Section 1 POLICY STATEMENT
The Department of Developmental and Mental Health Services is
committed to providing voluntary mental health care in a service system that
respects consumers' health, safety, and dignity. The Department recognizes the
right of a legally competent person to make decisions regarding medication. At
the same time the Department acknowledges that involuntary care is currently
unavoidable in certain circumstances as set forth in the Mental Health Act. The
Department continues to work toward the development of a service system in
which coercion and involuntary care will no longer be necessary. Until that
ideal is achieved, the Department will strive to provide involuntary care found
to be necessary in a manner that affords as much protection as possible for the
respect, dignity and rights of the individual.
Section 2 AUTHORITY
These rules are authorized by
18 V.S.A. §
7628.
Section 3 AVAILABILITY
A copy of these rules shall be made available to any person
who requests a copy.
Section
4 DEFINITIONS
4.1
The
Commissioner: The Commissioner of the Department of Developmental and
Mental Health Services or a designee as authorized by
18 V.S.A. §
7401(13).
4.2
Competence: A person is
competent if a person is able to make a decision regarding medication and to
appreciate the consequences.
4.3
Court Order: An order from the family court authorizing the
Department of Developmental and Mental Health Services to administer
involuntary medication to the person named in the order.
4.4
The Department: The
Department of Developmental and Mental Health Services.
4.5
Designated Facility: A
hospital or medical psychiatric unit in a correctional facility demonstrating
the ability to meet the requirements of this protocol, including the requisite
trained staff, medical personnel and physical space and as designated by the
Commissioner to provide care for a patient with mental illness.
4.6
Medical Staff: A
physician, nurse, or psychiatric technician.
4.7
Patient: An individual
who is the subject of a court order authorizing the Department of Developmental
and Mental Health Services to administer involuntary medication to that
individual.
4.8
Treatment
Team: The patient's community and treating psychiatrist(s), case
manager and any other individual the community treatment team deems clinically
appropriate. If the patient does not have a treatment team in the community,
the members of the team will be the patient's inpatient treating psychiatrist,
case manager and any other individual deemed clinically appropriate.
4.9
Impartial Evaluator: A
contracted individual not employed by the Department nor under the supervision
of the Commissioner, who has no prior personal knowledge of the circumstances
under review.
Section 5
NOTICE OF INTENT TO ADMINISTER MEDICATION
5.1
Prior to executing a court order authorizing the administration of involuntary
medication,
5.1.01 The Department shall:
a. Allow the patient's legal counsel
twenty-four hours to inform the patient of the court's order; and
b. Notify the patient's treatment team of the
court order.
5.1.02 The
patient's treating physician shall meet with the patient:
a. After the patient has been informed by his
or her legal counsel of the court order; or
b. After the patient's legal counsel has had
twenty-four hours to inform the patient of the court order, regardless of
whether the legal counsel has chosen to meet with the patient.
5.1.03 The treatment team must:
a. Inform the patient orally and in writing
in a language and in a manner understandable to the patient of:
i the type of medication to be
administered;
ii the dose that will
be administered;
iii the method of
delivery;
iv the route of
delivery;
v the frequency of
delivery;
vi the intended
effects;
vii any risks in keeping
with standard medical practice, including likely side effects, unlikely but
serious side effects, health problems that might be encountered, common drug
interactions including those of street drugs and alcohol, and in the case of
all women of child bearing age, the effects of neuroleptics on a fetus or
nursing child; and
b.
Offer the patient an opportunity to take oral medication unless the court order
authorizes the administration of a long-acting medication which can only be
administered by injection.
Section 6 ADMINISTRATION OF NONEMERGENCY
MEDICATION
6.1 The physician writing the
Physician's Order for the medication at the hospital shall be responsible for
assessing and documenting the following which shall then be provided to the
facility administering the medication:
6.1.01
The patient's current physical health status;
6.1.02 Whether the patient is currently
taking any other medications;
6.1.03 The patient's history of side effects
from medication;
6.1.04 Whether the
patient is pregnant if a woman of child bearing age;
6.1.05 The patient's medical history,
including any history of substance abuse; and
6.1.06 That the physician's order is in
compliance with the court's medication order with respect to the type of
medication, the dosage, the length of administration and the method of
administration.
