Giving Treatments to Schizophrenic Patients without their Consent

INTRODUCTION:
Schizophrenia Schizophrenia, a severe mental illness characterized by a variety of symptoms, including loss of contact with reality, bizarre behavior, disorganized thinking and speech, decreased emotional expressiveness, and social withdrawal. Usually only some of these symptoms occur in any one person.

Delusions
False beliefs that appear obviously untrue to other people. For example, a person with schizophrenia may believe that he is the king of England when he is not. People with schizophrenia may have delusions that others, such as the police or the FBI, are plotting against them or spying on them. They may believe that aliens are controlling their thoughts or that their own thoughts are being broadcasted to the world so that other people can hear them.

Hallucinations
People with schizophrenia may also experience hallucinations (false sensory perceptions). People with hallucinations see, hear, smell, feel, or taste things that are not really there. Auditory hallucinations, such as hearing voices when no one else is around, are especially common in schizophrenia. These hallucinations may include two or more voices conversing with each other, voices that continually comment on the persons life, or voices that command the person to do something.

Bizarre Behavior
People with schizophrenia often behave bizarrely. They may talk to themselves, walk backward, laugh suddenly without explanation, make funny faces, or masturbate in public. In rare cases, they maintain a rigid, bizarre pose for hours on end. Alternately, they may engage in constant random or repetitive movements.

Disorganized Thinking and Speech

People with schizophrenia sometimes talk in incoherent or nonsensical ways, which suggests confused or disorganized thinking. In conversation they may jump from topic to topic or string together loosely associated phrases. They may combine words and phrases in meaningless ways or make up new words. In addition, they may show poverty of speech, in which they talk less and more slowly than other people, fail to answer questions or reply only briefly, or suddenly stop talking in the middle of speech.

Social Withdrawal
Another common characteristic of schizophrenia is social withdrawal. People with schizophrenia may avoid others or act as though others do not exist. They often show decreased emotional expressiveness. For example, they may talk in a low, monotonous voice, avoid eye contact with others, and display a blank facial expression. They may also have difficulties experiencing pleasure and may lack interest in participating in activities.

Paranoid type
Characterized by persecutory (feeling victimized or spied on) or grandiose delusions, hallucinations, and occasionally, excessive religiosity (delusional religious focus) or hostile and aggressive behavior.

Disorganized type
Characterized by grossly inappropriate or flat affect (no facial expression), incoherence, loose associations, and extremely disorganized behavior.

Catatonic type

Characterized by marked psychomotor disturbance, either motionless or excessive motor activity.

Undifferentiated type

Characterized by mixed schizophrenic symptoms (of other types) along with disturbances of thought, affect, and behavior.

Residual type

Characterized by at least one previous, though not a current, episode; social withdrawal; flat affect; and looseness of associations.

Genetic factor
Research suggests that the genes one inherits strongly influence ones risk of developing schizophrenia. Studies of families have shown that the more closely one is related to someone with schizophrenia, the greater the risk one has of developing the illness. For example, the children of one parent with schizophrenia have about a 13 percent chance of developing the illness, and children of two parents with schizophrenia have about a 46 percent chance of eventually developing schizophrenia. This increased risk occurs even when such children are adopted and raised by mentally healthy parents. In comparison, children in the general population have only about a 1 percent chance of developing schizophrenia.

Neuroanatomic and Neurochemical factors

Some evidence suggests that schizophrenia may result from an imbalance of chemicals in the brain called neurotransmitters. These chemicals enable neurons (brain cells) to communicate with each other. Some scientists suggest that schizophrenia results from excess activity of the neurotransmitter dopamine in certain parts of the brain or from an abnormal sensitivity to dopamine. Support for this hypothesis comes from antipsychotic drugs, which reduce psychotic symptoms in schizophrenia by blocking brain receptors for dopamine. In addition, amphetamines, which increase dopamine activity, intensify psychotic symptoms in people with schizophrenia. Despite these findings, many experts believe that excess dopamine activity alone cannot account for schizophrenia. Other neurotransmitters, such as serotonin and norepinephrine, may play important roles as well.

