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Treatment Refusal 

Treatment Refusal
Chapter:
Treatment Refusal
Author(s):

Ariana Nesbit

, Steven K. Hoge

, and Debra A. Pinals

DOI:
10.1093/med/9780199387106.003.0007
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Approximately 10% of psychiatric inpatients refuse antipsychotic medications at some point during their hospitalization.1,2,3,4 These situations are often difficult for treating psychiatrists, as well as for other staff involved in patient care, and can lead to frustration, helplessness, and anger. However, if managed well, treatment refusal serves as an opportunity to gain a better understanding of the patient’s concerns, values, and wishes, which in turn can lead to a stronger therapeutic alliance (defined as a cooperative working relationship between client and therapist and considered by many to be an essential aspect of successful therapy5).

Vignette 1: Involuntarily Hospitalized Patient

Mr. V., a 22-year-old man, is brought to the hospital by emergency medical services after threatening his father with a kitchen knife. According to his father, over the past 3 weeks, Mr. V. has become increasingly disorganized and withdrawn, and he has been talking loudly to himself in his room. In the emergency department, Mr. V. is malodorous, is responding to auditory hallucinations, and states that he has been hearing the voice of the Devil telling him that he must kill his father. He refuses to sign himself into the hospital, stating that he is not ill. He is admitted involuntarily on the grounds of risk of harm to others due to mental illness. Once in the hospital, Mr. V. refuses to take prescribed antipsychotic medications because he is convinced that the staff members are working with the Devil and are trying to poison him. As the period of emergency commitment expires, the inpatient psychiatrist files for civil commitment, and a judge orders a continuation of the involuntary inpatient commitment, agreeing that Mr. V. poses an imminent risk of harm to his father.

Right to Refuse Treatment

History

As discussed in chapter 5, all adult patients are presumed to be competent to make decisions about their care on the basis of the doctrine of informed consent and the related concept of informed refusal. In principle, patients voluntarily admitted to psychiatric institutions have the right to refuse treatment, as their voluntary status allows them to choose to leave the hospital.6 Historically, however, patients involuntarily committed to psychiatric hospitals have had significantly more limited rights than voluntarily hospitalized patients and those in outpatient settings.2 For much of the 20th century, patients were committed to psychiatric hospitals on the basis of their need for treatment. Involuntary civil commitment was understood to be based on paternalism, with the state exercising its parens patriae power to provide care for those with mental disorders. In that context, it was clear that the purpose of civil commitment was treatment, and persons who were in need of treatment for mental illness but refused it could be hospitalized against their will. As a result of reforms in the 1960s and 1970s, however, civil commitment came to be justified by the state’s police powers, with the criteria for commitment based on dangerousness.2,6,7,8 Since the justification for commitment was no longer the need for treatment, it was possible to question whether the state had the authority to involuntarily treat a patient who had been committed. (Parens patriae, police powers, and civil commitment are described in detail in chapters 1 and 2.) In Vignette 1, Mr. V. is committed to the hospital on the grounds that he poses a danger to others because of mental illness, which in most states is not a sufficient basis for treating him against his will.

Legal Criteria

Currently, every jurisdiction recognizes that all patients who have not otherwise been found to be incompetent (or for whom court-ordered treatment is not required for other specific reasons) have the right to refuse treatment. How these rights are defined and managed depends on the jurisdiction, the type of facility, and the patient’s legal status.2,9 There are two legal models for dealing with treatment refusal: the rights-driven model and the treatment-driven model (see Table 7.1).10

Table 7.1. Procedures for Adjudication of Treatment Refusal, According to State

Procedure for Adjudication

State

Involuntary medication is permitted at the time of admission to a state hospital (often with the requirement of approval by an MD or clinical committee)

GA, MD, MI, MO, NJ, NC, PA, SC, TN, WV

An administrative hearing (not through the court system) is required for involuntary medication

