Refusal of Emergency Psychiatric Treatment

May 1, 2010 | Healthcare Risk, Quality, & Safety Guidance

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No issue provokes more controversy and contention in the mental health field than addressing a patient’s refusal of emergency psychiatric treatment. Dealing with a refusal can cause conflicts involving the patient and the patient’s physicians, caregivers, and family. The healthcare facility must also ensure that its handling of a patient’s refusal is in compliance with state and federal statutes and regulations, as well as case law involving treatment refusal. In some situations, mental health advocates may intervene to promote the patient’s fundamental right to choose or decline treatment.

Patients and their advocates may refuse treatment for a variety of reasons. They may be concerned about the side effects from medications commonly used in the treatment of patients with mental disorders. They may refuse treatment to avoid the stigma of being labeled as a patient with a mental disability. Patients may refuse treatment because they distrust the physician recommending the treatment. Or patients may deny altogether that they have a psychiatric disorder. There may be other reasons, too.

Whatever the reason, providers are caught in a conflict between those who say a patient has a right to refuse treatment and those who say the patient’s needs are being ignored by denying treatment and preventing the restoration of the patient to his or her autonomous self.

The conflict may culminate in involuntary admission if the patient is deemed to be a danger to him- or herself or to others. State statutes spell out the criteria for involuntary hospitalization, generally relying on the “danger to self or others” standard to allow clinicians to override treatment refusal without a patient’s consent.

To avoid having situations escalate into a crisis requiring involuntary admission, providers must follow a series of measures to build a therapeutic alliance with the patient. If refusal occurs, caregivers must know the process for handling such refusals. Risk management input and education on handling refusal for treatment is essential before a crisis occurs. Indeed, failure to adhere to important practices—for example, obtaining informed consent, determining a patient’s decision-making capacity, and ensuring complete documentation in the medical...

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