Problem
Presenting Patrick Smith, a 33-year-old single male on a Disability Support Pension who lives in a Supported Residential Service (SRS). Patient has previously been diagnosed with Paranoid Schizophrenia and been treated with antipsychotic medication for the past 5 years. However, Patrick has been non-compliant with anti-psychotic medication for the last 3 months. Patrick complains the medication makes him put on weight and make him feel "weird." Patrick states when he feels "weird" this includes him walking or pacing all the time as "my legs feel restless" and he is also distressed about putting on 20 kilos of weight since taking the medication and reports he always "feels hungry" when he takes the medication. Patrick was diagnosed with type 2 diabetes one year ago and he found this very upsetting as no one in his family background has diabetes. The GP had referred Patrick to a dietician when he began putting on weight, however Patrick found enormous difficulty complying with the meal plans as all the food is prepared in the Supported Residential Service and they do not provide individual meal requests. The dietician informed Patrick he was experiencing 'metabolic syndrome' however, Patrick does not know what this means and did not want to discuss this with the dietician as he did not want to appear foolish by asking questions where the answer appeared quite simple to clinicians around him. The dietician and GP have advised him to increase his physical activity, but after taking the medication Patrick reports feeling tired and exhausted all the time and mainly sits down to watch TV and smokes 30 cigarettes a day. He is only checking his BGL sporadically and taking some oral medications intermittently to control his blood glucose when prompted by the SRS staff. He is now required to self-administer insulin but has so far been non-compliant. SRS staff report that due to acuity of workload it is difficult to catch up with Patrick and encourage him to complete the BGL and have his insulin.
Patrick presented at the Emergency Department with an ulcer on his left foot. It is malodourous with significant purulent exudate. Patrick was reviewed by the Endocrinology Team who are concerned with Patrick's unstable diabetes. He has been reviewed by the Vascular Surgical team, who are concerned that the ulcer may lead to osteomyelitis and/or sepsis and believe that Patrick requires urgent surgery and antibiotic therapy.
Patrick should be taking the anti-psychotic medication: Olanzapine 20mg (nocte) and Quetiapine 200mg BD. Patrick is fearful of being in a strange place and finds being in hospital frightening as he feels someone might kill him. He tells you he is suspicious of a lot of people on the ward including other patients and health care professionals as he is scared, they might hurt him. He tells you he is fearful about being locked up for a crime he has never committed but there is a conspiracy against him, and he knows the CIA are involved, with a plot being organised against him the USA secret service, and it is the CIA who have sneaked into his room at night while he was asleep and put acid on his left foot which has caused this ulcer. In a phone call to you Patrick's parents have told you they were fearful of having Patrick at home as they are frightened as he has been verbally aggressive towards them recently, which they feel is out of character, accusing his mother, father, and siblings of being involved in the CIA plot to kill him. You are the nurse looking after Patrick and he tells you that he has no thoughts of suicide or self-harm. However, he will hurt someone in self-defence if he feels they are trying to kill him. He no longer wants the medical treatment, he clearly states he no longer consents to treatment and wants to discharge himself out of hospital against medical advice. He states he will see his GP post leaving hospital and arrange community treatment for his mental health and medical issues. He is clear with you that he no longer provides informed consent for medical treatment, that he has presumed capacity under the Mental Health Act (2014), and he is voluntary in status and wishes to discharge himself immediately.
The consequences of Patrick not having medical and surgical treatment puts him at significant risk of Sepsis and possible amputation of his left lower limb.
Task
How would you as a Registered Nurse prioritise and manage this situation?
In your answer you are required to consider the Registered nurse standards for practice, (Nursing and Midwifery Board of Australia [NMBA], 2016), Mental Health Act (2014); Recovery Focused Principles; Trauma Informed Care; Strengths Based Practice; The Mental Health Nursing Standards by the Australian College of Mental Health Nurse (2013); and consider the Medical Treatment Planning and Decisions Act (2016).