Mental illness
6. Legal environment
determine if the patient is a danger to themself, others, or property. If so, then the patient is committed to the hospital. The patient becomes an involuntary patient and cannot leave the hospital.
• Within 72 hours of the commitment, the patient has a hearing before a judge. The patient is provided legal counsel whose job is to guard the patient’s rights. The patient’s healthcare team led by the psychiatrist pres- ents evidence why the patient is to remain committed. The judge deter- mines the disposition of the patient.
The judge can also order that the patient receive medication against the patient’s wishes. The order may describe a three-step process for administering medication.
1. The patient is offered medication as a pill or liquid.
2. If the patient refuses, the patient is offered the medication as an injection.
3. If the patient refuses, then the order states that the medication is admin- istered as an injection.
The psychiatrist can at any time discharge the patient or make the patient a voluntary patient if the psychiatrist determines the patient is no longer a danger to themself, others, or property. For example, a patient diagnosed with schizophrenia may become noncompliant with medication, resulting in bizarre behavior. Once the patient becomes medication compliant, then the patient is no longer a danger to themself, others, or property and therefore must be made voluntary.
A voluntary patient may not have the right to immediate discharge from the hospital. Depending on the state law, the patient who wishes to leave the hos- pital can ask the psychiatrist to discharge them. The psychiatrist can refuse to discharge the patient. The patient then signs a document that officially notifies the psychiatrist that the patient wants to be discharged from the hospital. The psychiatrist has 48 hours to respond to the patient’s request. During the 48 hours the psychiatrist assesses the patient to determine if the patient is a danger to themself, others, or property. If so, then the psychiatrist must commit the patient. If not, the psychiatrist must discharge the patient.
Competency to Give Informed Consent
A patient must be competent to give informed consent for treatment and be of age to give consent based on state law, which is commonly 18 years of age. If the patient is not of age to give consent, then the patient’s parents or legal guardian will make the decision for the patient.
For an adult patient, the psychiatric nurse must make sure that the patient is competent to give consent based on assessment of the patient’s mental status.
The patient must
• Be alert and oriented to time, place, person, and situation.
• Be able to be attentive and to concentrate.
• Be able to understand.
• Be able to reason using abstract concepts.
• Be able to reason logically.
• Be able to communicate.
If the patient is not competent to give consent, then the psychiatrist may commit the patient. If the patient remains incompetent after treatment, then a judge will likely appoint a guardian for the patient until the patient is deemed competent by a psychiatrist.
It is important to understand that a patient can be competent even if the patient has been committed to the hospital by a judge. Commitment means that the patient is a danger to themself, others, or property and does not mean that the patient is incompetent.
Patient rights
The American Hospital Association’s Patient’s Bill of Rights, the American Nurses Association’s Code of Ethics, and Health Insurance Portability and Accountability Act (HIPAA) regulations specify patient’s rights. Within these regulations, a hospital has the right to create and enforce policies that limit a patient’s right compared to a person who is not hospitalized. For example, smoking might be prohibited and the patient’s diet may be restricted to food provided by the hospital.
The patient has a right to
• All communications between the patient and healthcare team, which are confidential.
• Their records, which are confidential.
• Refuse to have their photo taken.
• Decide who, if anyone, has access to their record. Written consent must be acquired before any information, including if the patient is a patient at the hospital, can be released.
• Rescind consent to share information.
patient information, these are:
1. A patient states they will harm another person upon discharge and the patient is being discharged. The healthcare team has a duty to warn the prospective victim.
2. A court order.
3. Education. Patient information contained in the patient’s record can be used for educational purpose as long as the patient’s identity is expunged from the record.
seclusion and restraints
Seclusion is placing the patient in a room that isolates the patient from other patients when the patient becomes agitated and is at risk of injuring themself or others. The seclusion room typically has a bed. There is nothing in the room that can be used by the patient to injure themself.
Open seclusion can be used to give the patient a time-out to compose them- self away from the distraction and stimulus of the unit. In this scenario, the seclu- sion door is open and the patient is free to leave the seclusion room at any time.
Locked seclusion is placing the patient in the seclusion room and locking the door, preventing the patient from leaving the room if the patient becomes vio- lent. The key to the door must always be inserted in the lock so that the door can be opened in an emergency.
Restraint is physically preventing the patient from injuring themself or oth- ers through the use of force such as holding a patient or strapping the patient to a bed. Placing a patient in a bed and raising four rails is also considered a restraint because the rails prevent the patient from leaving the bed.
Hospital policy will dictate who can place a patient in seclusion, locked seclusion, and restraints. For example, a registered nurse can direct the staff to place the patient in seclusion without a follow-up assessment by a practitioner.
Likewise in some hospitals, a registered nurse can place the patient in locked seclusion or restraints; however, a practitioner must be notified and assess the patient within an hour and determine if the patient should remain in locked seclusion or restraints.
Special procedures must be followed if the patient is in restraints. Depending on hospital policy, the patient must:
• Be placed on consent observation.
• Be asked if they need to use the toilet or want water or food frequently.
• Have their vital signs taken at a prescribed frequency.
• Have the patient’s circulation assessed every 15 minutes.
• Have the practitioner assess the patient and renew the order at a set fre- quency depending on the age of the patient.
• Be assessed and the restraint must be documented every 15 minutes.
• Have the practitioner release the patient from restraints once the patient is no longer a risk of injuring themself or others.
Chemical restraint is restraining the patient through the use of medication, which is illegal. Practitioners commonly prescribe Ativan 2 mg, Haldol 5 mg, and Cogentin 1 mg to the patient for extreme agitation, which is part of the patient’s treatment plan. This combination of medication has a calming effect and reduces the need for locked seclusion and restraints. The patient is offered the medication by mouth or by injection. Medication that is part of the patient’s treatment plan is not considered a chemical restraint.