The Three R’s for Psychiatric Hospital Patients:
Rights, Rules, and Responsibilities
By Ann Palmer
When in a psychiatric facility, a patient must follow hospital
rules. Accordingly, the hospitalized patient has rights
while hospitalized. The following are selected items of
the Patients’ Bill of Rights. All boldface type is
added to set off the important points.
As a patient in a hospital in New York State, you have the
right, consistent with law, to:
. Receive considerate and respectful care in a clean and
safe environment free of unnecessary restraints.
. Know the names, positions and functions of any hospital
staff involved in your care and refuse their treatment,
examination, or observation.
. Receive complete information about your diagnosis, treatment
and prognosis.
. Receive all the information that you need to give informed
consent for any proposed procedure or treatment. This information
shall include the possible risks and benefits of the procedure
or treatment.
. Refuse treatment and be told what effect this may have
on your health.
A patient’s right to "considerate and respectful
care" (#3, above) is a reflection of the type and level
of treatment received while in the hospital. This refers
to treatment by a psychiatrist, the ward nurses, mental
health aides, mental health assistants, recreational and
occupational therapists, social workers, phlebotomists,
and any other associated health care personnel involved
in the patient’’s care while in the hospital.
Patients have a right to know who is treating them (#6).
For this purpose, staff ID tags should be worn prominently
and at all times.
The type of treatment (#6, #8, #9, #11) the patient receives
is most commonly psychotropic medication. This includes
antipsychotic medications: sedatives, tranquilizers and
hypnotics. They affect mental activity, "psychological
functions, behavior or experience" (Glossary of Mental
Health Terms, p. 10). Many people may find the effects of
these medications tiring at best and, at worst, more uncomfortable
than the symptoms they are purported to treat. "All
antipsychotic drugs carry the potential of causing a variety
of discomforts. Oversedation, stiffness, muscle spasms .
. . and an intolerable restlessness (or agitation) called
akathesia" (Berger and Vuckovic, M.D., p. 38). The
side effects of these medications mainly impair the motor
system which controls muscular movement (extrapyramidal
symptoms). Other side effects include akinesia (halted speech,
apathy), dystonic reactions (muscle spasms, particularly
in eyes, face, neck and arms), parkinsonianisms (drooling,
muscle stiffness and rigidity), tardive dyskinesia (involuntary
movements of tongue, lips, face, arms, legs (which may be
irreversible), blurred vision, dry mouth, interference with
sexual functioning, low blood pressure, possible sudden
death" (Right to Refuse Psychotropic Medication in
New York, p. 39-40).
Having the right to complete information about
treatment (#8, #9) has its limits. "Facility may withhold
explanation if 1) risk is minimal or 2) physician believes
explanation will have an identifiable and adverse effect
upon patient’’s condition (Right to Refuse Psychotropic
Medication in New York, Undated, p. 40-41). "Except
for those emergency situations not requiring an informed
consent, (information) shall include as a minimum the specific
procedure, treatment or both, the medically significant
risks involved, and the probable duration of incapacitation,
if any" (The Buffalo General Hospital List of Patient
Rights 8/86).
In matters of treatment (#6, #9), a patient’’s
refusal is not an absolute right. Patients can be "forcibly
administered medication if in an emergency (i.e., a patient
engages in conduct or is imminently likely to engage in
conduct, posing a risk of physical harm to himself or others).
Treatment must be the most appropriate available means of
reducing dangerousness only so long as it is necessary to
reduce dangerous behavior... Staff may attempt to forcibly
administer medication to individuals who refuse under the
emergency exception"(Right to Refuse Psychotropic Medication
in New York, Undated, p. 40-41).
A patient’’s behavior may indicate the justification
for restraints and the administration (oral or injection)
of an anti-psychotic medication by the psychiatric ward
nurse. Staff may require that a person deemed as "dangerous"
be given pills over and above the daily regimen or be given
intramuscular injections in the buttocks. These additional
medications are prescribed by the psychiatrist and registered
in a patient’’s chart as PRN, Latin for pro
nata or on an as-needed basis. "Takedowns" are
situations in which staff may utilize physical force to
escort the patient to their bedroom or the seclusion room
to administer psychotropic medication. The patient is asked
to lower their underwear to expose their buttocks, where
the injection is applied. A patient secluded in the "quiet
room" is observed by a hospital staff member, who sits
at the open door. The staff will put the patient in four-point
(wrists and ankles) leather restraints on a hospital gurney
for as long as determined necessary. When given a potentially
"dangerous" situation, these measures are considered
necessary treatment to hospital staff.
In my experience, injections can be given when a patient
refuses to accept oral medication, awakens in the night
and cannot or will not go to bed, or (most commonly) is
deemed a threat to themselves, the other patients, staff
or visitors. Less intrusive treatments may be available,
but often, a person’s unwillingness to cooperate escalates
the situation, regardless of his right to refuse treatment.