ME, NE, NV, NH

Involuntary medication is allowed upon judicial commitment

AL, AR, AZ, DE, DC, KS, ID, IN, LA, MI, MT, WI, WY, UT

Involuntary medication is allowed upon judicial commitment provided that evidence of the need for medication is presented

MN, FL, IA, OK, RI, WA

Involuntary medication requires a separate judicial hearing, which often occurs at the time of commitment

AK, IL, TX

Involuntary medication requires a separate judicial hearing, which occurs after commitment

CA, CO, HI, KY, MA, NY, ND, OH, OR, SD, VT, VA

Involuntary medication requires a separate judicial order for a guardian

CT, NM

Source: The information presented in the table is from Beinner, 2007.10

The treatment-driven model emphasizes protection of the patient’s right to adequate treatment during involuntary hospitalization. A patient, under this model, has a limited right to refuse care if it is determined to be inappropriate. Because the standard is based on the appropriateness of treatment, determinations are generally left in the hands of psychiatrists or multidisciplinary panels. Formal judicial review is uncommon. As long as the treatment is deemed appropriate by the reviewer, it will be allowed to proceed. Federal courts tend to favor the treatment-driven model, because in several cases, the U.S. Supreme Court has found that determinations of appropriateness based on professional judgment sufficiently protect patients’ rights as defined by the Constitution.11 Constitutional rights that were considered in these federal court rulings include rights to free speech, freedom from cruel and unusual punishment, equal protection, and due process, along with consideration of issues related to the right to privacy, which some courts have found to arise from several other constitutional rights.2,6,12

Many states recognize more extensive rights than those established by the U.S. Constitution and federal courts and have thus adopted rights-driven models of adjudication. These models are based on state statutory law, state constitutions, or common law rights.2,6,13 The rights-driven approach emphasizes individual autonomy and attempts to minimize differences in the right to refuse treatment between voluntarily and involuntarily hospitalized patients. As discussed in chapter 6, in general, only patients who lack treatment-specific decision-making capacity can be treated against their will, except in the case of an emergency. Advocates of the rights-driven model argue that committed patients should have the same protection. Therefore, in contrast to the treatment-driven model, in which committed patients are allowed to refuse only inappropriate treatment, the rights-driven model stipulates that treatment refusal, in the absence of an emergency, can be overridden only if the patient is deemed incompetent. Since a determination of competence requires a legal judgment, the adjudication of the question is assigned to the court system.2,6 Patients are entitled to legal representation and have the full panoply of rights associated with legal due process: the right to legal representation, the right to timely notice, the rights to call witnesses and to cross-examine the hospital’s witnesses, and the right to an expert to assist the patient’s attorney. When attempting to override a patient’s treatment refusal, a psychiatrist practicing in a state with a rights-driven model should be prepared to testify regarding the patient’s lack of decision-making capacity and need for treatment. For example, in our case vignette, the psychiatrist treating Mr. V. would explain in court that Mr. V. lacks insight into his mental illness, that he is unable to appreciate his need for treatment or make rational decisions about it, and that the treatment is medically appropriate.

States with rights-driven models differ with regard to how treatment decisions are made following an adjudication of incompetence. In some jurisdictions, a guardian is appointed to make treatment decisions on behalf of an incompetent patient, as would occur for an incompetent medical or surgical patient. In other jurisdictions, appellate courts have expressed concern that family members, who usually act as guardians, might not adequately represent the interests of incompetent psychiatric patients. Courts in those jurisdictions have ruled that only judges are sufficiently neutral and objective to make treatment decisions, particularly for decisions about the use of ECT or antipsychotic medications.

