• Safety vs. rights
    January 24,2014

    Vermont’s mental health system is in a state of crisis, though work is underway to reconstruct parts of the system wrecked in 2011 by Tropical Storm Irene.

    In the meantime, patients in crisis have added to the difficulty of health care workers trying to treat them in less than ideal conditions. At a committee hearing in Montpelier this week, a psychiatrist from the Rutland Regional Medical Center described how a patient had attacked and injured a hospital worker. With inadequate facilities for handling acute cases, legislators are considering whether they should speed up the process of forcing medication on unwilling patients.

    As the law stands now, authorities must wait at least 40 days after the involuntary commitment of a patient before gaining approval for involuntary medication. In the eyes of many caregivers, that is too long. Sometimes people who are potentially dangerous to others or themselves, but who refuse medication, need to be medicated anyway.

    And yet as Sen. Richard McCormack observed this week, there are few deprivations of liberty as profound as forced medication, and the rights of patients must be protected with vigilance. As it is, Vermont’s system is protective relative to the systems in other states. At the same time, the lack of adequate facilities and programs, in the wake of Irene, has left caregivers struggling to keep control of patients who are sometimes dangerous.

    A story on vtdigger.org described the backlog of patients who are forced to wait for suitable placements. There are usually about eight people in correctional centers or emergency rooms waiting for placement in a hospital or acute-care facility, and about a fifth of them are forced to wait beyond the 72-hour limit prescribed by law. Figures from the Department of Mental Health showed that 119 patients in 2013 were forced to wait more than 72 hours. That leaves many hard-to-handle patients held in places not designed for their care and safety.

    Speeding up the legal process allowing them to be medicated against their will would be one way to get control of the situation. But it would have drawbacks, according to some who testified before legislative committees.

    Waiting before forcing medication on patients allows a window of time for caregivers to establish trust with patients and to develop a course of treatment that does not rely on medication. Also, a judge told the committees that speeding up the process would thrust cases before a judge that might otherwise be resolved before coming to court, creating new burdens on the court system.

    As with so many issues involving human rights, the medication issue requires a balance — between the safety of the patient and his or her caregivers, which can be protected through medication, and the patient’s right to refuse medication. Trampling on someone’s rights is not a good way to create the trust needed for therapy, even if the patient does not seem to be in a state conducive to making sound judgments. On the other hand, the judgment of caregivers must sometimes override the judgment of the patient, for the patient’s own good.

    How to codify these judgment calls is the question. The first priority must be to rebuild the system, including the new acute-care facility due to be completed in Washington County this summer. To deprive patients of their rights because the state doesn’t have its act together does not seem right.

    What legislators are hoping to do is eliminate the 40-day delay and decide on involuntary medication at the same time that the courts decide on involuntary commitment. If legislators go this way, they ought to consider a one-year time limit on the change, putting it in place as an emergency measure to help caregivers cope with the emergencies caused by the state’s tattered system. There is a danger that the change would never be rescinded; a sunset provision would make sure that reflexive recourse to medication did not become the rule.

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