Immunovirologic factors
Popular theories have emerged stating that exposure to a virus or the bodys immune response to a virus could alter the brain physiology of people with schizophrenia. Although scientists continue to study these possibilities few findings have validated them. Cytokines are chemical messengers between immune cells, mediating inflammatory and immune responses. Specific cytokines also play a role in signaling the brain to produce behavioral and neurochemical changes needed in the face of physical or psychological stress to maintain homeostasis. It is believed that cytokines may have a role in the development of major-psychiatric disorders such as schizophrenia.

Psychopharmacology
The primary medical treatment for schizophrenia is psychopharmacology. Antipsychotic medications, also known as neuroleptics, are prescribed primarily for their efficacy in decreasing psychotic symptoms. They do not cure schizophrenia; rather they are used to manage the symptoms of the disease.

Psychosocial Treatment

Individual and group therapy sessions are often supportive in nature, giving the client an opportunity for social contact and meaningful relationships with such other people.

Nursing Interventions

Promoting the Safety of the Client and Others Establishing a Therapeutic Relationship Using Therapeutic Communication

STATEMENT OF THE PROBLEM:

Our group thesis paper will focus on determining whether it is justifiable and ethical for nurses to carry out the treatment ordered by the doctor against the schizophrenic patients will based on the symptoms exhibited by this mental disorder. One of our limitations is that we wont be able to interview schizophrenic patients thereby we wont be able to get their opinions regarding this matter especially since schizophrenic patients are incompetent enough to understand their condition. This is of great importance as our study involves them and will affect them emotionally, physically and socially throughout their lives. Another limitation is that our respondents for our survey are very limited due to time constraints and lack of human resources. These limitations will hinder us from getting accurate results which is very important in our study if we want to come up with a concrete conclusion that will help and benefit both nurses and their schizophrenic patients in the future.

METHODOLOGY:
We will be conducting surveys to find out how the public views such actions by the nurses. This is also to find out the publics perception regarding schizophrenic patients. We will also be interviewing a lawyer and a nurse to get information regarding the laws in the Philippines to find out if such actions are legal and to get a first hand information from someone who has encountered a mental patient to get their opinion on the issue.

SIGNIFICANCE OF THE STUDY:

Our study will greatly help us in our nursing profession in determining whether are actions are appropriate with the condition of the patient. The problem of whether it is ethical to carry out the treatment ordered by the doctor against the will of the patient will be minimized. Nurses will be able to act confidently without having to fear doing something illegal and unethical. Thereby nurses will be able to plan and think of interventions that are safe and beneficial for the patient as well as for others in the environment. In other words our study will help and prepare nurses in dealing with patients that are schizophrenic.

OBJECTIVES:
After the study, the group will be able to: Explain what schizophrenia is Discuss the signs and symptoms, treatments and interventions Explain the answer to the ethical dilemma when giving treatments to Schizophrenic patients without their consent

Background of the Study

The nurse-client relationship has always been an issue in the medical field especially in mentally ill patients. Schizophrenia is one illness wherein we have to be very sensitive to the needs of the patients because they may be incompetent enough to understand what they are going through. The proper way of treating these mentally ill patients was always a controversial and sensitive topic. Studies have proven that there are situations wherein patients do not want to take their medications. Nurses get confused because they do not know if they should follow what the patient asks or give the medication or treatment whatever the patient says. Nurses usually think that they may violate the patients right by disobeying their orders and follow the doctors order instead.

 The study was chosen for additional knowledge about the nurse-client relationship especially when talking about Patients Rights and the nurses Principle of Beneficence. Being students in a medical field, the group would want to know more about this topic to be able to fulfill nurses duties and responsibilities and to know when their nursing interventions are proper or improper.

