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:
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.
Anyone can report suspected abuse or neglect of yourself or other patients. If you have something to say about your care or treatment in the psychiatric ward, it is your right to be able to complain without fear of reprisal. Internal and external patient advocates can assist in these matters. At ECMC, the Peer Educator/Advocate can be reached at (716) 898-3000, ext. 6225. The Buffalo Psychiatric Center Peer Advocate can be reached at (716) 885-2261. Mental health peer advocates can be contacted at the Mental Health Peer Connection, reached through the Independent Living Center at (716) 836-0822. In Monroe County contact the Mental Health Association to find a Peer Advocate or Consumer Guide Trainer at (716)325-3145. At the Rochester Psychiatric Center, Patient Advocates can be reached at (716) 473 -3230 ext.1735. The New York State Commission on the Quality of Care can be reached at 800- .
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.