There are competing formulations regarding how decisions about treatment for incompetent patients should be made. The treatment decisions may be based on the patient’s “best interests.” Using this standard of surrogate decision-making, the court or guardian would make treatment decisions based on what a reasonable person would choose as being in the patient’s best interests. Alternatively, when a court is the decision-maker, the court may make more individualized and subjective treatment decisions based on what the patient would want if he or she were competent. This “substituted judgment” approach has evolved through case law to require consideration of evidence such as family and religious beliefs that may influence the patient’s treatment decisions, the patient’s stated preferences when competent, the prognosis with and without treatment, and possible side effects of the treatment.6,14 Guardianship and the standards for surrogate decision making are discussed in detail in chapter 6.

In accordance with the doctrine of informed consent, competent patients must be provided with information that allows them to make their own decisions about medical care. The patient can then consent to or refuse the proposed treatment, with the potential for the refusal to be overridden if the patient is deemed to lack the capacity to make an informed decision about treatment. There are a few exceptions that allow the physician to bypass the full process of obtaining informed consent, whether the patient is agreeing to or refusing treatment, and for which formal adjudication of treatment refusal is not required. For example, physicians are allowed to provide treatment as necessary without obtaining full informed consent in emergency situations.

In the case vignette, if Mr. V. attacked his father or anyone else in the hospital, it would be appropriate to administer medications involuntarily on an emergency basis because of concerns about imminent danger (in which case, the physician would be likely to administer intramuscular or sublingual medication). To consider a situation an emergency, some courts require either the threat or the actual occurrence of significant bodily injury to the patient or another party. Other courts use a broader definition of emergency, including severe pain and the likelihood of rapid clinical deterioration as emergency situations.6 As discussed in chapter 5, the emergency exception extends only to treatment that is necessary to stabilize the patient’s clinical condition; it does not apply to treatment that is ongoing once the emergency has passed. Not infrequently, however, emergency treatment will lead to sufficient resolution of the symptoms that the patient regains capacity and can consent to, or explicitly refuse, the treatment.

There are variations in the approaches to treatment refusal in different forensic settings. (In this context, “forensic settings” refers to correctional settings, including jails, prisons, and forensic facilities for the detention of psychiatric patients before adjudication of guilt or after a finding of not guilty by reason of insanity in the criminal justice system.) For example, rulings in cases such as Washington v. Harper and U.S. v. Loughner have determined when treatment refusal on the part of prisoners and pretrial detainees, respectively, can be overridden through various provisions and procedures.15,16 In Washington v. Harper (1990), the Supreme Court addressed the question of whether a man with a mental disorder could be involuntarily treated with antipsychotic medications. The Court ruled that prisoners who were found to present as “dangerous” to the institution and for whom medication was medically appropriate could be involuntarily treated. In the Loughner case, the U.S. Ninth Circuit Court of Appeals found that pretrial detainees could be involuntarily medicated under the same circumstances.15,16,17

In recent years, the U.S. Supreme Court has ruled that in limited circumstances a criminal defendant can be involuntarily medicated for the purpose of restoration of competence to stand trial.18 A particularly controversial and ethically complicated situation arises when a prisoner refuses treatment that could restore competence to be executed.19

Prevalence and Outcome of Treatment Refusal

Across psychiatric treatment settings, rates of refusal of psychotropic medication range from 2% to 44%. When forensic settings are excluded, approximately 10% of psychiatric inpatients refuse antipsychotic medications at some point during the hospital course.1,2,3,4 Patients who refuse recommended medication generally lack insight, have more negative attitudes toward treatment, and are more severely psychotic than patients who provide consent to such treatment. Inconsistently reported risk factors for treatment refusal include higher socioeconomic status, lack of insurance, higher prescribed doses of antipsychotic medications, lack of prescribed anti-parkinsonian agents, and a greater number of past psychiatric hospitalizations.1,4

Patients may refuse treatment for a variety of reasons (see Box 7.1). Some reasons are rational, such as those based on side effects or religious beliefs. Others are irrational and result from delusional or other disordered thinking.

