Monday, October 28, 2013

Whose Rights Trump?


For as long as there's been Shrink Rap, there have been people writing in to tell us their awful stories about how they've been mistreated on inpatient psychiatry units.  Strip searches, restraints, seclusion rooms, lousy food, boring activities,  disrespectful care, feelings of helplessness, and a general sense that inpatient treatment is not always about fostering a healing process.  With the pressures that insurance companies exert to get patients out of the hospital as soon as possible, it's not about healing, it's about keeping people safe until the moment they can be booted out to heal elsewhere.  Still, the stories get to me, and my heart goes out to people who've experienced care that leaves them feeling so vulnerable, physically & mentally uncomfortable, and generally yucky (for lack of the proper scientific term).  Our readers have made me sensitive to the issue of patient rights and they have inspired ClinkShrink and I to want to write a book about forced psychiatric treatments.

This is the thing, as much as I feel for people with these awful stories, I feel pulled.  Physical restraints sound horrible; I personally would be terrified and furious.  But since the use of restraints has been curtailed by patient rights' advocates and laws, the rates of hospital assaults and murders have risen.  Don't the nurses have the right to be safe?  Don't the other patients on the unit have the right to be free from the fear of being raped, assaulted, or killed in the hospital?  I'm not suggesting that we restrain everyone ---not by any means -- I'm just asking the question. Obviously, if an out-of-control, violent, and disruptive patient can be managed with the judicious use of medications, more staffing, calming interventions with talk-downs, or seclusion without restraints, then those methods should be used.  But some patients are terribly sick and terribly dangerous.  Whose rights come first? 

Let me tell you about Mr. Kelly.  Mr. Kelly raped two women he didn't know and he broke into a house and killed a child and her father (strangers to him).  At his hearing, the judge questioned whether he was competent to stand trial.  He went to a forensic hospital where he could be evaluated and he was found to be delusional and incompetent to aid in his defense.  He'd remain in the hospital until he was competent to stand trial.  Mr. Kelly was a perfect occupant of the hospital, a model patient. He wasn't violent or difficult.  And he didn't want to take medications because he did not agree with the doctors that he was delusional.  A clinical review panel said he was sick and needed medications, and he fought the decision, taking the case to the state and it eventually made it's way to the state's court of appeals.  The court of appeals decided that a patient who is committed to a hospital for being dangerous to himself or others can not be medicated against his/her will if he is not dangerous inside the hospital.  

This ruling applies to all committed patients, even those who haven't raped, murdered, or jaywalked.  If you're committed to a hospital because you're dangerous (say you are delusional about your neighbors and you're going to kill them in self defense, but they aren't in the hospital), well now you can't be forced to take medications and you can't be released because you're dangerous outside the hospital.  Wait, really?  Yup.  Funny catch-22 isn't it? Or apparently some hospitals may be warning the victims then releasing the dangerous patient.  If you're the patient who doesn't want to take the medications, this is good, you've got rights and you've been released.  What if you're the person waiting for the subway who that released patient pushes onto the tracks?  Whose rights were more important?

Okay, so back to Mr. Kelly.  He couldn't be medicated.  He sat in the hospital for 8 years at a cost to the taxpayer of $208,000/year before he was declared competent to stand trial and was found guilty for his crimes to go off to prison.  If you were the mother of the child he killed or one of the women he raped, how would you feel?  Would you want the closure a trial might yield a bit sooner?   Is Mr. Kelly's right to refuse medications more important than the victims' rights?  What about the taxpayer's rights to have their tax dollars used more efficiently (I'm sorry to add a money issue here, but our state furloughs workers, and Mr. Kelly got over $1 million worth of hospital care when many go untreated).  

Our readers might say "but I wasn't going to kill anyone, I wasn't going to bite the nurse, or assault another patient."  Assaults in hospitals are common, and the staff does not necessarily have any special abilities to know which agitated patients will escalate to violence and which will not.  These are all tough situations and obviously there is no good or precise answer here.  It would be so nice if there were.

I did have the thought that seclusion rooms should have plexiglass screened iPads built into the walls so that patients could watch movies, read, listen to music, or play games and not be bored.  The activity might be distracting and help them de-escalate sooner.