SOUTH CAROLINA DEPARTMENT OF MENTAL HEALTH
Columbia, South Carolina

OFFICE OF THE STATE COMMISSIONER OF MENTAL HEALTH

DIRECTIVE NO. 537-80

(5-100)

 TO:             ALL Organizational Components

SUBJECT:  Refusal of Medication by Patients in Mental Health Facilities

I.       Voluntary Patients

A.     Voluntary patients may not be given medication over their objections except in medical emergencies.

B.     Upon refusal of a voluntary patient to accept his/her prescribed medication, the following procedure shall be followed:

1.  The attending physician shall determine the patient's reasons for refusing the medication.

2.  The patient shall be advised of the reasonably anticipated medical consequences of not taking the prescribed medication, if any.

3.  The physician shall review with the patient all available, alternative treatment modalities and medications seeking to employ a viable treatment alternative which is acceptable to the patient.

4.  If no viable alternative is available, or all alternatives are refused by the patient, the physician may seek the discharge of the patient unless the patient's mental condition necessitates involuntary hospitalization and treatment because:

(a)  the patient would be dangerous to others if discharged;
(b)  the patient would be dangerous to himself/herself if discharged; or
(c)  the patient would be substantially unable to care for himself/herself upon discharge, and there is no less restrictive alternative placement, outside the hospital, available and appropriate to the patient's condition.

C.      If  involuntary hospitalization is required, a petition shall be so filed.  The physician must then comply with the procedures of Section II prior to involuntary medication, unless emergency treatment is necessitated.

II.     Involuntary Patients

A.      Involuntary patients may receive medication over their objections.

B.      Upon a patient's objection to prescribed medication, however, the attending physician shall comply with the following procedure:

1.  The physician shall determine the reasons for the patient's refusal of prescribed medication.

2.  The physician shall advise the patient of the reasonably anticipated medical consequences of not taking the proposed medication.

3.  The physician shall review with the patient all available, alternative treatment modalities and medications, seeking to find a viable treatment alternative acceptable to patient.

4.  If no viable alternative is available, or the patient also refuses the alternative treatment, the attending physician will have the chief medical officer of the facility or his designee and at least one other staff physician, chosen by the facility, to personally examine the patient and review the suggested treatment and alternatives.

5.  When this review confirms the need for the medication prescribed by the attending physician or when the reviewing physicians and attending physician are in agreement as to the medication indicated, such medication can be administered over the patient's objections.

C.      Special considerations:

1.  This instruction governs medication for the treatment of a patient's mental illness only.  Treatment of physical injuries or diseases requires only the consent of an adult, competent patient, a parent of a minor patient, or the committee or guardian of an incompetent or legally incapacitated adult except in cases of medical emergencies where no consent is required if a patient's life is in danger.

2.  This instruction applies only to involuntary patients who are dangerous to others, dangerous to themselves, or substantially unable to care for themselves.  If an involuntary patient no longer meets these criteria, the physician may seek the discharge of the patient and may not involuntarily medicate such a patient.

3.  Where an involuntary patient's reasons for refusal is a religious conviction, not the product of his mental illness, these procedures may not be used in involuntarily medicate such a patient.  Where it appears that the religious objection is a product of the patient's mental illness, the medical officer may contact the attorney for the Department for further advice as is needed.

4.  Where a patient has been accepting medication without objection, and then objects to continued medication, medication may be continued while the procedures of Paragraph II. B are being followed if discontinuance of the medication poses a threat to the health and safety of the patient or to the safety of others.

5.  Medication which is still considered experimental in nature may not be administered pursuant to this instruction.  The experiment and research requirements of the Human Rights Regulations must be followed.

6.  Nothing herein shall be construed to prevent emergency mental health treatment required for the preservation of a patient's health.  When the emergency subsides, the physician must comply with these instructions.

III.      Documentation

A progress note detailing the procedures of this instruction shall be prepared by the attending physician and co-signed by the reviewing physician prior to involuntary treatment.  If this procedure concludes because the patient withdraws his objections or accepts alternative treatment, the progress note should so indicate.   Once a patient objects to medication and this procedure is implemented, the final result, whether it is involuntary medication or subsequent consent by the patient, will remain in effect for 45 days.  Any subsequent refusal of medication within the 45 day period will not require further compliance with this instruction unless the medication has been changed.  An increase or decrease in dosage shall not constitute a change in medication for the purposes of this instructions.

hall.GIF (6886 bytes)

April 30, 1980