Although many patients will refuse treatment at some point during their hospitalization, most episodes of treatment refusal are short and self-limited. About 50% to 90% of refusals in civil settings last for less than 1 week.20 In one prospective study, researchers interviewed psychiatric inpatients who voluntarily accepted treatment after initially refusing it. Of these 38 patients, 15 accepted treatment because, with encouragement from staff and/or family, they became convinced that the medication would be beneficial to them. Twelve patients decided to take the medication because they believed that it would help them to obtain a desired objective, such as discharge from the hospital. The remaining patients offered a variety of other explanations for acceptance of treatment.1

In the less common case of persistent refusal, even in states with rights-driven models, where refusals generally last longer than in states with treatment-driven systems (13.0 days vs. 2.8 days), the refusal is overturned in more than 90% of cases.1,2,4,21

In the vignette, if Mr. V. is in a jurisdiction with a rights-driven model of adjudication, at either his commitment hearing or a separate court proceeding, the judge may determine whether Mr. V. can be treated against his will. If Mr. V. is in a jurisdiction with a treatment-driven model, he is likely to receive treatment earlier because a judicial determination of incompetence is not required. Studies have shown that rights-driven models of review can result in delayed treatment, which lead to prolonged hospitalization, as well as to considerable costs for the time devoted to each case by judges, lawyers, paralegals, psychiatrists, and independent psychiatric evaluators.1,22,23 In addition to the economic costs, other costs include the potential for prolonged suffering related to untreated illness; the risk of an increased number of assaults, requiring use of restraints and seclusion; and damage to the therapeutic relationship caused by “adversarialization” of the process.3,22 Proponents of treatment-driven models argue that these costs can be diminished with more efficient and informal procedures without any significant change in the clinical outcome because, as discussed above, the vast majority of refusals are overturned regardless of the system of review and decision making. Furthermore, it has been argued that clinicians could spend more time actually working with patients if they did not have to dedicate so many hours to paperwork required by the court.22

However, it has also been argued that rights-driven models provide incentives for psychiatrists to more thoroughly discuss medication decisions with their patients.22 Moreover, proponents of rights-driven judicial mechanisms point out that these systems can help patients feel that they have a voice in a clinician-dominated process.11 In one rights-driven setting, by the end of the study period, most patients decided to take medications voluntarily after discussion with their psychiatrists.1 In this study, only 18% of treatment refusers were brought before a court, where their refusal was consistently overridden. A significant number of patients, 23%, were discharged from the hospital without treatment.

Patients who require court-ordered medication in the hospital are at increased risk for nonadherence after discharge, as well as for treatment-resistant illness.20 It is important to keep in mind that a patient’s perception of coercion can be reduced by providing information about medications and the process of adjudication.9

Assessment and Management of Treatment Refusal

When a patient refuses recommended treatment, the clinician must first assess the reasons for refusal (see Box 7.1). The appropriateness of the treatment should be considered, particularly if the need for a specific treatment is not clear-cut and the risk–benefit ratio is narrow. A thorough review of the records, including the patient’s history, diagnosis, and response to previous medication trials, should be performed. Current and previous side effects should be explored, including the use of appropriate laboratory tests and instruments such as the Abnormal Involuntary Movement Scale.

Throughout the assessment of the refusal and the care that follows, the psychiatrist should engage the patient. Clinicians often make the mistake of shifting too quickly into an adversarial role and viewing the refusal as a legal problem to be overcome as quickly as possible. Instead, the treating clinician should consider the refusal as a potential opportunity to better understand the patient’s values and concerns, which in turn may help to strengthen the therapeutic alliance. Legal or administrative proceedings should not be instituted unless absolutely necessary; even if an adversarial mechanism is required, it is important to continue to engage the patient and to try to maintain a working alliance. Throughout all stages of management, communications relevant to the patient’s refusal and the facts pertinent to the clinician’s decisions should be documented, including indications for treatment, response to prior treatment, reasons that the refusal is due to the illness, and any legal proceedings.6 When a patient declines the medications that have been prescribed, the psychiatrist should first engage the patient in a dialogue about treatment with the goal of helping the patient to accept the proposed treatment or a reasonable alternative.24 These discussions may provide opportunities for the psychiatrist to address bothersome side effects and clarify misconceptions about medication. They may also provide an opening for the patient to express frustration and voice unmet needs that may underlie the treatment refusal.6

