Risk Management in Medication Treatment: Medical, Legal, and Ethical Issues

1. Risk Management in Medication Treatment: Medical, Legal, and Ethical Issues Presenter: Philip Merideth, M.D., J.D. Adult, Child/Adolescent, and Forensic Psychiatrist Medical Director Brentwood Behavioral Healthcare Jackson, Mississippi (A subsidiary of Psychiatric Solutions, Inc.)

2. Brentwood Behavioral Healthcare/ A subsidiary of Psychiatric Solutions, Inc. Goals Discuss the informed consent process. Consider legal issues involved in psychiatric medication treatment. Consider ethical issues involved in psychiatric medication treatment. Discuss risk management and documentation strategies to improve patient care and decrease potential for malpractice liability. Questions and discussion.

3. Brentwood Behavioral Healthcare/ A subsidiary of Psychiatric Solutions, Inc. Informed Consent Is not a signature on a form. (“Have nurse witness consent”) Is a process that promotes clinically and ethically sound treatment and reflects society’s respect for autonomy and voluntary, informed decision making.

4. Brentwood Behavioral Healthcare/ A subsidiary of Psychiatric Solutions, Inc. Law School 101 “Every human being of adult years and sound mind has a right to determine what shall be done with his own body.” Justice Cardozo Schloendorff v. Society of New York Hospital 1914

5. Brentwood Behavioral Healthcare/ A subsidiary of Psychiatric Solutions, Inc. Elements of Informed Consent Competence (“adult years and sound mind”) Information (informed) Voluntary choice (consent)

6. Brentwood Behavioral Healthcare/ A subsidiary of Psychiatric Solutions, Inc. Informed Consent How much information to disclose? Canterbury v. Spence, 464 F.2d 772 (1972)- “the scope of the physician’s communications to the patient… must be measured by the patient’s need.” Treater should disclose the material risks that could potentially affect the patient’s decision.

7. Brentwood Behavioral Healthcare/ A subsidiary of Psychiatric Solutions, Inc. Exceptions to Informed Consent Emergency Waiver Therapeutic privilege

8. Brentwood Behavioral Healthcare/ A subsidiary of Psychiatric Solutions, Inc. Informed ConsentSpecific Issues to Discuss when Prescribing Medication Nature and purpose of the medication Benefits, risks, and side effects of the medication Alternatives to medication treatment, including the option of no treatment

9. Brentwood Behavioral Healthcare/ A subsidiary of Psychiatric Solutions, Inc. Informed Consent Forms A patient’s signature on an informed consent form is evidence that informed consent was obtained, but is not a substitute for the informed consent process.

10. Brentwood Behavioral Healthcare/ A subsidiary of Psychiatric Solutions, Inc. Legal Issues Licensure by appropriate agency Controlled Substance Registration Certificate (DEA number) Credentialed at facility Prescription must be written within the scope of the person’s legitimate professional practice

11. Brentwood Behavioral Healthcare/ A subsidiary of Psychiatric Solutions, Inc. Ethical Principles Nonmaleficence (Primum non nocere: “First, do no harm.”) Beneficence (Do good) Autonomy (Self-determination; let the patient decide) Justice (Social/economic issues, scarce resources, what is “just” for society) Veracity (Tell the truth) Fidelity (Faithful service)

12. Brentwood Behavioral Healthcare/ A subsidiary of Psychiatric Solutions, Inc. Ethical Issues in Medication Prescribing Self prescribing Prescribing for family members Gifts from industry (AMA CEJA Opinion 8.061) Related to work/educational purpose, minimal value, no strings attached

13. Brentwood Behavioral Healthcare/ A subsidiary of Psychiatric Solutions, Inc. When In Doubt Consider interest of patient: Benefit to patient vs. Benefit to physician Seek consultation- colleague or Ethics Committee “Do the right thing” Peter Blake, M.D. Jackson, Mississippi

14. Brentwood Behavioral Healthcare/ A subsidiary of Psychiatric Solutions, Inc. Risk Management Appropriate risk management technique may be summed up in one word….

15. Brentwood Behavioral Healthcare/ A subsidiary of Psychiatric Solutions, Inc. DOCUMENTATION Documentation DOCUMENTATION DOCUMENTATION DOCUMENTATION DOCUMENTATION DOCUMENTATION

16. Brentwood Behavioral Healthcare/ A subsidiary of Psychiatric Solutions, Inc. DID I MENTION DOCUMENTATION?

17. Brentwood Behavioral Healthcare/ A subsidiary of Psychiatric Solutions, Inc. Risk Management Tips Safeguard prescription pads Tamper-resistant prescription pads Duplicate prescription pads- provide exact copy of what was written; include in chart

18. Brentwood Behavioral Healthcare/ A subsidiary of Psychiatric Solutions, Inc. Risk Management Tips 4. Beware of “lost” prescriptions, excessive refills, early refills 5. Legitimate professional practice 6. Document informed consent and need for follow up 7. Write legibly-JCAHO and federal requirement (CFR 482.24 (c) (1))

19. Brentwood Behavioral Healthcare/ A subsidiary of Psychiatric Solutions, Inc. Risk Management Tips 8. Suicidality monitoring of children and adolescents on antidepressants. Document informed consent specific to this issue.

20. Brentwood Behavioral Healthcare/ A subsidiary of Psychiatric Solutions, Inc. Risk Management Tips 9. Monitoring for metabolic syndrome of patients on SGAs (see Brentwood form) Reference: Diabetes Care, vol. 27, number 2, February 2004

21. Brentwood Behavioral Healthcare/ A subsidiary of Psychiatric Solutions, Inc.

22. Brentwood Behavioral Healthcare/ A subsidiary of Psychiatric Solutions, Inc. Words of Wisdom The pen is mightier than the sword! The case for prescriptions rather than surgery. Marvin Kitman

23. Brentwood Behavioral Healthcare/ A subsidiary of Psychiatric Solutions, Inc. The assistance of Lisa Nichols, R.N., Risk Manager at Brentwood Behavioral Healthcare, Jackson, Mississippi, is acknowledged with gratitude.