Summary

The reasons for court-ordered treatment can be complex. If a person is thought to be a danger to themselves or others, or has a grave incapacity, they may be treated on an involuntary basis. This involves court recommendations and the continual monitoring of the client through the medical and court system. Each state designates the guidelines for mental health treatment when necessitated by court order. These directives address circumstances, length of time, and individual rights. Court-ordered treatment may take place inside a health-care facility, out in the community (whether residential or day treatment, including mandatory support group attendance), or in visits to mental health-care providers. There are two types of processes to initiate involuntary commitment: (1) emergency and (2) judicial. Some states permit emergency treatment orders, which allow provision of medically prescribed treatment with or without consent.

Nurses should not assume that clients are choosing to act violently; often clients may not be in control of personal responses. Ongoing nursing assessment with early intervention at lower stages of clients’ anxiety will contribute to safety for everyone involved. Further, appropriate nursing care includes teaching to increase the client’s self-management ability.

Though policies and procedures vary across facility settings in all states, safety for clients and staff and ethics in nursing practice are the truest guides. Person-centered, trauma-informed care directs nursing action. Least restrictive methods for management of aggressive behavior include the therapeutic relationship, time-out, and PRN medication. Most restrictive measures include the use of medication by court order, seclusion, and restraint.

Powers of attorney, health-care proxies, and other advance directives address decision-making by designated others when a person is not capable of making decisions themselves. State law varies as it applies to these concepts in terms of who a client can designate and the manner and documentation that must be used to designate them. The rate of psychiatric advance directives completion is low in the United States, which may suggest an opportunity for education in nursing practice. The nurse as advocate and educator is in position to inform individuals and families of the option to make an advance directive for mental health care.

Guardianships and conservatorships are created through the courts to manage financial, legal, and personal matters for a person who lacks competence to do so. Competence is a determination also made by the courts; it is defined by state law, and these laws vary. Someone can petition a court to secure a guardian for a client for a number of reasons, such as mental illness impairing judgment to make legal, financial, and personal decisions; inability to meet basic needs; cognitive impairment; or impaired by illness. While the purpose of guardianships is to honor the person’s wishes by appointing someone to make decisions in line with what they might have wanted, ethical considerations abound. Nurses grapple with the loss of autonomy experienced by these clients as weighed against ensuring their safety.