Shared decision-making and self-directed care can be helpful techniques to use in such discussions.24 It can also be helpful to figure out what the patient’s specific goals are—for example, to be able to go back to work—and to focus discussions on how the proposed treatment can help him or her achieve these goals. Negotiations may be more successful if other staff and family members are involved in helping the patient recognize the potential benefits of treatment.6 Throughout, the psychiatrist should be clear that he or she is acting in the best interest of the patient.

Clinicians should assess their patients’ side effects from medications. As noted, patients may refuse medications because of side effects or other very real and practical concerns about their medications (see Table 7.1).3 Because there are numerous ways to ameliorate side effects, such as changing the type of medication, overall dose, or dosing schedule or adding adjunctive medications, it is important to address the concerns about side effects that patients raise. Concerns about side effects should rarely be the reason for serious mental illness to go without long-term treatment in the absence of further justification for avoiding medication.

Patients may have had negative experiences with medications in the past and may presume, sometimes correctly, that they will have similar effects from the medication currently being prescribed. It is important to realize that seemingly minor and benign effects, such as constipation or dry mouth, may be cause for distress, depending on the patient’s specific concerns. For example, a clinician may assume that a patient of normal weight would see that the benefits from an antipsychotic that would allow the patient to live independently in the community clearly outweigh the risk of minor weight gain; however, the patient may find this side effect unacceptable.6 Similarly, if a patient places a high value on activities such as reading or watching television, blurring of vision related to the anticholinergic properties of some antipsychotics may be intolerable. Of note, patients tend to find side effects more disturbing if they are not prepared to expect them. Patients may also experience adverse effects in idiosyncratic ways and develop delusional beliefs about the effects.3,6 For example, if not warned about the potential side effect of postural hypotension, a patient with paranoia who experiences dizziness may view it as a sign that he or she is being poisoned and may therefore refuse treatment.

Extrapyramidal side effects, particularly akathisia and dystonias and dyskinesias that affect the muscles of the eyes, mouth, and throat, are often the most disturbing adverse reactions to antipsychotic medications. Some patients may also experience a dysphoric response to antipsychotics, which has specifically been associated with poor compliance and a poor prognosis.25 Prescribing clinicians should always ask patients about impotence, decreased libido, and retrograde ejaculation in relation to medication because they may be embarrassed to mention these particular effects6 and simply stop taking the medication because of them.

There are also several common illness-related reasons that patients refuse medication. Patients who do not believe that they have an illness are unlikely to accept treatment. Not surprisingly, poor insight is a major risk factor for medication refusal.1,19,26,27,28 Similarly, patients with mania may feel wonderful and therefore see no reason why they should take medications that will make them feel less euphoric. As mentioned above, patients may also refuse treatment on the basis of delusional beliefs; for example, they may think that the prescribing physician is attempting to poison them.6

Treatment refusal can also originate from issues related to the doctor–patient relationship. A poor therapeutic alliance is consistently associated with poor adherence to treatment.27,28,29 Specific issues may involve transference (defined as the displacement or projection onto the therapist of unconscious feelings and wishes originally directed toward important persons, such as parents, in the patient’s childhood5) or a breakdown in trust—if, for example, the psychiatrist breaches confidentiality or does not meet with the patient when promised. A patient who has little control over other areas of his or her life may refuse medication as a way to exert autonomy. Refusal may also be a way for the patient to communicate frustration or obtain more attention from staff.6

The context of the refusal may suggest the reasons for it. Patients on inpatient units are most likely to refuse medications shortly after admission, often because they do not believe that they need to be hospitalized.1 Reasons that patients may start refusing medications later in the course of hospitalization include increasing distrust of staff and development of negative transference or other interpersonal difficulties as discussed above; in less verbal patients, refusal may be a stereotypic response to distress.6,14 In forensic settings, prisoners may refuse medications with the hope of being transferred to a hospital or in order to remain incompetent to stand trial.