Survey
1) Do you think patients diagnosed with schizophrenia can live an ordinary/normal life with their family? Yes- (68.75%) No- (31.25%) Analysis: According to our survey results 68.75% felt that patients diagnosed with schizophrenia can live an ordinary/normal life with their family and 31.25% felt that patients diagnosed with schizophrenia cannot live an ordinary/normal life with their family. Evaluation: Most of the respondents answered that Schizophrenic patients can live a normal life. This can be better achieved with the help of the family and the treatments needed by the patient. Thanks to the increased progressiveness of antipsychotic drugs and advances in community-based treatment, many of these Schizophrenic patients live successfully in their community.

2) Do you think schizophrenic patients should be isolated from us? Yes- (68.75%) No- (31.25%) Analysis: According to our survey results 25% felt that schizophrenic patients should be isolated from us(normal people) and 75% felt that schizophrenic patients should not be isolated from us. Evaluation: Most of the respondents answered that they should not be isolated from us because they say that Schizophrenic patients can live a normal life. This can be done by taking their medications regularly and by closely following the treatment implemented by the doctors. Although Schizophrenic patients have the tendency to be rough sometimes, they still should not be isolated from normal people.

3) Were there instances wherein you came face to face with a schizophrenic patient? Yes- (37.5%) No- ( 62.5%) If yes, what did you feel? scared- (83.3%) nothing- (16.7%) okay- 0% others- 0% Analysis: The survey result shows that 37.5% came face to face with schizophrenic patients and 62.5% have not encountered schizophrenic patients. Out of the 37.5% who came face to face with Schizophrenic patients, 83.3% felt scared and 16.7% felt nothing.

Evaluation: Most of the respondents answered no. But those who said yes were mostly scared when they encountered a Schizophrenic patient. This is a very common reaction from people who meet Schizophrenic patients. This can be explained by the improper actions of a Schizophrenic patient and their ability to be aggressive from time to time.

4) Do you think as a future nurse, when you encounter such patients, you will know what to do? Yes- (68.75%) No- (31.25%) Analysis: The survey result shows that 68.75% knows what to do when they encounter schizophrenic patients and 31.25% dont know what to do when they encounter schizophrenic patients. Evaluation: Nurses must know the proper implementation of treatments to Schizophrenic patients. The nurse must know every important details about the current situation of the patient in order to know what to do. Also to ensure that the action implemented by them are ethical and legal.

5) Do you think schizophrenic patients are dangerous? Yes- (68.75%) No- (31.25%) Analysis: The survey result shows that 50% thinks that schizophrenic patients are dangerous and 50% thinks that schizophrenic patients are not dangerous.
Evaluation: Our survey results show that there is a split opinion between the respondents. Schizophrenic patients have different symptoms, some maybe considered dangerous and some may not. Therefore not all Schizophrenic patients are dangerous but we should not totally omit the possibility of them not being dangerous at all.

6) Do you think that schizophrenic patients are capable of making decisions concerning their treatment?

Yes- (68.75%)

No- (31.25%)

If no, why? they are lucid(they cannot think properly)- (27.3%) they cannot recognize actions that are harmful to themselves and to others.- (27.3%) they are delusional and hallucinating- (27.3%) all of the above- (18.2%)

Analysis: The survey result shows that 31.25% believed that schizophrenic patients are capable of making decisions concerning their treatment and 68.75% do not believed that schizophrenic patients are capable of making decisions concerning their treatment. According to the survey, 27.3% do not believe that schizophrenic patients are capable of making decisions because they are lucid (they cannot think properly), others 27.3% said that Schizophrenic patients cannot recognize actions that are harmful to themselves and to others, the other 27.3% said that Schizophrenic patients are delusional and hallucinating and 18.2% said that all of the choices mentioned are the reasons why schizophrenic patients are not capable of making decisions concerning their treatment.

