Current through Register Vol. 48, No. 12, March 22, 2024
This Section addresses the use of psychotropic medications or
electroconvulsive therapy (ECT) in the treatment of patients receiving services
within Department programs.
Definitions
"Authorized involuntary treatment" means psychotropic
medication or electroconvulsive therapy, including those tests and related
procedures that are essential for the safe and effective administration of the
treatment. [405 ILCS 5/1-121.5]
"Capable" means the ability of the recipient to make reasoned
decisions regarding treatment/habilitation alternatives.
"Code" means the Mental Health and Developmental Disabilities
Code [405 ILCS 5 ].
"Electroconvulsive therapy (ECT)" means the use of electrical
stimulation, for therapeutic ends, to induce a generalized seizure.
"Guardianship" refers to the legal relationship between an
adult recipient or ward and a court appointed guardian, including a public
guardian such as the Office of State Guardian. Illinois guardians may make
legally binding decisions on behalf of wards in personal or financial affairs,
or both. For the purposes of this Part, the guardian must have court authority
to make personal decisions for the ward. Guardians with personal
decision-making authority will typically act under a plenary guardianship. A
plenary guardian is one who has full decision-making authority over the person
without restrictions. However, a guardian may also legitimately act under a
temporary or a limited guardianship in which the guardian has clearly defined
medical decision-making authority. A parent of an adult recipient without
guardianship is not legally authorized to make binding decisions on behalf of a
recipient. When doubt exists as to the decision-making authority of a guardian,
the guardian shall supply either letters of office or a copy of a court order
documenting legal authority to act on behalf of the ward.
"Informed consent" means the voluntary and knowing choice by a
recipient or his/her legal guardian.
"Lack of capacity" means the inability, due to mental
impairment, to make reasoned decisions regarding treatment/habilitation
alternatives, including the taking of medication, by evaluating, among other
factors, information about the likelihood of therapeutic benefits and the risk
of side effects.
"Legally and clinically competent recipient" means an
individual who is not under guardianship and has the capacity to make reasoned
decisions and give informed consent.
"Legally and clinically incompetent recipient" means an
individual under guardianship or who lacks the capacity to make reasoned
decisions and give informed consent.
"Long-acting psychotropic medication" means psychotropic
medications, including but not limited to Haldol Decanoate and Prolixin
Decanoate, that are designed so that a single dose will have an intended
clinical effect for a period of at least 48 hours. [405 ILCS
5/1-113.5]
"Medical Coordinator" means the Medical Coordinator for Mental
Health (if the recipient resides in a mental health facility) or the Medical
Coordinator for Developmental Disabilities (if the recipient resides in a
developmental disabilities facility).
"Medication", as used in this Section, means psychotropic
medication.
"Psychotropic medication" means medication used for
antipsychotic, antidepressant, antimanic, antianxiety, behavioral modification
or behavioral management purposes, as listed in the Physician's Desk Reference
(PDR), Drug Information Manual and Drug Facts and Comparisons, as incorporated
by Section
112.80(a),
or where there is a body of peer reviewed medical literature supporting its
use.
"Substitute decision maker" means a person who possesses the
authority to make decisions under the Powers of Attorney for Health Care Law
[755 ILCS 45 /Art. IV] or under the Mental Health Treatment Preference
Declaration Act [755 ILCS 43 ]. [405 ILCS 5/1-110.5]
Procedures
a)
Evaluation
1) No psychotropic medication or
electroconvulsive therapy (ECT) shall be prescribed for a recipient unless
examinations have been conducted in accordance with Section
112.30.
The prescribing physician shall conduct the examinations personally, or shall
review the record of the examinations. The prescribing physician shall record,
sign, and date (with time) the prescription. The prescribing physician shall
also document in the recipient's clinical record any appropriate clinical
information.
2) With regard to
psychotropic medication on an emergency basis, the requirements of subsection
(a)(1) need not be met when the prescribing physician has determined by
personal observation or from information supplied by another clinician with
thorough knowledge of the recipient's current clinical condition that the
recipient is in need of immediate medication in order to prevent the recipient
from causing serious and imminent physical harm to self or others.
b) Informed Consent
Prior to prescribing psychotropic medications or ECT in
non-emergency situations, a physician shall ascertain and document whether the
recipient is capable of giving informed consent.
1) Legally and Clinically Competent
Recipients
A) If the recipient is able to give
informed consent, the physician shall advise the recipient, in writing, of the
following:
i) nature and purpose of the
proposed treatment;
ii) whether the
proposed treatment requires periodic testing/procedures to ensure
safety/efficacy;
iii) side effects,
risks and benefits of the proposed treatment;
iv) prognosis and risks without the proposed
treatment;
v) alternative
treatments and their risks, side effects, benefits and efficacy; and
vi) the right to refuse the proposed
treatment.
B) The
required information shall be given to the recipient in a manner consistent
with his/her ability to understand, including regular use of sign language for
any deaf or hard of hearing individual for whom sign language is a primary mode
of communication.
