Navigating Involuntary Treatment in the Mental Health Setting

by Rhonda Lawes, PhD, RN

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    00:01 Hi, I'm Dr. Rhonda Lawes, and in this portion of the video series, we're going to be talking about how you can navigate involuntary treatment in the mental health setting.

    00:10 Now, imagine someone who, due to their mental health condition, is in a state where they can't recognize they need help or refuse the help they desperately need.

    00:19 This is where involuntary treatment steps in.

    00:23 It's like if you saw someone standing in the middle of the road, oblivious to the oncoming traffic.

    00:28 You'd feel compelled to pull them to safety, right? Well, involuntary treatment acts on a similar principle, but within the context of mental health care.

    00:37 In the mental field, especially when you're dealing with mental health, healthcare professionals sometimes face really tough decisions.

    00:45 So one of the hardest of these decisions is deciding to treat someone without their consent, because they're unable to make informed decisions due to their condition.

    00:54 Now, this could be because they are in danger to themselves or others, or they're unable to take care of even their most basic needs.

    01:01 But here's the thing.

    01:02 It's not about just swooping in and taking over.

    01:05 The process is tightly regulated to protect the patient's rights and to make sure that the treatment is really in their best interest.

    01:13 Now, there's legal standards, safeguards, and checks in place to make sure that this power isn't misused.

    01:18 The idea is to balance the patient's autonomy with the need to prevent harm.

    01:23 Let's begin by emphasizing that phrase again.

    01:26 Providing care in a way that respects a patient's dignity and their rights.

    01:32 This begins by knowing what a patient's rights are.

    01:36 Every patient, whether they have a diagnosed or undiagnosed mental illness, has the same human right to make medical decisions for themselves, including the right to refuse treatment.

    01:47 Now, this is where it gets a little fuzzy, so stay with me.

    01:50 The right to refuse treatment is based on whether or not you're considered capable of making decisions.

    01:56 Now, everyone is assumed to be capable until a court of law determines otherwise.

    02:02 Determining whether someone is capable of making an informed decision about medical decisions is not always clear, and unfortunately, it is not usually medically or legally clear either.

    02:14 Decision-making capacity is defined as a person's ability to process information and make an informed decision about their care in a way that's in line with their beliefs, values, and preferences.

    02:26 From a medical perspective, providers think about an individual's decision-making capacity when they're trying to differentiate between someone whose decision-making may be impaired and someone who's exercising their right to autonomy.

    02:40 Now, some of the ways in which providers differentiate decision-making capacity is by performing many mental status exams.

    02:47 They might also check labs for acute intoxication with substances and so on.

    02:53 Now, since every individual has the right to refuse medical treatment, whether they have a diagnosis of mental illness or not, unless there is a court order in place already.

    03:05 Now, in order to administer treatment, the healthcare provider or system must prove that the individual lacks decision-making capacity to make informed healthcare decisions.

    03:16 Now, let's consider a scenario to help us understand the concept of decision-making capacity and how mental health providers work through gathering evidence to apply for involuntary treatment.

    03:27 Friends of 24-year-old Julia reach out to the crisis center.

    03:31 They are concerned because she's having increasing hallucinations over the last few weeks.

    03:36 She's saying she wants to fly from her rooftop apartment.

    03:40 Local police find her disheveled, pacing, in an agitated state, muttering to herself about wanting to die.

    03:47 Now, she's evaluated at a local mental health facility and found to be disoriented, agitated, and repeating that she wants to fly away forever to die.

    03:57 She's admitted under a 24-hour hold for observation She was given a provisional diagnosis of psychosis because that falls within the DSM five category of schizophrenia spectrum and other psychotic disorders.

    04:11 Now this is just pending the exclusion of other potential causes.

    04:15 During the first 24 hours, Julia will have lab work to determine if there's any medical reasons for her psychosis.

    04:22 She will be tested for any acute substance use or toxins as the cause of her psychosis.

    04:28 She'll be encouraged to rest, eat, and participate in baseline mental health testing to determine her decision-making capacity to make informed medical health decisions.

    04:39 Now, most states have policies that a 24-hour hold is acceptable to determine decision-making capacity before seeking longer retention.

    04:47 Some important questions and documentation happen during this 24-hour hold period, and this is what triggers the involuntary treatment issue.

    04:57 Julia makes a clear statement that indicates a danger to self.

    05:00 If it's determined that she is exhibiting a risk of danger to herself or others, a consideration for a legal application for temporary involuntary commitment will be made, including a forced medication administration.