Persistent Refusal

If negotiations regarding treatment refusal are unsuccessful, two options exist: discharge the patient against medical advice or use formal mechanisms in an attempt to resolve the issue. If the treatment facility is in a jurisdiction where an override of refusal requires a determination of incompetence, and the patient seems to have the capacity to refuse the treatment, as described in chapter 6, the clinician may be forced to discharge the patient against medical advice or to continue to work with the patient in an unmedicated or suboptimally medicated state. There are also situations in which it may be preferable to respect the wishes of the patient. For example, when the risk of harm without treatment is low, discharge may be preferable to putting the patient through an adversarial process that could exacerbate any distrust of the psychiatric system, increase the chance that the patient will avoid seeking help when needed in the future, and reinforce the patient’s opposition to medication should the judge find the patient competent or concur with the patient’s refusal. Even if the decision is to discharge the patient, the discharge should not constitute an abandonment of the patient; follow-up care should still be provided.6

Formal mechanisms to adjudicate treatment refusal should be used if negotiations fail, if discharge is not a safe option, if the patient continues to meet criteria for commitment, and if the patient does not appear to be competent to make treatment decisions. Even during this adversarial process, the clinician should attempt to preserve the therapeutic alliance, candidly informing the patient of the decision to try to override his or her refusal and the reasons for that decision. The clinician should describe the formal procedures to the patient, including the fact that conversations and clinical information will not be kept confidential, since this information will be necessary for adjudication by the consultants or the judge. The patient should be encouraged to participate in the adjudication process, which can be less coercive and more therapeutic if the patient has a way to express his or her thoughts and wishes during the process.30 Throughout the process of adjudication, it is important to continue the dialogue and negotiation with the patient, not only to maintain the therapeutic alliance but also because, as discussed above, many patients will eventually decide to take medications voluntarily.

When formally adjudicated, treatment refusal is overridden in the vast majority of cases. Once the court or other decision-making body decides to override the refusal, the judgment should be explained to the patient. The treating psychiatrist must then make provisions to offer and ultimately administer the medications in accordance with the authorized plan. At this point, even when the proposed medication is available only in oral form, most patients will accept it and eventually come to acknowledge the need for treatment.31 Although it is not legally required, the prescribing clinician should continue to engage the patient in a discussion of decisions about treatment and to respect his or her wishes about treatment whenever possible in order to maintain or repair the alliance and increase the likelihood of long-term adherence to treatment.

If the patient does voluntarily accept treatment, it is important to re-explore reasons for the initial refusal in order to facilitate longer-term treatment planning. Elucidating and documenting these reasons can be particularly helpful in the case of relapse and future hospitalizations, both for negotiating treatment and for use in legal proceedings, particularly in jurisdictions where substituted-judgment standards are used.6 Psychiatric advance directives and joint crisis plans can also be helpful in planning for future refusals. These forms allow patients to document their treatment preferences should they be deemed incompetent to make treatment decisions in the future.32,33

Refusal of Antipsychotic Medications in Outpatient Settings

The mental health community has debated the concept and practice of outpatient commitment for several decades. This type of mandated treatment is designed to prevent recurrent hospitalization by addressing the issue of treatment refusal in outpatient settings.34,35 Currently, all states except for Connecticut, Maryland, Massachusetts, New Mexico, and Tennessee have some form of civil outpatient commitment; however, specific statutes vary substantially, and only a minority of states actually implement such laws.36,37 These court orders often require patients to adhere to prescribed treatment in order to maintain outpatient status; however, the requirements are difficult to enforce because there are no provisions for involuntary medication administration. Outcomes of this intervention continue to be debated, especially given that in the few studies that compared mandated with voluntary treatment, success was seemingly dependent on effective implementation and availability of intensive community-based services. The results of these studies are difficult to generalize to other jurisdictions with different statutes, funding, and locally available services.38 Additional discussion of outpatient commitment can be found in chapter 2.

