Mental illness and the right to refuse care (Part 1)

The police bring in a woman in her 30’s – she’s in handcuffs. The officer says they had received a call from a friend that the patient was planning to kill herself, and had been found in her bedroom with a loaded revolver close to hand. She has been brought to the emergency department at St Erasmus for a mental health evaluation. Dr Rush is in the room, and talks with her briefly – she denies suicidal ideation, as most suicidal patients do. She also admits to having spent time in a mental health facility, and a past diagnosis of paranoid schizophrenia. She is running a borderline fever of 100 degrees, but we can’t send her to a mental health facility until she is cleared of any acute medical issue. Since she technically has a fever, the doctor works her up for infection.

The doctor orders an EKG, blood draws, and collection of a urine sample. I enter to get a urine sample. By now, the patient is starting to feel irritated. She says we have no right to keep her against her will, that she feels fine, and she doesn’t want all these tests! I, being a lowly ER tech, immediately punt the problem up to my RN. The RN punts the problem to the MD, and the MD punts the problem to social work. The social worker enters the room, informs the patient she is on a mental health hold, she has no rights, and she has a choice between peeing in the cup or being placed in restraints and having a catheter inserted.

The patient, realizing the social worker isn’t bluffing, backs down and consents to the tests. She provides the urine sample, holds still for the EKG, and allows the IV start and blood draw. Test results come back, show that nothing is wrong with her, and she is taken to the mental health facility without further incident.

This incident raised major concerns to me. Does any diagnosis of mental illness mean you waive all medical rights? Shouldn’t the patient still have some right to determine their medical treatment? Is the right way to start a course of treatment for a paranoid schizophrenic to threaten to strap them down and insert a catheter? These issues, and others, will be discussed in further posts – stay tuned for part II!

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2 thoughts on “Mental illness and the right to refuse care (Part 1)

  1. No easy answer, but I imagine the answer would differ between the patient and the patient’s mother if she believed her daughter would indeed kill herself without intervention. That also raises more questions : should we have the “right” to kill ourselves–be allowed to walk out of a hospital after stating our intention–and if yes should that right differ if someone is so seriously mentally ill that her thinking is compromised?

    • Ethically, I think we do have a “right” to commit suicide – if we don’t have the right to control our own bodies, what rights do we have? However, as a practical matter, I believe society should definitely add obstacles to committing suicide. That is basically the goal of the involuntary mental health hold. It forces the person to stop and think, and provides the opportunity to receive counseling and psychiatric treatment for any mental health issues they may have. However, if someone truly wants to kill themselves, we won’t be able to stop them over the long term.

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