C) Informed
written consent shall be obtained from the recipient.
D) If the recipient has previously executed a
declaration for mental health treatment under the Mental Health Treatment
Preference Declaration Act or a health care power of attorney under the Power
of Attorney for Health Care Law, the facility is required to act in accordance
with that declaration or power of attorney.
2) Legally and Clinically Incompetent
Recipients
A) Prior to prescribing
psychotropic medications or ECT in non-emergency situations, a physician shall
advise the recipient and the recipient's guardian or substitute decision maker,
in writing, of the following:
i) nature and
purpose of the proposed treatment;
ii) whether the proposed treatment requires
periodic testing/procedures to ensure safety/efficacy;
iii) side effects and risks of the proposed
treatment;
iv) prognosis and risks
without the proposed treatment;
v)
alternative treatments and their risks, side effects, benefits and efficacy;
and
vi) the right to refuse the
proposed treatment.
B)
The required information shall be given to the recipient and the recipient's
guardian or substitute decision maker in a manner consistent with his/her
ability to understand, including regular use of sign language for any deaf or
hard of hearing individual for whom sign language is a primary mode of
communication.
C) The recipient
shall be asked if he/she agrees to receive the proposed treatment. If the
recipient does not object, informed written consent shall be obtained from the
recipient's guardian or substitute decision maker and shall be documented in
the recipient's medical record. If the recipient has no guardian or substitute
decision maker or if the guardian or substitute decision maker does not provide
such informed written consent, any treatment must proceed in accordance with
subsection (c) (Refusal of Treatment).
D) If the recipient objects to the proposed
treatment, any treatment must proceed in accordance with subsection (c)
(Refusal of Treatment).
E) If the
recipient has previously executed a declaration for mental health treatment
under the Mental Health Treatment Preference Declaration Act or a health care
power of attorney under the Power of Attorney for Health Care Law, the facility
is required to act in accordance with that declaration or power of
attorney.
c)
Refusal of Treatment
A recipient's refusal to receive psychotropic medication or ECT
does not in itself constitute an emergency. Such refusal, as documented in the
clinical record, shall be honored except in the following circumstances:
1) Emergencies
In an emergency, when treatment is necessary to prevent a
recipient from causing serious and imminent physical harm to self or
others.
A) In such an emergency, a
member of the treatment/habilitation team shall document in the recipient's
clinical record that the staff have explored alternative treatment options to
contain the emergency. The documentation shall include a written explanation of
the reasons why alternative treatments are not appropriate.
B) For administration of psychotropic
medications the prescribing physician or a nurse in consultation with a
physician shall document his/her determination that an emergency exists based
on a personal examination of the individual. Administration of the medication
shall be accompanied by a physician's order.
C) In prescribing psychotropic medications on
an emergency basis the prescribing physician shall examine the recipient and
document his/her determination of the initial emergency and response, including
the circumstances leading up to the need for emergency treatment, in the
recipient's clinical record as soon as possible, but within 24 hours.
Psychotropic medication may not be continued unless the need for such
medication is redetermined at least every 24 hours and the circumstances
demonstrating that need are set forth in the recipient's clinical record. A
redetermination is based on a personal examination of the recipient by a
physician or a nurse with the consultation of a physician.
D) Treatment shall not be administered over a
recipient's refusal under Section 2-107 of the Mental Health and Developmental
Disabilities Code for a period in excess of 72 hours, excluding Saturdays,
Sundays and holidays, unless the treating physician with the support of the
treatment/habilitation team files a petition for a court order under Section
2-107.1 of the Code and the treatment continues to be necessary in order to
prevent the recipient from causing serious and imminent physical harm to self
or others. If no such petition is filed, treatment must be
discontinued.
E) A restriction of
rights form shall be completed for each administration of emergency
treatment.
F) ECT may be
administered over a patient's refusal only with a court order and prior written
physician's order or in emergency situations as defined in Section 2-107 of the
Code.
G) Upon commencement of
services, or as soon thereafter as the condition of the recipient permits, the
facility shall advise the recipient as to the circumstances under which the use
of emergency forced medication is permitted under Section 2-107(a) of the
Mental Health and Developmental Disabilities Code [405 ILCS
5/2-200(d) ].
Concurrently, the facility shall ask the recipient which form
of intervention he/she would prefer if any of these circumstances arise. The
recipient's preference shall be documented in the clinical record and
communicated by the facility to the recipient's guardian or substitute decision
maker, if any. If any such circumstances arise, the facility shall give due
consideration to the preferences of the recipient regarding which form of
intervention to use as communicated to the facility by the recipient or as
stated in the recipient's advance directive.
H) Under no circumstances may long-acting
psychotropic medications be administered under Section 2-107 of the
Code.
I) Under no circumstances may
ECT be administered to a minor recipient without a court order.