Evaluation: From our survey results, we can conclude that the public perceives that Schizophrenic patients cannot decide on their own. Decision-making usually lies in the hands of the immediate family because of the inability of the patient to think well due to their disorganized thinking.

7) Do you think that nurses have the right to decide for schizophrenic patients regarding their treatment?

Yes- (68.75%)
Analysis:

No- (31.25%)

The survey result shows that 43.75% think that nurses have the right to decide for schizophrenic patients regarding their treatment and 56.25% think that nurses have no right to decide for schizophrenic patients regarding their treatment.

Evaluation: Most of the respondents answered that nurses do not have the right to decide schizophrenic patients regarding their treatment. This shows that they know their duties and responsibilities as nurses. The doctors usually decide the treatment to be given to the patient and the nurse just implements the doctors orders.

 8) Do you think it is justifiable for nurses to give treatment to schizophrenic patients without their consent? Yes- (31.25%) No- (68.75%) Analysis: The survey result shows that 31.25% think that it is justifiable for nurses to give treatment to schizophrenic patients without their consent and 68.75% thinks that it is not justifiable for nurses to give treatment to schizophrenic patients without their consent.

Evaluation: For this question, most of the respondents chose that it is not justifiable for nurses to give treatment to Schizophrenic patients without their consent because they think that they still have the right to refuse the treatment (Patients Right). The respondents still gave more importance to the right of the patient but from the information we have gathered there are exceptions to this rights.

Effective New Treatment For Schizophrenia

Although numerous antipsychotic treatments are available, they can cause significant side effects and many patients experience only a partial relief of their symptoms and up to 30% no relief at all. In a new study, authors studied paliperidone extended-release (ER) tablets, an investigational drug which orally delivers the active metabolite of the drug risperidone, which is an already established efficacious antipsychotic. The authors recruited 444 patients who were experiencing an acute episode of schizophrenia and, after evaluating the severity of their symptoms, administered one of four treatments for 6 weeks: 6 mg or 12 mg/day of paliperidone ER, 10 mg/day of olanzapine (the active comparator), or placebo. During the six weeks of treatment, the investigators monitored the patients for side effects and assessed their symptom improvement.

Dr. Stephen Marder explains the findings: "This double-blind study found that two doses of paliperidone extended release tablets were more effective than placebo for treating the symptoms of acute schizophrenia. Patients receiving the most effective dose of paliperidone (6 mg) also demonstrated improvements in their social functioning." Jeffrey A. Lieberman, M.D., Chairman of the Department of Psychiatry at Columbia University and Director of the New York State Psychiatric Institute, comments, "This study demonstrates the efficacy of the 9-hydroxy metabolite of risperidone that has antipsychotic efficacy and an acceptable safety profile which provides psychiatrists with yet another treatment option. It has practical advantages with its long half life, duration of action and extended release formulation." Dr. Lieberman cautions though that this finding is not "a novel or breakthrough treatment and does not provide major differences or advantages over existing treatments." Additional studies are currently underway to further evaluate the long-term (up to one year) efficacy and safety of paliperidone ER in the treatment of schizophrenia.

History of the Topic

Although a broad concept of madness has existed for thousands of years, schizophrenia was only classified as a distinct mental disorder by Emil Kraepelin in 1893. He was the first to make a distinction in the psychotic disorders between what he called dementia praecox (early dementiaa term first used by psychiatrist Bndict Morel [18091873]) and manic depression. Kraepelin believed that dementia praecox was primarily a disease of the brain, and particularly a form of dementia, distinguished from other forms of dementia, such as Alzheimer's disease, which typically occur later in life.

 The word schizophreniawhich translates roughly as "splitting of the mind" and comes from the Greek roots schizein ("to split") and phrn, phren("mind")was coined by Eugen Bleuler in 1908 and was intended to describe the separation of function between personality, thinking, memory, and perception. Bleuler described the main symptoms as 4 A's: flattened Affect, Autism, impaired Association of ideas and Ambivalence. Bleuler realized that the illness was not a dementia as some of his patients improved rather than deteriorated and hence proposed the term schizophrenia instead.

