Wednesday, January 09, 2008

The Kelly Case and Forced Psychiatric Medications

Oops, I started this and had to run. I thought it was saved to "draft" but it actually posted before it even got started! This time for real:

This is a ClinkShrink issue: pure forensics, but it has my attention for the moment, and it has broad implications for the treatment of psychiatric patients in Maryland who are violent when they are mentally ill.

If you want to read about the Kelly Case in the
Baltimore Daily Record, CLICK HERE.

Okay, so in Maryland, a psychiatric inpatient can be forcibly restrained and forcibly medicated (by injection) if they are actively violent or threatening in a way that the facility staff and docs deem someone's imminent safety to be in peril. Such events are disturbing for everyone involved-- the patient is agitated, has often already struck or bitten someone, thrown an object or broken something, emotions are high, decisions are made quickly, things get intense. The medications administered are generally sedating and are short-acting. This is how it works for very acute situations.

Sometimes psychiatric inpatients are dangerous as a result of their psychiatric symptoms, but not imminently, and safety is a longer-term issue. These aren't people who are necessarily agitated or belligerent. If a dangerous patient is refusing to take medications, there is a legal mechanism to force them to take medicine-- in Maryland we call this a Medication Review Panel and it's a legal proceeding in which the patient gets to make his case and the psychiatrist gets to say why he thinks the patient needs to be medicated against their will. This is a more deliberate process, a legal proceeding.

I will tell you that the term "dangerous" is less narrowly defined. So someone who is hospitalized for depression who is not taking care of themselves such that a medical condition threatens their life (-- we're not talking about a sad diabetic who reaches for a piece of cake here, just to be clear on this). Most of the patients who come to Medication Review Panels have psychotic illnesses-- they are having hallucinations and/or are delusional, and they don't have the insight that they have an illness. Legally, someone can be as psychotic as they'd like and refuse treatment, the issue here is one of
dangerousness for someone who is already committed to an inpatient unit. Other examples might include someone who is so psychotic they are too disorganized to care for themselves and leave lighted cigarettes lying around, or they believe that the devil has instructed them to kill people, or use your imagination. Roy and ClinkShrink might be better at generating examples. Let me also clarify that the dangerousness must be a result of mental illness, otherwise we're simply talking about criminals.

No one has thought too hard about the exact location as Where someone might be dangerous. Until the Kelly Case, that is.

I've never met Anthony Kelly, I don't know his diagnosis or his symptoms. He is a dangerous man and he has been confined to a hospital for the criminally insane (okay, Clink, a maximum security forensic facility) since 2002. Mr. Kelly was deemed too sick to stand trial for his crimes and he refused to take medication. At a hearing in 2005, an administrative law judge said Mr. Kelly could be forced to take medications, but the ruling was reversed on appeal by Baltimore City Circuit Court Judge Lynne A. Battaglia. Judge Battaglia said that since Mr. Kelly is dangerous only when he's outside the hospital, but not while he's in the confines of a maximally secure facility, so he can't be made to take medications.

To the surprise of Maryland psychiatrists, the Court of Appeals upheld this decision:

"Because there was no finding that Kelly is a danger to himself or others during his confinement in Perkins Hospital, a prerequisite to forcible administration of medication pursuant to Section 10- 708(g) [of the Health-General Article], we shall affirm the judgment of the Circuit Court of Baltimore City."

This means that a person who is mentally ill and dangerous can only be forced to take medication if they are dangerous WHILE they are in the hospital --even if they would be dangerous if they were not in the hospital.

Many psychiatrists who work on inpatient units are not happy about this because it means that if someone is mentally ill and dangerous outside the hospital, but not dangerous inside the hospital, they can't be treated and and they can't be released. Because they are dangerous, they must be kept in the hospital, perhaps indefinitely.

I don't work in an inpatient unit, but what I don't like about this ruling is the assumption that someone has a crystal ball that accurately says When and Where and Under What Circumstances someone with a severe psychiatric disorder that renders them dangerous will act. People elope from psychiatric units, they commit suicide on inpatient units, they assault other patients and staff members.

Anthony Kelly remains in Clifton T. Perkins hospital, unmedicated, or so I understand. Outside the hospital, his illness presumably contributed to his actions such that he is in a hospital and not a prison for his crimes-- the rape of the women and the murder of two people including a child. He has presumably been a safe and non-violent patient on his unit, and he doesn't want medications. Psychotic patients have difficulty with reality testing, they can be unpredictable and some patients can be dangerous. I'm not sure how in the face of such heinous past actions that anyone can absolutely guarantee that a patient such as this might not suddenly attack another patient or a staff member even in the hospital.

While the Kelly Case has been a topic of discussion among psychiatrists in the state, all factual information for this blog post was taken from the article in the Baltimore Daily Record that I linked to above. Okay Clink, let's hear it.....

Sorry, no pic. I couldn't find one of Clifton T. Perkins Hospital and anything else seemed tacky for such a serious and disturbing topic.


Midwife with a Knife said...


Aqua said...

My gut tells me everyone should have a choice. In this case maybe the choice is psychiatric medication or jail? Maybe even solitary confinement if he/she is violent in jail.

I'm not familiar with the Kelly case, but in Canada there was a big ruling a few years back where a man with severe manic symptoms won his case against forced treatment.