6.2 The
treating physician shall conduct monthly reviews of the medication to assess
the continued need for involuntary medication, the effectiveness of the
medication, the existence of any side effects, and shall document this review
in detail in the patient's chart.
6.3 The treating physician shall provide
written notice to the court to terminate the medication order when involuntary
medication is no longer required.
6.4 The treatment team shall:
6.4.01 Make best efforts to obtain the
patient's preference on the manner of medication administration after the court
issues an order granting the application and immediately prior to the
administration of medication;
6.4.02 Provide the facility administering the
medication with a current, written medical history of the patient that includes
whether the patient has a history of trauma;
6.4.03 Have at least one member present when
the medication is administered and at the time of release; and
6.4.04 Assure that the patient has the
opportunity to choose a support person, to be present to offer emotional
support when the medication is administered. If the chosen support person is
not available within a reasonable period of time or interferes with the
administration of medication, or the frequency of administration precludes the
presence of the support person each time, medication may be administered
without the support person's presence.
6.5 Location
6.5.01 Medications must be administered at
the Vermont State Hospital or at a facility designated by the Commissioner of
the Department of Developmental and Mental Health Services as a hospital where
involuntary medication may be administered.
6.5.02 The medication must be given in an
area of the hospital that provides the patient with privacy.
6.5.03 If, and only if, the patient's
treating physician or another member of the treatment team makes an
individualized determination, documented in the patient's chart, that physical
restraint is necessary to prevent the patient from inflicting serious physical
injury to the patient or another person, a sheriff may transport the patient to
or from the designated facility.
6.5.04 If the patient is transported by
sheriff, a member of the treatment team shall be present when the sheriff picks
up the patient for transport, and will accompany the patient during the
transport, if the parties agree.
6.6 Oral Medication
6.6.01 The person who gives the medication to
the patient shall be:
a. A licensed nurse or
doctor, except that at Vermont State Hospital, a psychiatric technician may
administer the medication,
26 V.S.A. Section
1583(6); and
b. Trained in the administration of
medication when treating a resistant patient.
6.6.02 The person who gives the medication to
the patient shall:
a. Verify that the patient
is the subject of a current involuntary medication order;
b. Verify that the proper medication is
provided to the patient in the proper dosage; and
c. Follow clinically appropriate practices
and procedures for the administration of oral medication.
6.6.03 The person who gives the medication to
the patient may perform a mouth check to verify that the patient has swallowed
the medication.
6.6.03 After
administering the medication, a hospital staff member shall personally observe
the patient long enough to ensure there are no adverse side effects and to
ensure patient safety.
6.6.04 If
the patient refuses to comply with a mouth check then, in the discretion of the
treatment team, voluntary oral medication may not be offered the next time
medication is administered.
6.7 Injectible Medication
6.7.01 The person who administers the
medication to the patient shall be:
a. A
licensed nurse or doctor; and
b.
Trained in the administration of medication when treating a resistant
patient.
6.7.02 The
person who administers the medication shall:
a. Verify that the patient is the subject of
a current involuntary medication order;
b. Verify that the proper medication is
prepared in the proper dosage;
c.
Fully inform the patient of all aspects of the procedure;
d. Give the patient a choice of clinically
appropriate injection sites and follow that preference if medically
safe;
e. Follow clinically
appropriate practices and procedures for the administration of injectible
medication;
f. Be of the gender
chosen by the person receiving the medication if at all possible;
g. Ensure that a physician is immediately
accessible; and
h. Be responsible
for assuring that a support person of the patient's choosing is present when
the medication is administered, unless the support person interferes with the
administration of the medication or, the frequency of administration precludes
the presence of the support person each time.
6.7.03 The person who administers the
medication shall be accompanied by at least one health professional of the
gender chosen by the patient.