 The term schizophrenia is commonly misunderstood to mean that affected persons have a "split personality". Although some people diagnosed with schizophrenia may hear voices and may experience the voices as distinct personalities, schizophrenia does not involve a person changing among distinct multiple personalities. The confusion arises in part due to the meaning of Bleuler's term schizophrenia (literally "split" or "shattered mind").

Overview
Our paper focuses on determining whether a nurse violates the right of a Schizophrenic patient when she follows the doctors order against the patients will. We will try to clarify things concerning patients rights and the principle of beneficence by weighing the advantages and the disadvantages of the treatment to be implemented to the patient. Nurses by profession follow orders directly from the physician or doctor. Whatever the agreement was between the doctor and the family will be strictly followed. The decisions made by the immediate family of the patient will therefore be the basis for treatment. Because the patient has distorted and bizarre thoughts, perceptions, emotions, movements and behavior, he has no ability to think of what is best for him. Based on the results gathered and on the different viewpoints of other disciplines especially the church, we will try to resolve the issue regarding nurses implementing the doctors order to a Schizophrenic patient against the patients will.

Viewpoints of other disciplines

Medical: In the medical field, it is not the Schizophrenic patient who decides for themselves because of their incompetence or due to their impaired thinking. The decision making usually lies in hands of the immediate family. The doctors usually explain the treatments to be implemented to the family for them to fully understand what they are (and the patient) getting into. There are no rights violated because the treatments were first explained to the family. The medical professionals have the right to implement the treatment regardless of whether the patient likes it or not.

 Legal: According to the legal perspective, the nurse will only become liable if he/she does something beyond the contract under the Law of Guardianship signed by the family of the patient and the doctor, the nurses carelessness and not in the treatment regimen that has been prepared by the physician. There are also certain laws that explain the legal and illegal duties a nurse can do. As long as the nurse follows the orders, whether the patient complies with it or not, the nurse does not violate any right.

Church viewpoints:
- The church follows the principle of patients autonomy, if the patient can be considered an autonomous person then his decision to refuse treatment must be respect by the nurse, but if the patient (mentally ill people) is not considered autonomous, then abided by the principle of beneficence the nurse can proceed with the treatment with or without the patients consent.

LAW: Rule of the court- (rule 101)proceedings for hospitalization of insane person.

Section 01: VENUE, PETITION FOR COMMITMENT. - a petition for the commitment of a person to a hospital or other place for the insane may be filed with the court of first instance with the province where the person alleged to be insane is found. The petition shall be filed by the director of health in all cases where in his opinion such commitment is for the public welfare or for the welfare of said person, who in his judgement is insane and such person or the one having charge of him is opposed to his being taken to the hospital or other place for the insane. Section 02: ORDER FOR HEARING. Section 03: HEARING AND JUDGEMENT. - the commitment applied for is for the public welfare or for the welfare of the insane person and that his relatives are unable for any reason to take custody of him. Section 04: DISACHARGE OF INSANE( by director of health) Section 05: ASSISTANCE OF FISCAL IN THE PROCEEDINGS.

 Psychological: To Michael Robins, a psychoanalyst, persons with schizophrenia live out their lives in an internal psychological world that cries out for understanding. he compellingly demonstrates the importance of thinking pluralistically about the treatment of schizophrenia.

 Sociological
mental illness (schizophrenia) has been conceptualized as a maladjustment to society. Reciprocally, sociological studies in this area would also be concerned with the attitudes of society toward the

mentally ill person as a deviant. Studies show, normal people want the mentally ill patients to be isolated from the society because they believed that mentally ill patients are dangerous, harmful and violent.

Effects
Patients Rights- A patients rights mean the moral and inviolable power vested in him as a person to do, hold or demand something as his own. When the nurse carries out the treatment given by the doctor without the patients consent, the patients rights is violated.

