. I've seen some people quite naively only order 1 court-ordered med, and then it doesn't work and now have to wait several days for the next court hearing to add more meds. Whenever I court ordered med requests for antipsychotics, I included ALL atypicals, several typicals, and with mood stabilizers ALL OF THEM, with documentation that I would not give more than needed and aim for efficacy, safety and use of less medication if possible.

 

[comp1]

Definitely concur with requesting all possible relevant meds, including LAIs if your jurisdiction allows it. I have only once had a judge read through it all, ask about each one and strike the meds he didn't think were appropriate.

 

[esob]

Thanks for the responses. Interesting article about QTC for sure.

Some additional points:
- we don't have the ability to check any box for requiring labs on our court paperwork
- our paperwork varies from county to county, but in some cases you can simply check every med on an institution-generated list, while in other jurisdiction they simply approve entire classes (antipsychotics, antidepressants, etc).

So, it seems the general consensus is, if it keeps them from harming themselves or others, y'all would find the treating physician not liable for iatrogenic harm if placed in the juror box?

 

[docksan]

Love the QTc, love the QRS and JT more.

 

[esob]

I would never, ever, ever call a psychiatrist at harm for not getting labs on a patient outside of lithium or clozapine.
Also, I would never, ever be in a juror box on a physician case finding a physician guilty. Are you foaming at the mouth to testify against other doctors or punish other doctors for following the standard of care? Because in no way shape or form is mandating 3 month labs even remotely good medicine. you should seriously read about the actual things you're thinking about because you're coming across incredibly naive and offensively.

I'm not sure how you extrapolated "foaming at the mouth to testify against other doctors" from anything I've written, but I'll chalk that up to SDN culture.

It's just a legitimate question based on incongruent information. The following was distributed to the dept in the wake of this topic, so again, legitimate question.

 

[annoyedpsychiatrist]

You are going to be horrified when you find out the percentage of patient's who are on those medications who actually get that lab work done even in high functioning/affluent ambulatory practice settings.

lol so true. For some people I may as well ask them to buy a ticket on jeff bezos rocket and go to the moon, because its equal probability of happening.

 

[littlefred]

I'm not sure how you extrapolated "foaming at the mouth to testify against other doctors" from anything I've written, but I'll chalk that up to SDN culture.

It's just a legitimate question based on incongruent information. The following was distributed to the dept in the wake of this topic, so again, legitimate question.

View attachment 382377

Funny Texas HHS has these guidelines but then getting Medicaid (HHS) through Texas is almost impossible, especially for mental health needs. Exceptions would be pregnancy. Then when the patient actually has Medicaid look at all the guidelines they recommend... Complete trash. These guidelines make it seems like the actually "care" about the patients, but in reality it's the opposite.

 

[FlowRate]

lamotrigine is 1 in 2500 - even with slow up-titration - and yet we prescribe it with just some words of caution.

I can't find it with quick googling now but I seem to recall some articles implying it's (much) lower than that with the modern slow titration to psychiatric doses. The first hit on google that gives you 1 in 2500 incidence includes RCT's back to 1993 and use for epilepsy. LTG was first approved for use in the US in 1994 so you're going to catch a lot of fast titrations to high doses for epilepsy in that date range.

 

[calvnandhobbs68]

I'm not sure how you extrapolated "foaming at the mouth to testify against other doctors" from anything I've written, but I'll chalk that up to SDN culture.

It's just a legitimate question based on incongruent information. The following was distributed to the dept in the wake of this topic, so again, legitimate question.

Sure you'll find guidelines for all kinds of stuff. I have literally never seen a psychiatrist once do a waist circumference...I barely even did that in primary care clinics. I agree with most of the QTc thing being hysteria and nobody twists themselves into knots about QTc more than psychiatry...even vs the cardiology floor lol. I also very rarely get EKGs on outpatient when I'm starting a low dose second gen antipsychotic, but kids also basically very minimal risk for prolonged QTc to begin with.

Otherwise yeah for all the labs it's 50/50 whether people EVER get them. Comes up with ASD/ID patients in outpatient all the time too who are a beast to get labs on typically unless they're like sedated or in the ER. Am I really gonna stop the risperdal or abilify that keeps them from putting someone through a wall because I can't get a lipid panel? I'll say I recommended doing it and gave them the order but I'm not going to cut it off.

 

[Merovinge]

Sure you'll find guidelines for all kinds of stuff. I have literally never seen a psychiatrist once do a waist circumference...I barely even did that in primary care clinics. I agree with most of the QTc thing being hysteria and nobody twists themselves into knots about QTc more than psychiatry...even vs the cardiology floor lol. I also very rarely get EKGs on outpatient when I'm starting a low dose second gen antipsychotic, but kids also basically very minimal risk for prolonged QTc to begin with.

Otherwise yeah for all the labs it's 50/50 whether people EVER get them. Comes up with ASD/ID patients in outpatient all the time too who are a beast to get labs on typically unless they're like sedated or in the ER. Am I really gonna stop the risperdal or abilify that keeps them from putting someone through a wall because I can't get a lipid panel? I'll say I recommended doing it and gave them the order but I'm not going to cut it off.

Oh yeah, I had family's who noted that their kid had actually punched a phlebotomist before. I don't even write the orders in cases like that, just that we documented the standard of care lab monitoring, why it was not doable in this instance, and everyone agreed the risks outweighed the benefits. I think there's even a good chunk of adult psychiatrists (much less any other field or lay person) who do not understand just how hard it can be to get through a day in the life of a parent for a mod/severe ID or ASD kid who is aggressive.

 

[comp1]

I would strongly recommend against getting waist measurements. That seems really ripe for an assault charge without any major benefit over just a BMI.

 

[Stagg737]

I'm not sure how you extrapolated "foaming at the mouth to testify against other doctors" from anything I've written, but I'll chalk that up to SDN culture.

It's just a legitimate question based on incongruent information. The following was distributed to the dept in the wake of this topic, so again, legitimate question.

View attachment 382377

This document is ridiculous. I agree that I also don't know anyone who does waist circumference. ECG is also unnecessary for most patients and neither the APA or ACC have specific recommendations for ECG monitoring and the FDA only recommends ECG for every patient for IV Haldol. The fact that the guidelines above recommend a baseline ECG but then only "as clinically indicated" for monitoring also implies that the baseline ECG is unnecessary.

The troponins and CRP I think are also misguided. FIN-11 and several other studies have shown some decent evidence that clozapine is actually one of the safer antipsychotics from a cardiac standpoint, even accounting for increased monitoring, and that while we learn about clozapine-induced myocarditis that it's not unique to clozapine at all. That aligns with my clinical experiences as I've seen Haldol, risperidone, quetiapine, and Geodon cause just as many cardiac issues as clozapine.

 

[esob]

I've never seen anyone do waist circumference or been told that we should perform it. The document was distributed without any mandate, though I took it as "this is what HHS is saying the guidelines are and we are falling short."

 

[ClosetCentrist]

I can't find it with quick googling now but I seem to recall some articles implying it's (much) lower than that with the modern slow titration to psychiatric doses. The first hit on google that gives you 1 in 2500 incidence includes RCT's back to 1993 and use for epilepsy. LTG was first approved for use in the US in 1994 so you're going to catch a lot of fast titrations to high doses for epilepsy in that date range.

Hey thanks, always appreciate a correction. I'll see if I can find some more up to date numbers.