Involuntary Chemical Sedation–The Right Patient

In my last blog post, I argued that chemical sedation was safer that prolonged physical restraint for patients who represent an acute threat to themselves or others.  Today, I would like to explore who is an appropriate candidate for involuntary chemical sedation—and who is not.  This is the first part of the Four Rights of Chemical Sedation:  Right Patient, Right Medication,  Right Follow-Up and Right Documentation.

RestraintFirst, let’s define what we are talking about here.  The key concepts in Chemical Sedation-Restraint are:

  1. It is an urgent situation.  Consider again the patient who is running his head into the wall.  We have to stop him now.  There is no time to consult with superiors or obtain a court order.  The patient is harming himself now and we must stop him–now.
  2. It is an alternative to prolonged physical restraint.  We are restraining patient behavior using medication because this is safer for the patient than is prolonged physical restraint.  In fact, we are using chemical sedation precisely so that we can release the patient from physical restraints.
  3. It is involuntary.  The patient does not want it to be done.  Sometimes, when a patient is in a restraint chair and you say, “Would you like something to help you calm down?”  They will say “Yes.”  The sedation there is not involuntary anymore.  We are talking here about someone who is refusing any type of medication.
  4. We are using sedating psychotropic medications.  There are many medications that can be used for sedation but they all have in common that the patient will be sedated at the end.  The end goal is that the patient will be asleep (but arousable) and no longer requires any type of physical restraints.

There are many terms we could use to convey these concepts.  We could say: Urgent or Emergency for the first concept, Restraint or Sedation for the second, Involuntary or Forced  for the third, and Chemical or Psychotropic for the last concept.  This could lead to some cumbersome terms like “Emergency Involuntary Psychotropic Restraint” or “Urgent Forced Chemical Sedation.” The emergency medicine literature tends to use the more concise term “Chemical Sedation” for this procedure.  Since the overall goal is to get the patient out of physical restraints, I prefer the term “Chemical Sedation” instead of “Chemical Restraint.”

Who Is A Candidate for Emergency Involuntary Chemical Sedation?

There are four indications for Chemical Sedation in a correctional facility:

  1. The patient is a danger to himself.  The patient who is running his head forcibly against the wall is an obvious example.  I once had a patient who kept climbing up onto the sink in his cell and doing a swan dive onto the floor.  Head-bangers, I think, would qualify as would those patients who pull out fist-fulls of hair or gouge at their eyes.  I also would include poop-eaters, since as a trained medical professional, I know that eating poop is considered bad for one’s health.  Poop-smearers probably qualify, as well.  On the other hand, screamers may not qualify since screaming obscenities, even for prolonged periods of time does not represent a danger to self.
  2. The patient is a danger to others.  There is an element of a judgment call here in assessing the level of danger involved with those inmates who threaten others with violence. For example, if you happened to have John “Bones” Jones (world champion mixed martial arts fighter) in your facility and he were to say “I will kill anyone who comes into my cell,” you should believe him.  Mr. Jones would represent a true danger to others and probably should be chemically sedated.  On the other hand, a frail 90-year old man who makes the same threat might not be a real danger to others and chemical sedation based on that statement alone might not be warranted.  Other examples of inmates who pose a true threat to others might include poop-throwers, biters, and maybe even spitters.
  3. The inmate represents a threat to the integrity and security of the institution.  For example, an inmate who is tearing apart his cell, damaging the door or plexiglass, might qualify for chemical sedation.  Another example would be an inmate who screams racial taunts at other inmates, inciting them to anger and a potential riot, also could qualify for sedation.
  4. To assist in the medical assessment and management of the patient.  Sometimes, I don’t know for sure why an inmate is being aggressive and threatening.  An example here would be a newly booked inmate who is acting bizarrely.  Let’s say he is not talking coherently.  He will not cooperate even with getting vitals signs.  Is he high on meth?  Delirious?  Drunk?  Psychotic? Sometimes, the only way to be able to assess this patient is to chemically sedate him so that we can examine him..

Two Reversible Medical Conditions Can Cause Agitation

When deciding to chemically sedate someone, we need to keep in mind that there are two easily reversible medical conditions that can cause agitation.  These are

  1. Hypoglycemia
  2. Hypoxia

Fortunately, both can be quickly and easily assessed if there is any question in a particular patient (say the patient described above, who is acting bizarrely in booking and we do not know why).  Once a patient is physically restrained, and before injecting the chemical sedating agents, it is simple to check a blood sugar and an oxygen saturation in appropriate patients.  It is embarrassing to sedate a patient and then find out later that he had a blood sugar of 20.  Oops.