 Paternalism- Paternalism is the common societal response for protecting another (usually someone the person perceives to have less knowledge and experience and/or fewer problem solving skills) from harm. This is usually the principle followed by medical professionals when treating a mentally ill patient. In our case, if through the assessment made by the nurse, the patient is found incapable of making decisions regarding his welfare, the medical professionals will then exercise their power of Paternalism. However, the family must agree with the treatment such that it would be for the patients welfare. Paternalism must be safe, it must promote good and prevent harm at all costs.

 Principle of Beneficence- This principle refers to the moral obligation to act for the benefit of others. This is one of the important principles that justifies the issue on giving treatments to patients against their will especially if the patient has the tendency to hurt himself or others. This is the principle that overrides the patients right. As we have emphasized throughout our paper, medical professionals can give treatment to a mentally ill patient without their consent, if and only if the family agrees to the treatment. The treatment must be for the schizophrenic patients best interest and that it prevents harm from occurring to the patient and others around him.

 Utilitarianism- the rightness and wrongness of actions is determined by the goodness and badness of their consequences. actions are good insofar as they tend to promote happiness, bad as they tend to produce unhappiness. Consequences, effects, result and outcomes are the most important. We ought to choose the action that produces the most benefits at the least cost of pain or unhappiness. In our case, the nurse carry out the treatment to the schizophrenic patients without their consent, but the effect is that they will be cured. As we have said earlier, the treatment implemented must be for the patients best interest, we need to consider which of the available options has the greatest potential to create benefit to the patient. The best-interest standard reflects a utilitarian perspective with the emphasis on consequences and greatest utility.

Viewpoint of the Church

Group viewpoint:
Our group feels that it is ethical and justifiable to treat schizophrenic patients against their will if they are really dangerous because most likely, they can harm themselves and others. Treating schizophrenic patients is necessary for them to live a normal life again with their loved ones and to do their everyday responsibilities

Summary
To summarize everything, schizophrenic patients exhibit symptoms of delusions, hallucinations, bizarre behavior, disorganized thinking and speech and social withdrawal. There are different types of schizophrenia, the paranoid type, disorganized type, catatonic type, undifferentiated type and residual type and is caused by several factors. They are the genetic factors, neurochemical factors and immunovirological factors. As nurses, even though we only carry out the doctors order, we still need to be familiar with the disorder so that we can accurately assess the patients decision making capability. Proper implementation of treatments must be carefully planned to be able to successfully achieve the desired outcome.

Conclusion
In conclusion, when dealing with schizophrenic patients the nurse must know the signs and symptoms of schizophrenia. It is only by knowing the symptoms of schizophrenia can the nurse get accurate results during the assessment of the decision-making capacity of the patient. Our survey results showed that 68.75% of our respondents felt that schizophrenic patients are incapable of making decisions regarding their treatments. 50% of our respondents felt that schizophrenic patients are dangerous and that 83.3 % of those people who had encountered a schizophrenic patient felt scared. This result show the need for schizophrenic patients to get treated as soon as possible especially if there are instances where they exhibit signs of harming themselves or others around them.

 If they are found incapable of making decisions, their immediate family must decide for them regarding their treatment. Hence in this sense, it is ethical and justifiable for nurses to carry out the doctors order of treatment even without their consent as long as the family of the patient has agreed to the treatment especially if the treatment is for the patients best interest.

Recommendation
When giving treatment to schizophrenic patients, the nurse must provide safety and extra care. The nurse must be familiar with the signs and symptoms of the mental disorder in order for the nurse to make an accurate assessment of the schizophrenic patients decision-making capability. The nurse must always bear in mind that the patients welfare is in her hands. Hence, whatever the nurse does must be appropriate to the clients situation. Proper implementation of treatments must be carefully planned to be able to successfully achieve the desired outcome. The nurse must also know his duties and responsibilities so that she will always be on the right track.