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Covert medication hits balance of ethics, safety

Ethics Forum. Feb. 5, 2007.

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Is it ethical to medicate an agitated patient without his or her consent?

Scenario: Is it ethical to medicate an agitated patient without his or her consent?

A young man comes into the emergency department saying he has bipolar disorder. He admits to not taking his medication and complains of homicidal and suicidal ideation. Hospital records show that, on a prior admission, the patient and staff were injured during application of physical restraints. When the patient becomes increasingly agitated, refusing treatment or admission, the ED physician offers him a sealed orange juice container into which antipsychotic and anxiolytic medications have been injected. Is the physician's action ethical?

Reply:

This scenario raises far more questions than it answers. No one is likely to argue that covert medication is superior to informed consent, but often the so-called consent process is really a show of force followed by physical restraint and medication. The question posed here is controversial because, given this limited information, reasonable people can disagree about the best clinical decision.

Not every emergency department is staffed or equipped to handle psychiatric emergencies, and this action would not be taken unless the physician felt there was no safe and decent alternative.

The attending emergency physician is confronted by the competing interests of the agitated patient and the safety of staff and other patients. He or she also must determine whether there is a surrogate (e.g., family member or friend) present or an advance directive from the patient or his psychiatrist that states how the patient wishes to be treated if his decision-making capacity is compromised.

No published data exist on the incidence of injury to patient or staff during emergency department take-downs. Similarly, there is little or no research from stable psychiatric patients about their preferences when faced with this scenario.

There are, however, many instances in which medication is given without consent, covertly or otherwise. It happens every day in nursing homes, intensive care units and in the dental treatment of patients with developmental disabilities -- all vulnerable patient populations whose "best" interests are being decided by a variety of surrogates.

This scenario is not much different from others in which a patient is unable to give informed consent, except this patient can be informed later (when stabilized) of the circumstances under which the medication was administered covertly.

Before judging this physician's action, it is necessary to question assumptions about the standard of care and to evaluate the physician's decision in the context of lack of research and legal precedent in this area.

Emergency physicians are faced with many problems simultaneously and have to make decisions in non-ideal circumstances and based on incomplete information.

Suppose the patient had a cervical collar and was at risk for permanent physical disability just for the sake of being informed? Should staff be compelled to risk exposure to highly contagious disease? Has the patient been triaged to an open area with other vulnerable patients present?

There are other considerations, too. Is this scenario taking place in the United States or elsewhere, where the physician's action might be considered culturally appropriate behavior? Is the patient from another culture and accompanied by a family member able to inform the staff of this practice as it is sometimes applied in Asia and the United Kingdom?

If the physician believed that patient or staff safety would be compromised by forcibly restraining the patient, I applaud the doctor's decision to defuse the potentially dangerous situation by peaceful, if deceptive, means.

I argue in no uncertain terms that the patient's right to be completely informed and forewarned does not supersede the right of staff and other patients to a safe environment. I do not accept the slippery slope argument I have heard -- no one suggests that the ethical physician do this frivolously or as a general practice.

Was the physician lying if he said, "Here, have a drink -- you'll probably feel better"? Cui bono -- for whose benefit -- is "informing" if it is carried out at the expense of consent? Here again, there is no research about the efficacy of informing psychiatric patients of the consequence (i.e., physical restraint and forced medication) of not giving consent for medication.

If the physician had the time and resources to isolate the patient, consult a psychiatrist or convene a Reese-type hearing, all these actions would probably have been taken. Of course, this would require that the patient has been medically cleared.

Do we even know whether the patient is having a psychiatric emergency or has an underlying medical condition or brain injury precipitating the agitated behavior? Again, assuming this physician is a competent, ethical, reasonably intelligent, resourceful person in a bind, I maintain the action is not only ethical but compassionate and probably legal, too.

Even more than arguing whether the physician acted ethically or not, I wish to emphasize the gaping hole in research concerning the practice of covert medication in the emergency department, psychiatric facilities and myriad other situations during which a patient's decision-making capability is compromised or willingly abdicated. These are readily addressed, fundamental questions; addressing them will challenge assumptions about ethical, practical and standard practices.