6.7.04 After administering the medication, a
staff member shall:
a. personally observe the
patient long enough to ensure there are no adverse side effects endangering
patient safety;
b. offer emotional
support to the patient.
6.7.05 All procedures shall be documented in
accordance with standard medical practice.
Section 7 FUTURE ADMINISTRATION OF
INVOLUNTARY MEDICATION
7.1 Where the court's
medication order authorizes future administration of involuntary medication,
the treating physician shall execute and file with the Commissioner a
certification executed under penalty of perjury stating the following:
7.1.01 The patient has refused
medication;
7.1.02 The patient is
not competent to make a decision regarding medication and to appreciate the
consequences;
7.1.03 The proposed
medications, the dosage range, length of administration and method of
administration; and
7.1.04 The
substantial probability that in the near future the person will pose a danger
of harm to self or others if not hospitalized and involuntarily
medicated.
7.2 Within 24
hours of receipt of the physician's certification, the Commissioner shall
provide the amount of notice required by the court order to the patient, the
patient's attorney and the court.
7.2.01 The
notice shall state that the patient may request an immediate hearing to contest
the order.
7.2.02 The patient may
be hospitalized in a designated hospital on the date specified in the notice
for up to 72 hours in order to administer involuntary
medication.
7.3 The
procedures set forth in Section
6 of these
rules shall be followed for any patient subject to a future administration of
involuntary medication.
Section
8 USE OF RESTRAINTS WHEN ADMINISTERING NONEMERGENCY INVOLUNTARY
MEDICATION
8.1 Restraints only may be used in
emergency circumstances to protect the safety of the patient or others.
Restraints should never be used:
a) as a
threat;
b) in lieu of adequate
staffing;
c) as a technique for
behavior management or control;
d)
as a replacement for active treatment; or
e) as a convenience. The following should be
prohibited under all circumstances:
a) orders
that trigger restraint without an individual assessment of need, and
b) policies automatically assigning patients
to any form of restraint.
8.2 Each use of restraints shall be
authorized only by a physician who has personally evaluated the patient and who
has checked the patient's record for a history of trauma.
8.3 No form of restraint which places the
individual in a prone (i.e. face down) position should be done.
8.4 Restraint should never occur in a public
place or in the individual's own hospital room, unless no other appropriate
alternatives are available.
8.5
Before applying restraints, the medical staff shall:
8.5.01 Strive to calm the patient and to
reassure the patient's concerns;
8.5.02 Attempt to redirect the patient and to
gain the patient's cooperation; and
8.5.03 Address any questions or concerns
raised by the patient.
8.6 If the patient still refuses to cooperate
with medication administration, a physician shall assess the safety risks,
taking into account:
8.6.01 The patient's
risk to harm himself or herself by struggling when medication is
administered;
8.6.02 The patient's
risk to harm others by struggling when medication is administered;
and
8.6.03 Any other pertinent
factors.
8.7 A
Certificate of Need for emergency restraints shall be entered into the
patient's record that documents the emergency circumstances requiring the use
of restraints.
8.8 Legal counsel
for the patient shall be notified and provided with a copy of the Certificate
of Need within twenty-four hours following administration of
medication.
8.9 The least
restrictive method of restraint must be used and applied in a manner which
provides for padding and protection of all parts of the body where pressure
areas might occur by friction and shall:
8.9.01 Be adjusted to eliminate the danger of
gangrene, sores and paralysis;
8.9.02 Allow room for healthy breathing;
and
8.9.03 Allow the patient as
much freedom as possible.
8.10 Restraints shall be applied under direct
supervision of a nurse who is trained in the use of restraints. The following
should not be used under any circumstances:
a) face down restraint with back
pressure;
b) any technique that
obstructs the airway or impairs breathing,
c) any technique that obstructs
vision,
d) any technique that
restricts the recipient's ability to communicate.
8.11 Medical staff must constantly observe a
patient in restraints. Vital signs should be checked initially and regularly
thereafter (every fifteen minutes at a minimum) if abnormal.