    05:16 Remember, this is a legal application, not a medical one.

    05:21 Even if a court of law waives Julia's right to autonomy for a time period, it is usually time-limited and it's subject to frequent re-evaluation and it's dependent on her continuing to exhibit a lack of decision-making capacity.

    05:35 These parameters are legal safeguards to ensure that Julia's autonomy is returned to her as soon as possible.

    05:43 As we wrap this topic of involuntary treatment, every state, region, and country has different laws, policies, and forms for how this all works.

    05:54 So you as a prescriber and provider are going to have to become familiar in your own area.

    06:00 Now, what we've reviewed today is the general process.

    06:03 No matter the specific situation, however, when it must be used, when you have to initiate involuntary treatment, here are five best practices that we're going to end this video on.

    06:13 First, assess and document the patient's capacity to make informed medical decisions.

    06:20 Two, assess and document the complete medical and mental history and physical exam.

    06:27 Number three, assess and document the danger to self or others.

    06:33 Number four, assess and document all attempts and interventions to avoid involuntary treatment.

    06:41 And the fifth best practice, assess and document compliance with facility, regional, state, and federal policies and behavioral health crisis guidelines.

    06:53 These are the definitions for capacity versus competence.

    06:57 Capacity refers to an individual's decision making capabilities within a particular situation, such as medical treatment.

    07:04 Competence involves legal determination of an individual's overall ability to make autonomous decisions within broader contexts.

    07:13 When you're assessing capacity, you will need to evaluate the four decision making abilities: understanding, expressing a choice, appreciation, and reasoning.

    07:25 Now, understanding involves the ability to explain the meaning of relevant information, such as a diagnosis and treatment options.

    07:32 A sample question you could use would be: "can you summarize what I just told you about?", and then insert the topic that you're discussing.

    07:41 Expressing a choice refers to the ability to state a decision based on the information provided. A question you could use would be: considering our discussion about, the topic, what would you prefer? Appreciation now.

    07:55 This assesses the ability to relate information to oneself.

    07:58 Sample questions could include things like asking the patient to explain their understanding of their medical condition, the potential benefits of treatment, and the potential risks.

    08:08 The fourth ability is reasoning.

    08:10 Now this involves comparing information and predicting the consequence of choices.

    08:15 Now, sample questions include asking how one treatment option may be better than another, or how a treatment decision may impact daily activities.

    08:24 There are validated instruments to measure capacity, but they're not usually used in routine care.

    08:30 Now, these examples would be the MacArthur Competence Assessment Tool for Treatment, or the Assessment of Capacity for Everyday Decision making.

    08:39 In order for informed consent to hold validity, the patient must demonstrate sufficient decision making capacity.

    About the Lecture

    The lecture Navigating Involuntary Treatment in the Mental Health Setting by Rhonda Lawes, PhD, RN is from the course Role Transitions (APRN).

    Included Quiz Questions

    1. The ability to make informed decisions about care, including the processing of information
    2. The ability to control medical treatment without any external interference
    3. The capability to dictate medical procedures to healthcare providers
    4. The capacity to undergo medical procedures without understanding their implications
    5. The authority to refuse treatment without consequences
    1. Involuntary treatment is regulated to protect patient rights and ensure treatment is in their best interest.
    2. Involuntary treatment can be initiated without any legal oversight to ensure patient safety.
    3. Legal standards and checks exist to empower healthcare providers to make unilateral decisions.
    4. Patients undergoing involuntary treatment have no rights and must comply with all medical decisions.
    5. Healthcare providers do not need to consider patient autonomy when recommending involuntary treatment.
    1. Document attempts and interventions to prevent involuntary treatment
    2. Minimize documentation to avoid legal complications
    3. Disregard patient history and only focus on current symptoms
    4. Avoid evaluating potential danger to self or others to maintain patient confidentiality
    5. Overlook adherence to facility and legal policies to expedite the treatment process
    1. The patient's ability to explain the meaning of relevant information, such as diagnosis and treatment options
    2. The patient's ability to state their decision after reviewing the treatment options
    3. The patients ability to compare information and predict the consequences of choices
    4. The patient's knowledge of the pathophysiology of their medical conditions
    5. The patient's IQ (intelligence quotient) and highest education level achieved

    Author of lecture Navigating Involuntary Treatment in the Mental Health Setting

     Rhonda Lawes, PhD, RN

    Rhonda Lawes, PhD, RN

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