8. Rights relating to treatment and care
(a) Right to participate in treatment planning and decision making
From the very beginning of the hospital stay, a patient has the right to discuss his or her treatment plan and participate with professionals in decision-making regarding care. Therefore, a patient must be informed of who is on his or her treatment team and what kind of care each person will be providing. In addition, the patient also should have access to professionals who can provide medically necessary medical, psychiatric, and dental care, regardless of the patient’s ability to pay. A service is “medically necessary” if it is reasonably calculated to prevent, cure or alleviate the patient’s condition and there is no other equally effective, less invasive or less costly and appropriate treatment available. If the hospital does not have qualified staff to provide medically necessary treatment, a patient may get this care from professionals in the community.
A patient may choose his or her doctor, nurse, or therapist, to the extent possible. A patient may hire a private doctor at his or her own expense, and that doctor may come into the hospital to treat the patient at any reasonable time.
A patient can always request to discuss the treatment plan with hospital staff. Though a patient may suggest different treatment options, the treatment team will only follow suggestions that the team decides are medically necessary.
This right to have input in treatment decisions is broader than just decisions regarding a patient’s mental health or medical treatment. For example, a patient has the right to receive food and meals based on the patient’s individual medical needs or consistent with the patient’s religious beliefs. A patient can explain his or her dietary or religious practice to a treatment team member so that the diet becomes a part of the treatment plan.
(b) Rights relating to the hospital’s level system
All patients, whether forensic or civil, are classified under the hospital’s level system based on his or her individual treatment needs. A patient’s level determines what privileges he or she has in the hospital. A patient can find out what privileges he or she has by asking a member of the treatment team to see the level system policies or guidelines.
A patient’s level can affect many things. For example, as a patient’s level increases, he or she may get permission to visit additional places in the hospital. Such places may include the sun porch or outside areas. A patient also can get increased access to personal items, such as radios and televisions. For a civil patient, the level will determine whether he or she can visit places outside of the hospital. A patient can move up and down levels based on changes in his or her treatment needs. If a patient disagrees with his or her level, there are several options available. These options are outlined in Section II of this booklet.
(c) Right to refuse antipsychotic medication, Electroconvulsive Therapy (ECT), or other treatment
In general, a patient has the right to refuse antipsychotic medication, although there are some exceptions. These exceptions are complicated and depend on the type of commitment, the length of commitment, and the circumstances (like an emergency). If a hospital is trying to force a patient to take antipsychotic medications, the patient should contact the attorney, if any, that represented him or her at the last commitment proceeding. A patient can also ask staff or their treatment team members at WSH and ESH for their antipsychotic medication policies and call DRW for technical assistance.
A patient has the right to refuse Electroconvulsive Therapy (ECT), and any surgery that is not emergency life-saving surgery, unless ordered by a court. A patient also has the right to refuse psychosurgery, including a lobotomy.
A patient may refuse emergency life-saving surgery if he or she has given the hospital an advance health care directive that states the patient does not want to receive such surgery. This document can indicate what type of medical care the patient would like if he or she becomes unable to communicate his or her treatment desires in the future.
A patient also can give the hospital a mental health advance directive. Mental health advance directives can say which specific mental health treatment and interventions a patient wants or does not want. They can also say which treatments a patient prefers. In the directive, a patient can choose a person, called an agent, to help with mental health decision making. For more information, please see the DRW publication “Writing Your Mental Health Advance Directive.” Contact DRW to request a copy of this publication.
(d) Seclusion and restraint
A patient has the right not to be placed in restraints or seclusion unless it is an emergency and it is necessary to ensure the immediate physical safety of the patient, staff, or others. Restraint is limiting a patient’s ability to move using physical devices like straps, as well as by staff using their hands or bodies. Restraints also include the use of drugs to manage behavior or restrict movement. Seclusion is when a patient is placed in an area by him or herself and prevented from leaving.