8.12 A patient in restraints shall be
encouraged to take liquids, be allowed reasonable opportunity for toileting and
shall be provided appropriate food, lighting, ventilation and clothing or
covering. An individual being restrained should always be informed about what
is happening, verbally and during the restraint period. Information should
include what events or behaviors precipitated the use of restraint, and when
and under what circumstances the patient can expect to be released.
8.13 A patient shall be removed from
restraints as soon as it is determined that safety reasons no longer
necessitate the use of restraints. Restraint orders should always be
time-limited, and should be removed as soon as it becomes safe to do so, even
if the time-limited order has not expired. Every hour, a nurse shall review the
need for continued restraint. No physician's order for the use of restraints
shall extend beyond a two-hour period.
8.14 Medical staff shall examine a patient
for injuries immediately after being released from restraints.
8.15 Following the removal of restraints,
medical staff must inquire if the patient wishes to have a particular person
notified of the use of restraints. If so, medical staff must notify that person
within twenty-four hours of the restraint.
8.16 Patient and staff debriefing should be
required after every incident of seclusion or restraint, both separately and
together. Gender concerns should be addressed as part of the
debriefing.
Section 9
DISCHARGE OF PATIENT NOT SUBJECT TO ORDER OF HOSPITALIZATION
9.1 If a person is brought into the hospital
only pursuant to a medication order, a physician must determine the amount of
time that the patient will be required to stay at the hospital prior to
discharge, but in no case longer than the time period allowed in the court
order. This decision shall be based on appropriate clinical practices and
procedures regarding the discharge of a patient who has received the type of
medication administered to the patient.
9.2 Prior to discharge, the patient shall
receive any support and counseling necessary to ensure the patient's
comfort.
9.3 Prior to discharge, a
member of the treatment team shall provide the patient with written
instructions regarding:
9.3.01 Side
effects;
9.3.02 Required
after-care;
9.3.03 A person's or
persons' name and phone number to contact if the patient has any questions or
concerns or starts to experience side effects;
9.3.04 Grievance procedures; and
9.3.05 Follow-up with the community mental
health center.
9.4 A
physician must approve the patient's release after making a determination that
there are minimal clinical risks.
9.5 A member of the treatment team shall
arrange transportation to return the patient to their residence. If the patient
does not have housing available, a member of the treatment team shall arrange
temporary housing for the patient.
Section 10 COMPLIANCE AND ENFORCEMENT
10.1 A member of the treatment team shall
report to the Commissioner every time a patient is administered involuntary
medication in a designated facility within seventy-two hours of entering the
hospital.
10.2 The Commissioner
shall review on a periodic basis every instance of a patient being administered
involuntary medication in a designated facility.
10.3 The Commissioner shall conduct periodic
reviews of every patient who is subject to an involuntary medication
order.
10.4 A facility's
designation shall depend upon strict compliance with this protocol.
10.5 Any patient who is subject to an
involuntary medication order may file a grievance with the appropriate agency
alleging a violation of this protocol. The grievance must be filed within
ninety (90) days of the action that is being grieved. This time limit may be
extended if the patient did not know or understand the right to appeal. The
agency shall report the filing and substance of a grievance to the Commissioner
within seventy-two hours of receiving the grievance.
10.6 Within thirty (30) days of receiving the
grievance, the community mental health center or designated facility shall
notify the patient of its decision in writing, in a language and manner
understandable to the patient, including the reasons for the
decision.
10.7 The decision made by
the community mental health center or designated facility concerning the
grievance may be appealed to the Commissioner. Any such appeal must be filed
within thirty (30) days of the day the patient received written notice of the
decision.
10.8 Upon receipt of the
appeal, the Commissioner shall assign an impartial evaluator to conduct a
review of the appealed incident. Within thirty (30) days of receipt of the
appeal assignment, the evaluator shall recommend to the Commissioner whether to
affirm or change the decision of the agency or designated facility. Within ten
(10) days of receiving the evaluator's decision, the Commissioner shall notify
the patient of his/her decision in writing, in a language and manner
understandable to the patient, including the reasons for the
decision.