Brief
the patient posed a danger to self or others (N=23, or 9 percent), those for whom permission to mcdicate was given by conservators (N= 39, or 1 5 percent), patients who consented to medication (N=77, or 29 percent), and those who refused mcdication (N= 1 1, on 4 percent). For the next six months, service utilization data were obtained in order to follow the patients’ clinical status. These data included the numhem ofpatients immediately hospitalized, the number hospitalized within six months ofbcing seen in the cmcmgency service, the mean duration of immediate and subsequent hospitalcause
Reports
Effects of the Right to Refuse Medication in an Emergency Psychiatric Service Yvette Martha
Sheine, Beanie,
M.D. Ph.D.
antipsychotic
Rights
of patients itt the mental system, especially the might to refuse medication, have gained increased recognition. Court cases have emphasized the patient’s capacity to make treatment decisions through the informed consent process and have included a legal review process (1-3). In the most recent decision in this area (4), Riese v. St. Mary’s Hospital, the California Supreme Court held that involuntarily committed patients have the statutory right to give or refuse informed consent to antipsychotic medication in nonemergency situations unless theme is a judicial determination of their incapacity to make treatment decisions. Studies of the relationship between the acuteness ofpatients’ cliical state and the decision to refuse
health
Dr. Sheine is assistant professor in the department ofpsychiatry at Washington University School of Medicine in St. Louis. Dr. Beanie is research health scientist at the Center for Health Care Evaluation in Palo Alto, California. Both authors were formerly affiliated with the Santa Clara County Men-
tal Health
Bureau
in
San
Jose,
California. Address correspondence to Dr. Sheine, Department of Psychiatry, Jewish Hospital of St. Louis, 216 South Kingshighway Boulevard, St. Louis, Missouri 63110. This paper is based on one presented at the annual meeting of the American Psychiatric Association held May 12-17, 1990, in New York City.
640
medication
have
had
mixed results (5-8). Although these studies have described patient cliical chamactemistics, including hospital length ofstay and use ofseclusion and restraints, patients have not been followed up after discharge to assess longer-term outcome. The purpose ofthe study reported here was to describe patients affected by the Riese ruling and to assess whether theme were immediate and longer-term differences in clinical outcome between patients who consented to medication and those who refused medication under the new ruling. Patients’ cliical course was followed for six months, starting with the emergency psychiatric evalnation, to determine their subsequent use ofclinical services.
izations,
tropic dicated.
patients
medication
when
was
Demographic, clinical and outcome variables pared for five groups (N=265
patient
a psycho-
medically
episodes
in-
treatment, were cornof patients [248
mdi-
vidual patients]): those for whom no psychotropic medication was mdicated (N= 1 1 5, or 43 percent), those for whom the requirement for permission to medicate was waived be-
June
1992
VoL
43
No.
number
mcadmissions
of
service, and the mental health
Results
Methods The study was conducted in a metropolitan emergency psychiatric service that is part ofa public psychiatmic hospital in San Jose, Califbmnia. The service primarily treats involuntamy patients; 80 percent are admirted on a temporary commitment order. A prospective study was undertaken with a five-week initial enmollment period (August 22, 1989, to September 24, 1989) during which treating psychiatrists documented on a short form the actions taken for involuntary
the
to the emergency number of outpatient clinic visits.
6
During the six-week study enrollment period, 743 patients were evaluated in the cmemgency service. Sixty-inc voluntary patients (9 pencent) were excluded from the study because the Riece ruling did not affect their treatment. Of the remaining 674 admissions, study forms were completed for 265 patient episodes (39 percent). The 265 patients did not differ statistically from the overall sample of743 patients. They were similardemographically to the 7,643 patients evaluated in the emergency service in fiscal year 1989. Results of immediate
and
six-month
of the five patient in Table 1.
follow-up
groups
Demographically,
are shown
the
only
sig-
ificant difference between groups was in gender. Females were more likely to refuse medication than males, and males were more likely to require
emergency
Clinically, cation
those were
medication.
