Verbal approach to involuntary psych patients

[u/strawbqu]

I am a newer ER RN in Canada, I’m looking for advice on approaching patients that are placed on an involuntary hold. Specifically with approaching an individual with restraining and chemical sedation (I know.. seems brutal but if you know you know. I’m not sure if this is legally relevant in all countries but it’s how we do it here). I find it difficult particularly with paranoid and manic patients. What is your spiel for the reasoning of the intervention, when you especially know they need it and they are refusing (and ultimately will have no choice but to take the medication and/or be restrained)

I tend to start off with the fact that the doctor needs them to take sedation.. if they are compliant they will not need to be restrained etc..

[u/Old_Glove9292]

Gentle reminder that the World Health Organization considers both forced restraints and involuntary hospitalization to be human rights abuses, and is advocating for those interventions to be banned globally:

https://www.who.int/news/item/10-06-2021-new-who-guidance-seeks-to-put-an-end-to-human-rights-violations-in-mental-health-care

[u/strawbqu → u/Old_Glove9292]

In a perfect world, I would totally agree. But when you have someone charging around the emergency department climbing the walls, throwing chairs at people, spitting in the faces of other patients.. that is unfortunately not safe for anyone. But it is always a last resort.

[u/Old_Glove9292 → u/strawbqu]

Spitting in someone's face is assault. I agree that shouldn't be tolerated, but restraints and involuntary hospitalization are not the answer. Call the police.

[u/arcanistmind → u/Old_Glove9292]

Truthfully, many of these patients lack insight into their conditions and treatment of the precipitating condition will not occur in custody of law enforcement. An elderly patient with a UTI does not need law enforcement as their capacity (or lack thereof) would preclude conviction of any criminal offense. There are times where law enforcement is necessary, this is the place for clinical judgement and de-escalation.

[u/Old_Glove9292 → u/arcanistmind]

An elderly patient with a UTI should never be abused with restraints and seclusion. Clinicians are trained in medicine, and should defer legal matters to law enforcement and the courts. Restraints and seclusion encroach on basic human rights, and suspending those without due process is a human rights violation. It's insane to me how much liberty clinicians take with this stuff. I mean talk about a God complex... The arrogance is unreal.

[u/arcanistmind → u/Old_Glove9292]

I'm largely curious as to your background. I personally struggle with this often working in healthcare and I generally agree with you as it relates to especially patients with dementia as there is currently no effective cure and their experience is obviously terrifying to many of them, which is heartbreaking and a deep ethical dilemma that I do not enjoy. However, we have a duty to care for these people under both the principles of implied and explicit consent from next of kin or legal guardian. I am not sure that restraints and seclusion for the purpose of safety and necessary medical care to alleviate the UTI that is the proximate cause of the confusion constitutes abuse. This may just be that we take the use of the tool seriously and understand the harm of the tool and weigh the risks and benefits of it. Healthcare regularly operates with tools that come with a high risk for abuse. This is why we have accountability, but we do not abandon those in need when we have tools that can alleviate disease and suffering.

Capacity is a critical component in ethical considerations of medical autonomy, which is why it is removed for children and those who lack insight and understanding of their situation. I'm not sure the harm they could do to themselves would be an acceptable alternative. Do we simply allow them to die because they refuse to take medicine that they are incapable of understanding the purpose of? Swaddling an infant is a form of restraint yet it is done routinely to temporarily calm and assist in medical care. Would you have law enforcement swaddle an infant? Anesthesia is a chemical restraint and physical restraints are routinely used in surgery to prevent nerve damage while the patients are under the effects of anesthesia. Would you have all anesthesiologists be law enforcement officers first? Writing this out, it kind of seems like we effectively already do this via licensure. As an RN and paramedic, I have guiding principles of my role and I am authorized by law to assist a licensed provider to utilize restraints in a limited capacity to deliver necessary medical care with provisions to de-escalate them. We as a society routinely already engage in this debate as evidenced by nursing homes limiting the use of side rails to prevent them from acting as restraints.

Licensure and assessment from a professional for the need for temporary emergency use restraints for the immediate safety of a patient or staff is the due process. (In FL, not sure of all other states, but many follow suit) Psychiatric holds greater than 72hrs require a face to face with a judge. Extended (>4hrs violent or 24hrs nonviolent) use of restraints almost always requires a licensed psychiatric specialist (not just a licensed medical provider) and appropriate initiation of involuntary hospitalization and the court required procedures for that or allow the situation to become unsustainable thus requiring re-initiation of emergency measures. Required documentation, accreditation, limitations on the duration of restraints, and the ability to sue for improper use of the tools are the accountability mechanisms.