2) Administration of Treatment on
Court Order
A) If the treating physician, with
the support of the treatment/habilitation team, determines that psychotropic
medication or ECT is clinically indicated for a recipient who does not at the
time pose an imminent risk of serious physical harm to self or others, and the
situation described in subsections (b)(2)(c) or (b)(2)(D) of this Part applies,
the facility may file a petition in the circuit court under Section 2-107.1 of
the Code for court-ordered treatment.
B) If the treating physician, with the
support of the treatment/habilitation team, files a petition under Section
2-107.1 of the Code, a physician shall examine the recipient and address the
following issues for the court:
i) whether the
recipient has a serious mental illness or developmental disability;
ii) whether, because of the mental illness or
developmental disability, the recipient exhibits any one the following:
deterioration of his/her ability to function, suffering, or threatening
behavior;
iii) whether the illness
or disability has existed for a period marked by the continuing presence of the
symptoms set forth in subsection (c)(2)(B)(ii) or the repeated episodic
occurrence of such symptoms;
iv)
whether the predicted benefits of the treatment will outweigh any possible
harm;
v) whether the recipient
lacks the capacity to make a reasoned decision about the treatment;
vi) whether other less restrictive treatment
methods have been explored and found to be inappropriate;
vii) the specific treatments proposed,
including dosage range and/or frequency of administration, as applicable;
and
viii) if the petition seeks
authorization for testing and other procedures, the physician shall include a
statement that such testing and procedures are essential for the safe and
effective administration of the treatment.
C) If the court grants the petition for
involuntary treatment pursuant to Section 2-107.1 of the Code, the recipient
may be administered treatment over his/her refusal (or the guardian's or
substitute decision maker's refusal if the recipient was legally incompetent
but did not object) within the constraints and for the duration of the court
order.
d)
Monitoring of Treatment
1) Documentation
A) The attending physician shall examine and
document the status of the recipient's condition in the recipient's clinical
record as often as the recipient's clinical condition warrants but no less
often than every 30 calendar days. Documentation of the rationale for
treatment, including type, dosage or frequency of the proposed treatment as
applicable, shall be included. Beneficial effects and significant side effects
as well as their treatment and/or management or the absence of treatment and/or
management shall also be noted.
B)
Facility staff shall document in the recipient's clinical record additional
clinical information such as assessments, evaluations or laboratory results as
they become available.
2) Treatment Review
A) When a recipient at a State-operated
mental health facility has been receiving psychotropic medications and/or ECT
continuously or regularly for a period of three months, and if such treatment
is continued, every six months thereafter for so long as the treatment shall
continue, the facility medical director, or other physician designated by the
facility director, shall convene a treatment review panel.
B) The panel shall consist of representatives
from at least two of the following clinical disciplines: psychiatry, medicine,
clinical pharmacy and nursing. At least one panel member shall be a physician
with expertise in the use of psychotropic medication (for example, psychiatrist
or behavioral neurologist).
C) At
least 7 days prior to the date of the treatment review panel meeting, the
recipient, guardian or substitute decision maker, if any, and any person
designated under Section 2-200(b) of the Mental Health and Developmental
Disabilities Code shall be given written notification of the time and place of
the treatment review panel meeting. The notice shall also advise the recipient
of his/her right to designate some person to attend the meeting and assist the
recipient in accordance with Section 2-107.2 of the Mental Health and
Developmental Disabilities Code.
D)
The panel shall provide a recommendation concerning the suitability of
continued treatment.
E) If, during
the course of the treatment review panel meeting, the recipient advises the
committee that he/she no longer agrees to continue receiving medication or ECT,
or if the recipient has a guardian or substitute decision maker and the
guardian or substitute decision maker refuses medication or ECT for the
recipient, the treatment shall be discontinued, except when the recipient is
receiving treatment pursuant to subsections (c)(1) and (c)(2) of this Section.
i) If the panel determines that the recipient
is receiving appropriate treatment and that the benefit to the recipient
outweighs the risk of harm to the recipient, treatment shall be continued,
provided that the recipient does not object (and the guardian or substitute
decision maker, if any, does not refuse). (See Section 2-107.2 of the
Code.)
ii) If the findings of the
treatment review panel are not in agreement with the current treatment plan,
revision shall be considered by the treatment/habilitation team.
iii) If there is disagreement on the
implementation of the panel recommendations, the facility medical director or
lead physician (designated by the facility director) shall review the case and
make a final decision. The facility medical director (or lead physician) may
consult with the appropriate Medical Coordinator in making a final
determination.
F) The
participation of the recipient and guardian or substitute decision maker if
any, and the recommendations of the treatment review panel shall be recorded in
the recipient's clinical record.
3) Annual ECT Report
The Department of Human Services shall summarize on an annual
basis all quarterly reports (prepared in accordance with Section 2-110.1 of the
Mental Health and Developmental Disabilities Code) from State-operated
hospitals or facilities at which ECT is performed.