not
significantly
needing less
mcdilikely
than others to have a primary diagnosis of psychosis defined as schizophmenia, schizoaffectivc illness, major depression with psychotic features, or bipolar disorder, manic, with psychotic fratumcs. The clinical status of the group not needing medication was less acute than that of other groups as measured by the DSM-IIIR axis V Global Assessment of Functioing scone. Compared with other groups, the clinical status of those
Hospital
and
Community
Psychiatry
Table
1
Demographic consent status
outcome
and
differences
among
episodes
ofinvoluntary
treatment
at an emergency
psychiatric
service,
by medication
Consent
Medication not
not sought due to
Variable
required (N=115)
emergency (N=23)
Demographic Mcan±SDage(years) Male1 White Employed full
32.8±12.7
40.2±15.6
49.6% 65.5% 12.5%
61.9% 66.7% 0.0%
17.9%
35.0%
73.7%
50.4±15.6
24.0±13.6
10.4±5.6 13.9%
13.9%
time
Clinical Majorpsychosis2 Mean±SD current
Medication re-
(N=39)
(N=77)
lasers (N=11)
Total (N=265)
37.3±15.7
32.8±9.6
36.5±13.2
34.2±12.8
55.3%
72.0%
54.5%
58.1%
73.5%
61.8%
54.5%
20.0%
65.1% 7.7%
54.7%
54.5%
39.8%
32.4±14.5
37.2±14.6
28.7±9.1
40.8±14.8
11.0±6.6 56.5%
15.7±6.7 23.1%
14.4±6.4 40.3%
15.8±6.4 90.9%
29.8%
52.2%
64.1%
32.5%
90.9%
33.2%
27.8%
56.8%
29.7%
70.0%
23.0%
44.9±58.7
10.9±7.3
11.6±11.5
25.1±41.2
33.3%
67.6%
37.8%
70.0%
30.6%
48. 1±53.5 .2±.9
57.7±52.8 .9±1.4
96.0±98.5 2.5±2.8
29.3±35.8 .7±1.2
25 .3±36.8 1.0±.9
55.0±70.8
.5±1.2
1.2±1.9
2.2±5.3
1.2±1.9
.2±.4
4.0%
0.0%
outcome
hours ofvisit
Discharged Admitted medical
to
service4 on involuntary
emergency
to any
hold5 for
hospital
12.7±6.5
or psychiatric
treatment6 Admitted to study hospital for psychiatric treatment7 Mean±SD length of immediate
1.8% 24.5±19.1
hospitalization(days)8
Six-month
Medication conrenters
Assess-
Global
mentofFunctioningscore3
Immediate Mean±SD
Consent given by conservator
outcome
(based
8.4±7.5
on 248
patients)
Hospitalized in next six months9 Mean±SD length of hospitalization (days)1#{176} Mean±SD hospitalizations” Mean±SD readmissions to emergencyservice12
One
or more
outpatient
I
X2=9.65,
32.1%
3 F=25.12,
df=4, df=4,
p
the patient posed a danger to self or others (N=23, or 9 percent), those for whom permission to mcdicate was given by conservators (N= 39, or 1 5 percent), patients who consented to medication (N=77, or 29 percent), and those who refused mcdication (N= 1 1, on 4 percent). For the next six months, service utilization data were obtained in order to follow the patients’ clinical status. These data included the numhem ofpatients immediately hospitalized, the number hospitalized within six months ofbcing seen in the cmcmgency service, the mean duration of immediate and subsequent hospitalcause
Reports
Effects of the Right to Refuse Medication in an Emergency Psychiatric Service Yvette Martha
Sheine, Beanie,
M.D. Ph.D.
antipsychotic
Rights
of patients itt the mental system, especially the might to refuse medication, have gained increased recognition. Court cases have emphasized the patient’s capacity to make treatment decisions through the informed consent process and have included a legal review process (1-3). In the most recent decision in this area (4), Riese v. St. Mary’s Hospital, the California Supreme Court held that involuntarily committed patients have the statutory right to give or refuse informed consent to antipsychotic medication in nonemergency situations unless theme is a judicial determination of their incapacity to make treatment decisions. Studies of the relationship between the acuteness ofpatients’ cliical state and the decision to refuse
health
Dr. Sheine is assistant professor in the department ofpsychiatry at Washington University School of Medicine in St. Louis. Dr. Beanie is research health scientist at the Center for Health Care Evaluation in Palo Alto, California. Both authors were formerly affiliated with the Santa Clara County Men-
tal Health
Bureau
in
San
Jose,
California. Address correspondence to Dr. Sheine, Department of Psychiatry, Jewish Hospital of St. Louis, 216 South Kingshighway Boulevard, St. Louis, Missouri 63110. This paper is based on one presented at the annual meeting of the American Psychiatric Association held May 12-17, 1990, in New York City.