Refusal of Antipsychotic Medications in Nursing Homes

Antipsychotic medication use in nursing homes has gained attention in recent decades. Antipsychotics are frequently used to address the behavioral and psychological symptoms of dementia, despite evidence suggesting a limited benefit of these medications in patients with dementia.39 Antipsychotic use in the elderly is particularly problematic because this population is at increased risk for such adverse effects as orthostatic hypotension, sedation, cardiovascular events, and falls. Moreover, the Food and Drug Administration has issued a black-box warning concerning the risk of death associated with the use of atypical antipsychotics in elderly patients with dementia.40,41

Before the Omnibus Budget Reconciliation Act of 1987 (OBRA ’87), antipsychotics were used freely in nursing homes as a form of “chemical restraint,” often without an appropriate diagnosis and sometimes for the convenience of staff. OBRA ’87 laid out revisions to the statutory Medicare and Medicaid requirements for nursing homes, including limitations on the use of antipsychotic medications. This act was intended to protect nursing home residents from inappropriate or excessive use of antipsychotics.40 As in other settings, treatment refusal in nursing homes can occur. In most jurisdictions, legal remedies are available to address treatment refusal in a nursing home, allowing the consulting psychiatrist to obtain authorization of treatment over the patient’s objection.

Federal laws also assert that nursing home residents or their legal health care decision makers must provide informed consent before they are given any medication, including an antipsychotic.42 Federal legislation allows individual states to decide the process by which a patient is deemed incompetent. Some states have specific regulations regarding use of antipsychotics in incompetent nursing home patients. For example, in Massachusetts, where antipsychotics are considered “extraordinary treatment,” administration of an antipsychotic medication over the objection of the patient or health care proxy or in a person who is thought to lack the ability to make treatment decisions requires a specific probate court hearing, during which the judge must make a determination of incompetence and then authorize a medication treatment plan. In Massachusetts, the substituted-judgment paradigm is used to make the decision about the treatment plan, which means that the judge hears testimony and determines what treatment the incompetent person would want if he or she were competent.43

Refusal of Electroconvulsive Therapy

Electroconvulsive therapy (ECT) is an effective therapy for many psychiatric disorders and is considered a first-line treatment for catatonia, psychosis in a patient with neuroleptic malignant syndrome, and mania during pregnancy.44 Despite the proven efficacy of ECT, many states heavily regulate its use. The reasons for government involvement in and regulation of ECT parallel the reasons for regulation of antipsychotic use in a patient who refuses such treatment, including advocacy by patients’ rights groups and prior misuse of the treatment. However, in contrast to involuntary antipsychotic treatment, which all the states address in administrative codes and/or legislation, 33 jurisdictions in the United States do not specifically comment on involuntary ECT.45 In these jurisdictions, providers should follow the American Psychiatric Association guidelines and requirements by the Joint Commission on Accreditation of Health Care Organizations, which include evaluation of and agreement on the appropriateness of ECT by a psychiatrist with ECT privileges.44,45,46

In the absence of specific legislation or regulatory provisions, involuntary treatment with ECT should proceed by the same mechanism as involuntary treatment with any other medical therapy or procedure in that jurisdiction. The state statutes that do address ECT vary widely. For example, in some states, patients who are involuntarily committed to a hospital are not eligible to receive ECT, whereas other states allow involuntary ECT if a court finds clear and convincing evidence that the patient is incompetent to make treatment decisions and that the treatment is appropriate on the basis of substituted judgment.45