Keep Breathing said...
This comment has been removed by the author.
ClinkShrink said...

We've touched on this topic before, in Dangerous On The Outside and in Side Effect: Possible Death.

The appellate court was concerned that the standard for dangerousness for involuntary medication was the same as the dangerousness standard for civil commitment. They didn't think that everyone who was committed should by definition be at risk of forced medication. Leaving someone ill and untreated, in addition to the obvious clinical risks, can leave criminally committed pretrial forensic patients in a legal limbo---never wholly free but neither guilty. In the Federal system this was addressed in Sell v. U.S., 539 U.S. 166 (2003), which developed the four Sell criteria for involuntary medication:

1. There must be an important government interest in treating the defendant
2. Medication would further that government interest
3. The medication is necessary
4. The medication is medically appropriate

Treatment of criminal defendants can also occur involuntarily if the defendant is at risk of dangerous clinical deterioration without it. This was what allowed the Feds to treat Russell Weston, the capitol shooter.

Here is a concise summary of the issues on FindLaw.

ClinkShrink said...

Oh yeah, I found you a pic of Perkins.

Anonymous said...

EEK, This is a rough one Hanid. Personally some of the rational seems flawed to me. This is a person who was deemed incompetant to stand trial. If this is true then under what I always knew as "implied consent" the patient can be given meds because he has already been deemed "incompetant."
If he has the legal right to refuse treatment, shouldn't he then have the ability to stand trial?
Again I am not a lawyer or a shrink, but I was a paramedic, and under a number of circumstances patients can not refuse treatment. Of course this is sometimes a very grey area. For example the person having an acute MI often tries to refuse treatment, mostly out of denial. We would work very hard to convince this person to agree to treatment. If they continued to refuse, we could say that they are not rational because they are hypoxic. (this only can be said when the patient is symptomatic) and under "implied consent" we would treat them. Hypoxia being one criteria for a patient who is not legally able to refuse treatment.
Of course most medical emergencies differ, (although I have fought with many hypoglycemic patients), from psychiatric emergencies because there is a grey area here.
My point though is that this just seems like something out of "One Flew Over the Cuckoo's Nest" Where the lead character was placed in a mental institution (forgive me my lack of political correctness on the term) because he wanted to get out of going to jail. Maybe this is a stark example but it seems to fit somewhat the Kelly case.
I can see why the shrinks are pissed.

Dinah said...

Keep breathing-- thanks, I'll fix it, I just get too excited to keep my thoughts straight.

eek, abf: Maryland has different laws than Mass, and emergencies in the field are completely different then in an inpatient facility, and I've never worked at a forensic psychiatric hospital so I'll have to leave this to ClinkShrink.
Thanks for reading and commenting.

NeoNurseChic said...

Kerap. I posted under the wrong account. So much for protecting my anonymity! I need to get the accounts straightened out in my brain! heh

Here's my comment again:
I definitely think this is a problem. For one, it's a problem for the safety of the other patients and staff working at a maximum security facility because you're right: who is to say when and where a person's illness might make them very dangerous? Also, if the person is so dangerous as to need this secure facility but can only be forced to take medication once they are on the outside, then how will the physicians, nurses, and other staff ever know if this person is controlled on medication enough to be released? (Not necessarily this particular person, as I don't know what his terms of commitment are, but I'm referring to the average person who has the chance to be released but cannot be forced to take medication while "safe" in the facility.) Basically you can never treat this person on a stable medication regimen and enforce that they take the medication until they are doing better, so the only point in having them in the facility is simply to keep them out of society, but not to rehabilitate them. So what is the point?

I know I'm not saying anything differently than what you wrote, but still - this is just mind-boggling! I agree that people should have a choice, but when they are unable to make that choice, this seems a very bizarre and non-sensical solution from the courts.

One correction... You wrote: "This means that a person who is mentally ill and dangerous can only be forced to take medication if they are not dangerous WHILE they are in the hospital even if they would be dangerous if they were not in the hospital."

I may not be reading this correctly as it is a wordy sentence, but do you mean that a person who is mentally ill and dangerous can NOT be forced to take medication if they are not dangerous WHILE they are in the hospital even if they would be dangerous if they were not in the hospital? Or perhaps that they can ONLY be forced to take medication if they are dangerous while they are in the hospital AND dangerous while outside the hospital. Either way - something about that seems to be off...

Good topic, and I would definitely like to hear Clink and Roy chime in on it as well. I imagine that Clink can comment on the forensic psychiatry component and that Roy can comment on severely ill inpatients. Both of those perspectives would be a great addition to the topic!

Take care,
Carrie :)

Anonymous said...

I'm a psych nurse on a forensic unit in a state hospital. This is a huge concern and actually tends to lengthen the loss of liberty of patients. What is also a concern is patients found not guilty by reason of insanity. They can be held in the hospital for years and some for life. If they refuse medications they could be unmedicated for years which has shown to cause significant degeneration to brain function even if they become medicated at a later date. Emergency medications given during an episode of imminent risk are usally limited to sedatives which will have no bearing on long term mental health symptoms.

Unknown said...

An assumption being made in all of this discussion is that the medication will work. Sometimes medications don't work, and not only that, but sometimes medications create side effects and paradoxical reactions and make the patient suffer greatly. In some cases forced medication could be seen as cruel and unusual punishment.