640
medication
have
had
mixed results (5-8). Although these studies have described patient cliical chamactemistics, including hospital length ofstay and use ofseclusion and restraints, patients have not been followed up after discharge to assess longer-term outcome. The purpose ofthe study reported here was to describe patients affected by the Riese ruling and to assess whether theme were immediate and longer-term differences in clinical outcome between patients who consented to medication and those who refused medication under the new ruling. Patients’ cliical course was followed for six months, starting with the emergency psychiatric evalnation, to determine their subsequent use ofclinical services.
izations,
tropic dicated.
patients
medication
when
was
Demographic, clinical and outcome variables pared for five groups (N=265
patient
a psycho-
medically
episodes
in-
treatment, were cornof patients [248
mdi-
vidual patients]): those for whom no psychotropic medication was mdicated (N= 1 1 5, or 43 percent), those for whom the requirement for permission to medicate was waived be-
June
1992
VoL
43
No.
number
mcadmissions
of
service, and the mental health
Results
Methods The study was conducted in a metropolitan emergency psychiatric service that is part ofa public psychiatmic hospital in San Jose, Califbmnia. The service primarily treats involuntamy patients; 80 percent are admirted on a temporary commitment order. A prospective study was undertaken with a five-week initial enmollment period (August 22, 1989, to September 24, 1989) during which treating psychiatrists documented on a short form the actions taken for involuntary
the
to the emergency number of outpatient clinic visits.
6
During the six-week study enrollment period, 743 patients were evaluated in the cmemgency service. Sixty-inc voluntary patients (9 pencent) were excluded from the study because the Riece ruling did not affect their treatment. Of the remaining 674 admissions, study forms were completed for 265 patient episodes (39 percent). The 265 patients did not differ statistically from the overall sample of743 patients. They were similardemographically to the 7,643 patients evaluated in the emergency service in fiscal year 1989. Results of immediate
and
six-month
of the five patient in Table 1.
follow-up
groups
Demographically,
are shown
the
only
sig-
ificant difference between groups was in gender. Females were more likely to refuse medication than males, and males were more likely to require
emergency
Clinically, cation
those were
medication.
not
significantly
needing less
mcdilikely
than others to have a primary diagnosis of psychosis defined as schizophmenia, schizoaffectivc illness, major depression with psychotic features, or bipolar disorder, manic, with psychotic fratumcs. The clinical status of the group not needing medication was less acute than that of other groups as measured by the DSM-IIIR axis V Global Assessment of Functioing scone. Compared with other groups, the clinical status of those
Hospital
and
Community
Psychiatry
Table
1
Demographic consent status
outcome
and
differences
among
episodes
ofinvoluntary
treatment
at an emergency
psychiatric
service,
by medication
Consent
Medication not
not sought due to
Variable
required (N=115)
emergency (N=23)
Demographic Mcan±SDage(years) Male1 White Employed full
32.8±12.7
40.2±15.6
49.6% 65.5% 12.5%
61.9% 66.7% 0.0%
17.9%
35.0%
73.7%
50.4±15.6
24.0±13.6
10.4±5.6 13.9%
13.9%
time
Clinical Majorpsychosis2 Mean±SD current
Medication re-
(N=39)
(N=77)
lasers (N=11)
Total (N=265)
37.3±15.7
32.8±9.6
36.5±13.2
34.2±12.8
55.3%
72.0%
54.5%
58.1%
73.5%
61.8%
54.5%
20.0%
65.1% 7.7%
54.7%
54.5%
39.8%
32.4±14.5
37.2±14.6
28.7±9.1
40.8±14.8
11.0±6.6 56.5%
15.7±6.7 23.1%
14.4±6.4 40.3%
15.8±6.4 90.9%
29.8%
52.2%
64.1%
32.5%
90.9%
33.2%
27.8%
56.8%
29.7%
70.0%
23.0%
44.9±58.7
10.9±7.3
11.6±11.5
25.1±41.2
33.3%
67.6%
37.8%
70.0%
30.6%
48. 1±53.5 .2±.9
57.7±52.8 .9±1.4
96.0±98.5 2.5±2.8
29.3±35.8 .7±1.2
25 .3±36.8 1.0±.9
55.0±70.8
.5±1.2
1.2±1.9
2.2±5.3
1.2±1.9
.2±.4
4.0%
0.0%
outcome
hours ofvisit
Discharged Admitted medical
to
service4 on involuntary
emergency
to any
hold5 for
hospital
12.7±6.5
or psychiatric
treatment6 Admitted to study hospital for psychiatric treatment7 Mean±SD length of immediate
1.8% 24.5±19.1
hospitalization(days)8
Six-month
Medication conrenters
Assess-
Global
mentofFunctioningscore3
Immediate Mean±SD
Consent given by conservator
outcome
(based
8.4±7.5
on 248
patients)
Hospitalized in next six months9 Mean±SD length of hospitalization (days)1#{176} Mean±SD hospitalizations” Mean±SD readmissions to emergencyservice12
One
or more
outpatient
I
X2=9.65,
32.1%
3 F=25.12,
df=4, df=4,
p
