Download Position Statement on An Act Relating to Involuntary Treatment and

Position Statement on an Act Relating to Involuntary Treatment and Medication (S-287)
Vermont Organization of Nurse Leaders (VONL)
Executive Committee
February 2014
OVERVIEW
The Vermont Organization of Nurse Leaders believes that every person deserves access
to the timely treatment of severe mental illness, including psychiatric medication. The
population that the proposed act is intended to serve is a very small percentage of those
Vermonters that have mental health issues and who, by virtue of their acute or chronic
symptoms of mental illness, lack the capacity to assess the benefits and risks of taking
and refusing medications and have proven to be dangerous to either themselves or
members of the community based on the clinical assessment of a trained psychiatrist.
VONL realizes that society has an obligation to respect an individual’s liberty and right
to self-determination. VONL also realizes that there is a small percentage of the
population of persons with severe mental illness who because they lack capacity, and
because of shortcomings in the involuntary mediation system, suffer long delays between
when they are admitted to a psychiatric inpatient facility and when the court rules they
can be medicated. Although this delay may be intended to be a protective measure to
ensure individual liberty it actually prolongs the length of time of inpatient
hospitalization as these patients are not safe to be discharged prior to the onset of
psychotropic treatment. This often extends the periods of time that they spend away from
family members, their home and their community as well as increasing the risk of
assaultive behaviors resulting in harm to themselves or caregivers. The time spent
waiting also equates to time in which an illness remains untreated and is allowed to
progress. All existing studies show that the prognosis of individuals that remain
psychotic for extended periods of time is poorer than those that receive timely treatment.
Extended periods of prolonged psychosis are associated with increased assaultive
behavior, restraints and seclusion (Russ & John, 2013).
BACKGROUND
According to the Vermont Department of Mental Health, some patients who refuse
medication after involuntary commitment to a psychiatric treatment facility have
experienced anywhere from 15-253 days waiting for judicial decisions to authorize or
deny the involuntary medication of these patients. These delays are associated with staff
and patient injuries, compromised patient flow throughout the facility, increased length of
stay and downstream delays for patients in emergency departments throughout the state
who are awaiting treatment placement.
S287 seeks to streamline the current system for involuntary treatment and medication of
psychiatric patients. Specifically, the act proposes to:
 substitute a mandatory probable cause hearing for the current voluntary hearing
 create an expedited application for involuntary treatment and petitions for
involuntary medication
 enable joint filings of certain applications for involuntary treatment

eliminate “automatic stays” and “automatic stays pending appeal” for orders of
involuntary medication.
Vermont is the only state that does not have mandatory probable cause hearings for
patients who are involuntarily admitted.
Although there is international consensus among mental health professionals that
deprivation of liberty should be an extreme mode of crisis intervention (Kuosmanen, et al
2007) the following points should be noted:
 The act does not address the appropriateness of involuntary medication for
the mentally ill patient
 The act does not define mental illness, nor does it seek to deny the patient
the right to refuse treatment or medication.
 The act also does not address the treatment of behavioral health patients in
the outpatient or emergency department setting.
VONL POSITION
Therefore, it is the position of VONL to support the legislation of S287 to focus on the
judicial review portion of the process.
Furthermore, VONL recommends continued research, literature review and
and dialogue about the medico-legal approaches to managing cases of psychotropic
medication refusal (Jarrett, Bowers & Simpson, 2008).
VONL advocates for the continued assessment of involuntary patients’ satisfaction with
treatment and perceptions of coercive measures associated with their care. Patients’
feelings of coercion may depend less on the use of specific coercive measures and more
on the way such treatment is explained, negotiated, and delivered. (Katsakou et al, 2010).
VONL also advocates for involving the stabilized patient in a Psychiatric Advanced
Directive process to be used in the event that they return to a state where they are
psychotic and lack capacity.
VONL encourages a “rights-driven” approach. The rights-driven model addresses the
treating provider’s judgment about the need for treatment and the patient’s competency to
refuse treatment. There is some evidence that a rights-driven approach may result in
fewer instances of involuntary medication (Russ & John, 2013).
REFERENCES:
Jarrett, M., Bowers, L., Simpson, A. (2008). Coerced medication in psychiatric inpatient
care: literature review. Journal of Advanced Nursing, Dec; 64(6): 538-48.
Katsakou, C., Bowers, L., Amos, T., Morris,R., Rose,D., Wykes,T., Priebe,S. (2010).
Coercion and treatment satisfaction among involuntary patients. Psychiatric Services,
61(5). www.ps.psychiatryonline.org.
Kuosmanen, L., Hatonen, H., Malkavaara, H., Kylma, J., Valimaki, M. (2007).
Deprivation of liberty in psychiatric hospital care: the patient’s perspective. Nursing
Ethics, 14; 597 doi:10.1177/0969833997080205.
Russ, M.J.,John, M. (2013). Outcomes associated with court-ordered treatment over
objection in an acute psychiatric hospital. The Journal of the American Academy of
Psychiatry and the Law., 41: 236-44.