Seclusion or restraints should only be used if other, less restrictive options have not kept the patient and others safe. Staff must record which less restrictive methods they used, and the use of restraint or seclusion in the patient’s chart. A patient should not be restrained or secluded because it is the easiest option for staff, as a form of punishment, or to force the patient to do something. A patient should be told why he or she is in restraints or seclusion and what to do to be released. A patient should not be in restraints in a public area of the ward such as a day room or hallway, unless the patient is being moved due to an emergency or he or she is a danger to himself or herself or others.
While in seclusion or restraints, a patient must be examined by a medical professional no more than an hour after the start of the seclusion or use of restraints. A patient should be monitored, or looked at, at least every fifteen minutes by hospital staff. A patient who is in restraints and seclusion at the same time must be monitored, or watched, continuously by a staff person. If a patient continues to be an immediate danger to him or herself or others and therefore must stay in seclusion or restraints, a physician may renew the order for seclusion or restraint every four hours.
The seclusion and restraint must end at the earliest possible time or as soon as the patient no longer is an immediate danger to themselves or others. A patient who is secluded or restrained must be allowed to exercise his or her individual rights. Upon request, a patient may be provided with reading, writing and educational materials, reasonable access to legal services, mail, visits, and telephone calls. A patient may be denied the exercise of these rights when the registered nurse or physician determines that an item or request could result in harm to the patient or others. When such rights are restricted, the staff must write down the rationale in the patient’s chart.
(e) Discharge rights
(i) Discharge planning for civil patients
A civil patient has the right to active discharge planning. This means that as soon as a civil patient arrives at the hospital, he or she can begin talking to the treatment team about what the patient needs to do to be discharged back to the community. A civil patient may need to ask for a discharge evaluation before a discharge plan can be created. Once this is done, a civil patient can work with hospital staff to create a discharge plan. This discharge plan will try to help the civil patient meet his or her basic and medical needs after release from the hospital.
(ii) Conditional release and related rights for forensic patients
The discharge process for forensic patients is called “conditional release.” A forensic patient is conditionally released when he or she no longer meets the criteria for commitment to the hospital. Like the civil patient’s discharge plan, a forensic patient may begin the conditional release discussion with their treatment team as early as the first day at the hospital.
The conditional release process is complicated and has changed in recent years. Patients should work with their defense attorney when making decisions about how and when to petition for conditional release. Patients are entitled to the assistance of their defense attorney throughout their forensic commitment at the state hospital.
Every six months, forensic patients are entitled to an evaluation of their mental condition. A forensic patient may hire an expert to do this evaluation. If the patient cannot afford an expert and requests the appointment of an expert by the court, the court may appoint one. The Secretary of the Department of Social and Health Services (DSHS) receives a copy of each of these expert reports. DSHS must provide a letter to the court showing how the hospitals are meeting the requirements of these six-month reviews.
Following the six-month examination, a forensic patient can submit an application for conditional release to the Secretary of DSHS (the Secretary). The Secretary sends it to the court with a recommendation. If the Secretary recommends conditional release, the Secretary will also forward the petition to the public safety review panel, which will also submit a recommendation to the court. The public safety review panel may order additional evaluations. If the Secretary does not recommend conditional release, the petition is forwarded to the court, but not the public safety review panel.
A forensic patient also can submit a petition for conditional release directly to the court at any time. The petition must be given to the prosecuting attorney and the Secretary of DSHS, where it follows a similar process as explained above.
Additionally, a forensic patient can submit a writ of habeas corpus at any time, challenging their continued commitment and seeking release. A “writ of habeas corpus” is a document a patient gives to the court to ask for a review of his or her commitment. It explains to the court why the patient feels he or she is unlawfully detained, and that he or she would like to be released.
All patients are entitled to receive reasonable accommodations in petitioning the court. Additionally, forensic patients are entitled to an attorney throughout their commitment. This attorney represents the patient during the commitment and conditional release process and can help a patient pursue discharge in any of the above ways.
Forensic patients cannot be committed to the hospital for a longer time period than the possible maximum sentence for any offense charged for which the patient was acquitted not guilty by reason of insanity.