Is it legal to administer a standing IM antipsychotic medication PRN severe agitation to adults in psychiatric units against their will? If not, in the absence of a clear hospital policy, what state or federal organization rules provide unequivocal guidance in respect to this practice? In my workplace, the medical director, the unit manager, and most staff RNs insist the practice is correct and legal, and that there is no need to call the psychiatrist to give by force or coercive intimidation an IM antipsychotic or benzodiazepine for agitation when the patient refuses.
Nancy Brent replies:
Your question cannot be responded to fully within the context of this column. Initially, it should be said that your staff need legal advice from the facility lawyer. If there is no attorney who represents the facility with its clinical issues, a consultation with a nurse attorney or attorney in your state in essential to make certain that any policy and any clinical practice conforms to the applicable laws in this area. Although not a complete list, those laws would include the state mental health code (or similar name), state and federal constitution mandates on the right to refuse treatment, and guardianship law.
There is no question that a nurse can administer medications with a PRN order (again, when consistent with facility policy, third-party reimbursement requirements, and Joint Commission requirements, as examples). However, in the area of psychiatric nursing, constraints exist. As examples, are the recipients of mental health services in your facility voluntary or involuntary patients? Has there been a court order entered, if required in your state, to administer medications against the will of the recipient? How are standing orders for the PRN medications handled procedurally in your facility? What are the policies on restraint and seclusion and how do these policies help or hinder the use of forced medication administration?
Suffice it to say here that the indiscriminate use of psychotropic medication is not acceptable. There must be a clinical reason for administering medication that is supported by legal and ethical mandates. Members of the psychiatric staff have an obligation to protect the safety of any patient, including the patient who is agitated or out of control. Restraint, seclusion and/or medication administration are all options in such situations.
If you are not already a member, you should consider joining the American Psychiatric Nurses Association. Its Web site at www.apna.org has a wealth of information for general use and also for its members. The Associations Scope and Standards of Practice for Psychiatric-Mental Health Nursing might be of help to you and your staff. The Association also has various educational programs, Webinars, and PowerPoint presentations focusing on clinical practice in this specialty area of nursing.