Question:
Dear Nancy,
Is it legal to administer a standing IM antipsychotic medication PRN for severe agitation to adults in psychiatric units without their consent? If not, in the absence of a clear hospital policy, what state or federal organization rules provide unequivocal guidance with 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.
Sincerely,
Andy
Nancy Brent replies:
Dear Andy,
Your question cannot be responded to fully within the context of this column. Initially, it should be said that your staff needs legal advice from the facility lawyer. If no attorney represents the facility with its clinical issues, a consultation with a nurse attorney or attorney in your state is essential to make certain that any policy and 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, for example).
However, in the area of psychiatric nursing, constraints exist. For example, 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 they 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 a 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're not already a member, you should consider joining the American Psychiatric Nurses Association. It has a wealth of information for general use and also for its members. The association's Scope and Standards of Practice for Psychiatric-Mental Health Nursing might help you and your staff. The association also has various educational programs, webinars, and other resources focusing on clinical practice in this specialty area of nursing.
Sincerely,
Nancy