The bottom line is that rights of patients are not are as
powerful as hospital policy in the name of protecting the
patient and others from harm. The Psychiatric Survivors’
Guide, an Internet website, expresses a former psychiatric
patient’’s perspective:
Underlying each act of voluntary participation is the threat
of force. It may not be expressed, it may not be acknowledged,
but it is ever-present . . . Voluntary treatment remains
so only as long as the word "no" remains unspoken;
with its utterance how easily can that treatment be made
involuntary ().
Current and former patients’ complaints may hinge
around their treatment by psychiatric staff and the perceived
abridgment of their rights. Many people with mental and
emotional problems voluntarily sign in to the hospital when
seeking help. If help comes in a form that was not expected
or seems "unfair," sometimes that is less an infringement
of rights than in not understanding exactly what psychiatric
hospital care and treatment represent. Staff’s ultimate
authority in any inpatient situation may contribute to patients
feeling mistreated or feeling their rights have been taken
away.
There are many reasons why people with mental illness don’t
make complaints about the psychiatric system. According
to Ria Strong patients can be too scared to complain, see
no point in it and may be overwhelmed by the stress of complaining.
They may doubt themselves, thinking they were delusional
or hallucinating, or their complaints may not be believed
(or dismissed as delusional). "Patients natural reactions
to staff mistreatment and to the hospital setting were misattributed
to their psychiatric disorders" (Neugeboren, p. 279).
For those reeling under the effects of psychotropic medication,
it may be nearly impossible to coherently make a case against
the hospital’s abridgment of their rights.
Some other patient rights and responsibilities may include
"the right to know the hospital rules and regulations
that apply to your conduct as a patient. You are responsible
for making it known whether the contemplated course of action
(treatment) is understood and that you know what is expected
of you." You are expected to follow the treatment plan.
This includes "following the instructions of nurses
and allied health personnel . . . as they enforce the applicable
hospital rules and regulations." While hospitalized,
you are responsible for "complying with hospital rules
and regulations affecting patient care and conduct."
It is your responsibility to be "considerate of the
rights of other patients and hospital personnel . . . you
are responsible for being respectful of the property of
other persons and of the hospital" (The Buffalo General
Hospital List of Patient Responsibilities, No. 1-5, 14,
8/86).
Other psychiatric hospitals list rules for patients in several
visible areas on the ward. Respecting and following unit
policy and respecting the rights of others to space and
quiet are key rules to follow. Also, patients are not allowed
in other patients’’ rooms, in the nursing station
or in their (own) rooms during activities which they are
scheduled (and expected) to attend. There are rules about
wearing street clothing during the day and specific rules
about visitors, visiting hours, TV times and telephone usage
( Patient Rules, ECMC poster).
Other, mainly unspoken, rules apply to discipline of patients,
control of privileges (passes, access to smoking, etc.),
and phone and visitor restrictions ordered by the psychiatrist
or the ward nurse. You have a right to ask why restrictions
exist and what you can do to avoid them in the future.
There are some basic things to keep in mind: Try to get
along with other people and staff on the wards, let a member
of the staff know when you have a problem or feel sick,
take care of hospital and your own personal property, and
keep yourself clean and dressed (insofar as you are able).
Common sense dictates that any unbecoming conduct (certain
disruptions or violent, endangering, or lascivious activities)
is against the rules. Some rules about conduct, however
arbitrary or unspoken, are in place for the proper regulation
of hospital policy. Inappropriate behavior is determined
by staff. Staff has little time or manpower to counsel patients.
So in the case of errant patient behavior, their job is
to shut it down smoothly to maintain a safe environment,
optimally with the least intrusive means available.
Information about patient rights is clearly posted in all
psychiatric wards; yet staff and patients’ understanding
and respect of those rights can be improved. Posting lists
on hospital regulations affecting patient care and conduct
and unit policy (including patients’ responsibilities
and rules) would assist people acclimating to the ward environment.
The implementation of procedures that maximize the patients’’
participation in treatment would also be helpful. The hospital
can improve informed consent for psychiatric medication
policies, addressing benefits and risks, recommended dosages,
and any freedom of choice. In other words, the staff can
assist patients in identifying what medications they are
taking and why, what they are intended for, their possible
side effects, alternatives and consequences of refusal.
BIBLIOGRAPHY
Berger, Lisa and Vuckovic, M.D., Alexander, Under Observation:
Life Inside a Psychiatric Hospital, Tickner & Fields,
New York, 1994.
Buffalo General Hospital List of Patient Rights and Responsibilities,
BGH #3454, 8/86.
Glossary of Mental Health Terms, BGH CMHC, undated.
Neugeboren, Jay. Transforming Madness: New Lives for People
Living with Mental Illness, William Morrow & Co., New
York, 1999.
Patient Rules, ECMC poster, undated.
Patients’’ Bill of Rights, Public Health Law
2803 (l) (g) Patients’’ Rights, 10NYCRR, 405.7
(a) (l), 405.7 (a) (2)
Right to Refuse Psychotropic Medication in New York, Photocopy,
Date unknown.
Your Rights as a Hospital Patient in New York State, Revised
1/98. |
