COVID-19, Autonomy, and the Inpatient Psychiatric Unit
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THE LEARNER'S VOICE
COVID-19, Autonomy, and the Inpatient Psychiatric Unit Stephanie London 1 Received: 19 May 2020 / Accepted: 8 September 2020 # Academic Psychiatry 2020
Jacob could not keep his mask on. The material felt harsh and irritating against his skin. He felt claustrophobic and found it difficult to breathe. Jacob is a young man with schizophrenia who was hospitalized involuntarily on our psychiatric unit, a medical psychiatric unit in a major urban hospital, at the peak of the COVID-19 crisis (his name has been changed to protect confidentiality). Jacob was one of the first patients I cared for on what happened to be my first inpatient psychiatry rotation as a doctor and psychiatry resident. It was also during this time that our hospital adopted new rules around COVID protection, including a requirement that all patients wear masks whenever they are outside their rooms. This is especially limiting to the psychiatric patient population, who are otherwise physically healthy and ambulatory and usually move freely throughout the psychiatric unit. Jacob struggled with disorganized thinking and found it particularly difficult to comply with our hospital’s mask policy. Even when Jacob would agree to wear his mask, it would inevitably end up ripped, tucked beneath his chin, or hanging off his ear entirely. Alongside nursing and occupational therapy, we tried different approaches to encourage Jacob to wear his mask appropriately. Efforts to make the mask more comfortable were not successful. Extensive conversations about the importance of mask wearing, while met with some understanding and motivation, could not overcome his discomfort. Our team discussed the risks posed to others by allowing Jacob not to wear a mask with the potential harms of damaging our therapeutic relationship and potentially triggering agitation. Psychiatric units are especially susceptible to viral outbreaks given patient challenges with personal hygiene as well as frequent interactions with others in day rooms and during groups [1]. Mask wearing is not just a question of personal autonomy, but also a choice that puts others at risk. The choice by one
* Stephanie London [email protected] 1
Massachusetts General Hospital/McLean Adult Psychiatry Residency Program, Boston, MA, USA
patient not to wear a mask jeopardizes the safety of all other patients on the unit, an already vulnerable population. On the other hand, even in the community where mask wearing is strongly encouraged, it is rarely enforced. We often protect individual autonomy to make medical decisions, even when those decisions could affect the health of others, such as with vaccines. As a practical matter, if a patient on a psychiatric unit refuses to wear a mask, the only way to keep them out of common spaces is through seclusion or restraint, which has proven to be traumatic and have serious repercussions on patient well-being. Ultimately, our team continued to ask Jacob to stay in his room and only come into common spaces if he was wearing a mask. This led to near co
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