One of the most common forms of treatment for individuals with mental illnesses involves the use of psychotropic medications.  For many patients, such medications have a beneficial impact and are considered the treatment of choice.  Despite the potential benefits, many patients refuse to voluntarily accept prescribed psychotropic medications during inpatient hospitalizations.  New York State’s Mental Hygiene Law does not specifically address the involuntary administration of treatment to patients in psychiatric hospitals.  However, controlling case law and regulations adopted by the Office of Mental Health (OMH) authorize hospitals to administer medication to patients over their objection under certain circumstances.   

The Court of Appeals (the state’s highest court) in Rivers v. Katz established the circumstances in which psychotropic medications may be administered to hospitalized patients who refuse them.  In that case, the Court ruled that involuntary patients have a constitutional right to refuse medication.  The Court also ruled, however, that the right to refuse medication is not absolute and that hospitals may treat patients with psychotropic medications over their objection if they are either (i) imminently dangerous to themselves or others, or (ii) have been found by a court to be mentally ill and to lack capacity to make reasoned decisions concerning their treatment.

After the Rivers case was decided, OMH adopted regulations setting forth the processes for administering medications to patients in psychiatric hospitals.  The regulations provide that hospitals may give “emergency treatment” (commonly referred to as STAT or PRN treatment) to any inpatient, regardless of admission status, who is “presently dangerous and the proposed treatment is the most appropriate reasonably available means of reducing that dangerousness.”  Treatment includes, among other things, the administration of psychotropic medications and electroconvulsive therapy (ECT).   The term “dangerous” is defined in the regulations to mean that “a patient engages in conduct or is imminently likely to engage in conduct posing a risk of physical harm to himself of others.”  Any treatment provided under these circumstances may continue only as long as necessary to prevent dangerous behavior.             

The regulations also establish the administrative process that hospitals must complete in order to seek court authorization to treat involuntary patients over their objection.  It is important to note that the regulations do not authorize hospitals to seek a court order to involuntarily treat informal or voluntary patients.  

If an involuntary patient refuses to accept the proposed treatment, the treating physician must formally evaluate the following:

1. whether the treatment is in the patient’s best interest in light of the risks, benefits, and available alternatives;
2. the nature of the patient’s objections; and
3. whether the patient is capable of making an informed decision about whether to accept the treatment.

If the physician concludes that the treatment is in the patient’s interest and the patient lacks capacity to make a reasoned decision, he or she must inform the patient and Mental Hygiene Legal Service (a branch of the New York State court system that provides legal services, advice and assistance to persons receiving care at inpatient facilities.)

If the patient continues to refuse to accept the proposed treatment after the treating physician’s evaluation, the hospital’s clinical director must arrange for a second physician’s opinion of the three issues listed above.  The second physician must review the patient’s hospital chart and personally examine the patient.  If the second physician concurs with the first, he or she must inform the patient.

If the patient continues to refuse the proposed treatment, the hospital’s clinical director must determine whether the patient has capacity to make a reasoned decision concerning treatment and whether treatment is in the patient’s best interests. If the clinical director determines the patient lacks capacity and needs the treatment, he or she may apply for court authorization to administer the proposed treatment.

Upon the hospital’s application for treatment over objection, the court will schedule a hearing (commonly known as a “Rivers hearing”) to determine whether (i) the patient lacks capacity to make a reasoned decision regarding treatment due to his or her mental illness and (ii) whether the proposed treatment is appropriately tailored to the patient’s condition.  The court must make these determinations upon clear and convincing evidence presented by the Hospital.  The patient is entitled to present evidence at the hearing and to be represented by an attorney from Mental Hygiene Legal Service.