Conclusion

The right to refuse treatment with antipsychotic medications has only recently been recognized. When a patient refuses recommended treatment, psychiatrists and other treating clinicians should explore the reasons for refusal and attempt to negotiate treatment with the patient. If such negotiations are unsuccessful, the treatment team may either discharge the patient or attempt to override the treatment refusal through formal mechanisms. There are two models of mechanisms for adjudication of treatment refusal: the rights-driven model and the treatment-driven model. The mechanism used varies depending on the jurisdiction and treatment setting, and treating clinicians must be aware of local practices, which are driven generally by case law, policy, and/or statutory requirements. Regardless of the outcome, treating clinicians should attempt to maintain a positive therapeutic alliance, use shared-decision making to reach an agreement, engage patients even in adversarial processes, and when appropriate, plan for future treatment refusals as part of working with patients over the long-term. Refusal of ECT and refusal of antipsychotic medications in outpatient settings and nursing homes are handled in a variety of ways, depending on the location of practice, and readers should be familiar with the laws in their jurisdiction.

Frequently Asked Questions

Is a patient who is involuntarily committed to a hospital still able to refuse antipsychotic medication?

The procedure for treating a patient involuntarily with antipsychotic medications varies according to the location and type of hospital the patient is committed to, and readers should be familiar with the legal or administrative mechanisms relevant to their jurisdiction (see Table 7.1). In some states, involuntary treatment can begin after an administrative hearing within the hospital, which does not involve the legal system. In other states, involuntary treatment requires a judicial hearing, which may occur only after commitment to the hospital.

Why are the procedures for involuntary psychiatric treatment, particularly with antipsychotics, different from the procedures for involuntary treatment with other medical therapies and surgical procedures?

Historically, mental health patients have had very limited rights to refuse treatment. Over the past century, however, many jurisdictions have started to offer greater protections for mentally ill patients who refuse treatment, on the basis of concerns about the quality of care delivered in psychiatric institutions, the risk of tardive dyskinesia, distrust of the motives of family members authorizing treatment, and the view of some courts that antipsychotic treatment is especially intrusive, affecting thought. These jurisdictions use competence as the criterion for decisions about treatment refusal. In other jurisdictions, treatment refusal by a psychiatric patient who is competent may be overturned if it is deemed appropriate to do so, and the patient may be treated involuntarily on the determination of a single doctor or a panel. These less stringent protections are justified on the grounds that the person has already been committed, that commitment is intended for treatment, and that the state has an interest in providing that treatment. The patient who is refusing treatment has an interest in receiving appropriate treatment but not in refusing treatment altogether.

Can you treat a patient with electroconvulsive therapy against his or her will?

Many states address involuntary ECT in specific statutes, and these statutes vary widely: some states do not allow any involuntarily committed patients to receive ECT, whereas others allow involuntary ECT for patients who are deemed to be incompetent and for whom treatment is believed to be appropriate on the basis of a substituted-judgment decision-making process.

Is there any way to force a patient to continue taking prescribed antipsychotics as an outpatient?

Almost all states have some form of mandated outpatient treatment, usually referred to as “outpatient commitment.” However, there is no form of mandated outpatient treatment that provides for forced administration of medications. Outpatient commitment statutes, which vary widely, are difficult to enforce, and few are actually implemented.

Are there things that a clinician can do to try to make the relationship with a treatment-refusing patient less adversarial?

Yes. Before seeking formal adjudication of the treatment refusal, the clinician should carefully assess the reasons for the refusal, engage the patient in discussions about his or her treatment, negotiate treatment, and try to use the refusal as an opportunity to learn more about the patient’s values and concerns, which may help strengthen the therapeutic alliance. Even if a legal or administrative proceeding is ultimately required, it is important to continue to engage the patient and try to maintain the therapeutic alliance throughout the process.

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