Other medical conditions can potentially cause a patient to be agitated, such as brain tumors, delirium, and being post-ictal after a seizure.  However, these are not easily reversible as are hypoglycemia and hypoxia.  If a patient has one of these, they usually will be sedated and then the underlying medical cause will hopefully be sorted out thereafter.

Chemical Sedation Should Never Be Punitive!

Always remember that the goal of restraining and sedating patients is for their benefit, not ours.  I have found that when jail deputies find out how much better chemical sedation is than prolonged restraint, both for the patient and for them, they sometimes want to chemical sedate everyone who is a management problem.  However, most jail management problems are not candidates for chemical sedation.

Even patients who are appropriate candidates for chemical sedation should always be offered less restrictive means of calming down.  Sometimes, just putting a patient in a restraint chair preparatory to getting chemical sedation is enough for them to settle down.  More often, however, patients facing a cell extraction, or who are already in a restraint chair  will accept oral medications rather than receive an injection.

Summary.  Is This the Right Patient for Chemical Sedation?

1.   Is he a danger to himself?

2.  Is he a danger to others?

3.  Is he a danger to the safety and security of the facility?

4.  Is sedation the only way he can be medically assessed?

5.  Does he have a reversible medical condition?

6.  Will he accept a less restrictive form of sedation?

What is your experience with chemical sedation?  Please comment!

 

9 thoughts on “Involuntary Chemical Sedation–The Right Patient

  1. Al Cichon

    At the risk of being a real PIA, one critical factor is that it must also be accompanied by a diagnosis.
    There are some inmates who, because they are trying to ‘make a point’, will ‘act out’ and cause as much disruption as they can…
    Chemical (restraint) sedation should not be employed when an inmate is ‘just’ misbehaving.

    Reply
  2. Doc,

    What about the patient / inmate who would be otherwise unable – as a consequence of his/her mental illness – to participate in a course of therapy and rehab efforts provided to other inmates?

    Reply
    1. jeffk2996 Post author

      Thanks for the question. Such a patient would not be a candidate for Involuntary Chemical Sedation–unless he/she was an acute danger to self or others. Someone who is an ongoing management problem, say a schizophrenic who refuses to take medications, should be referred to the court system for commitment or for a court order authorizing forced medications.
      Once I have a court order authorizing forced medications, it is no longer technically “involuntary” since the court has assumed guardianship of the patient and is authorizing the treatment as a guardian. It is very like a child who refuses to get her vaccination booster–but her parents (guardians) override that and she gets the shot.
      Once I have a court order for ongoing medications, I can also use haldol decanoate, which lasts 2-4 weeks. Such a long acting medication would be inappropriate to give as a chemical sedation med.

      Reply
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  4. gary white

    In the State of Texas. The jail standards commission has some legal guidelines that one can follow. I have found that many times just talking to the inmate can change his behavior. Depending on the case I try and do everything to avoid it. I also feel my primary responsibility for my staff is just if not more important than the welfare of inmate. My question would be if anyone has had an unforeseen consequence of using chemical sedation ? Gary

    Reply
    1. Jeffrey Keller MD Post author

      Thanks Gary!

      I agree that the least invasive method of controlling self injurious behavior is preferable. I also have talked many patients down. I’ve also seen many patients way beyond that point! As to harms, I am aware of many cases of patients being harmed by physical restraints. I am aware of no cases of harm from properly done chemical sedation. That is not to say this procedure is without risks! It is instead that the risks are less than the alternatives: prolonged physical restrains or not intervening at all.

      Reply
      1. Rebekah Mills

        Chemical agents commonly used in chemical sedation such as haloperidol have predictable and well-documented negative physical and mental effects on a significant minority of people; it is impossible to predict in advance how a given dose on a given person will affect the person. Negative effects include akathisia, an almost intolerable restlessness and inability to keep still; and suicidality. Haloperidol can even cause a potentially fatal condition “neuroleptic malignant syndrome”. Forced administration of drugs is traumatizing as well and does nothing to address the reasons for the “self injurious behavior”. Criteria used to order the administration of these drugs are arbitrary; forced administration can cause a physical struggle with potential for injury.

        Reply
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