--Matthew R. Lewin, MD, PhD, assistant professor of medicine, Division of Emergency Medicine, University of California, San Francisco

Reply:

I believe it is unethical to medicate an agitated patient without his knowledge for these reasons:

• It is probably illegal, and the state licensing board and hospital bylaws should be checked. It is likely that medical and psychiatric facilities use differing legal standards of emergency and consent. In my hospital, covertly medicating a patient would be grounds for dismissal.
• Many patients have allergies to psychiatric medicines and should be told in advance what they are about to receive. Would you really want to be the doctor giving medication-laden orange juice to a patient who could have protested to you that he cannot breathe if given that medicine? And when patients quiet down, is it because they are more calm and rational, or simply anoxic? Patients' rights exist to prevent adverse outcomes and to ensure they are treated with respect.
• It is a common mistake to presume that patients with mental illness are incompetent to make medication decisions. I saw a patient last week with a bipolar diagnosis who was pressured in his speech and delusional -- he believed that he was a "one-armed bandit." He was equally clear that "depa-anything," i.e., Depakene, Depakote or Depakote ER (name brands for generic valproic acid) made "everything come up," and he emphatically gesticulated retching. One of valproic acid's most common side effects is nausea and vomiting. The patient was adamant that he would not take valproic acid, but agreed to take any other mood stabilizer. He was mentally ill, but competent to make medication decisions.
• Initial deception has long-term consequences. For the last 20 years as a psychiatrist, I have written orders to restrain or give medicines by injection. Not only have I been viciously attacked myself, I have worked with staff who have sustained broken backs, lost teeth, a detached retina, skin bitten to the bone by possible AIDS patients -- and these are just the assaults that come readily to mind. I have seen the hurricane strength of psychotic agitation destroy all in its swath and can fully understand the desire and need to quell it immediately, by whatever means. But I also handle the aftermath of poor information. It can take many weeks for a roughly handled or deceived patient to trust again, if he or she ever does. Patients with paranoia become more suspicious about being poisoned. Tricking them sedates them quickly, but it damages the longer-term relationship between a doctor and a patient. Abuse begets abuse; lying begets lying.
• Ordering medicine truncates exploration of other alternatives. Usually, a desperate doctor resorts to habit, i.e., writes for medicine to solve a problem, but the problems and pains of psychiatric patients rarely respond to a single dose of any medicine and usually need much more than what comes in a pill.

I benefit greatly from seeing seasoned staff handle highly agitated patients, often those coming off methamphetamines and PCP atop their untreated mental illness. Many of the best staff subtly can calm and distract patients. The physician, often thinking of himself as "the all-knowing doctor," can learn much from them.

Burgeoning literature suggests numerous alternative approaches to seclusions/restraints/emergency medicines. The specifics are too broad to be addressed by this column, but their ease and simplicity are quite tantalizing.

Changes that are surprisingly low- tech and inexpensive can reduce staff injury and greatly enhance patient satisfaction. Such a shift, however, involves cooperation from the hospital chief executive to the techs in the emergency department.

The bottom line is that, as in all other areas of medicine, the proverbial ounce of prevention is worth a pound of cure.

In sum, I believe medication without knowledge is probably illegal, increases the incidence of allergic reactions, ignores the possibility that the patient is competent to make medication decisions, invites mistrust of health care professionals, and preempts consideration of nonmedical alternatives.

--Emilie Attwell Becker, MD, child, adolescent, adult and forensic psychiatrist, Texas Dept. of State Health Services; Austin State Hospital

Ethics Forum discusses questions on ethics and professionalism in medical practice. Readers are encouraged to submit questions and comments to philip.perry@ama-assn.org or to Ethics Group, AMA, 515 N. State Street, Chicago, IL 60654; fax 312-464-4613. Opinions in Ethics Forum reflect the view of the author and do not constitute official policy of the AMA.

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