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California could change how nursing home residents receive antipsychotics

California could change how nursing home residents receive antipsychotics

Picture of William Heisel

There’s a debate stirring over the use of antipsychotic drugs in nursing homes.

The California Culture Change Coalition is considering a recommendation that doctors be able to sign a consent form ostensibly on behalf of nursing home residents, allowing the doctors to give those patients antipsychotic drugs.

The Coalition is advising California’s 1,200 skilled-nursing facilities and the agencies that regulate them.

Members of the Coalition include patient advocates, members of nursing home lobby, and members of the California Hospital Association. The industry groups have been arguing for a form that does not require a patient or family member signature, the idea being that at times patients are so incapacitated that they can’t make effective decisions for themselves.

Marian Hollingsworth is a member of the coalition, and a veteran patient advocate who has been monitoring the debate. She thinks that the Coalition would be making a significant change in course with just this one form. She wrote me to say:

My father was the victim of antipsychotic drugs given in a nursing home without my knowledge or consent – so I have a personal interest in the outcome of the vote. … My concern is that this vote is being done quietly and secretly even though it will be affecting thousands of Californians. … The fact that the group is even entertaining the idea of a consent form without a signature is frightening.

The Coalition was scheduled to vote on the consent form in August but tabled the vote at the last minute because of the level of disagreement among the members.

The challenges are complex.

One question is whether to include dementia as a reason for giving residents antipsychotic drugs. Estimates show that more than half of all nursing home residents suffer from Alzheimer’s or some other form of dementia, and yet the antipsychotic drugs prescribed to combat these illnesses have proven to be harmful and even fatal. Read Risperdal’s black-box warning, for example.

The Centers for Medicaid and Medicare Services have been pushing to lower the rates of antipsychotic use in nursing homes. The agency challenged states to reduce antipsychotic use among elderly patients with dementia by 15 percent six months after the target was set in 2012, followed by another 15 percent in the second six-month period.

The project did not hit the full goal, but did succeed in lowering antipsychotic use a total of 15 percent. Also, it’s worth noting that this is based on self-reported numbers by the nursing homes.

Were California to allow dementia to be one of the reasons to give nursing home residents antipsychotics, it would run counter to the national trends and counter to the FDA recommendation against antipsychotics for elderly patients with dementia.

There also is a question of what current California law requires. The industry members of the coalition note that state law does require that consent be obtained or verified but does not specifically say a signature is required. A doctor, for example, could note in a patient’s records that the patient consented to be given antipsychotic drugs. 

The group should receive high marks for making its deliberations accessible. It publishes its meeting minutes online shortly after the meetings are held. In the August 19 meeting minutes, the group noted:

It is clear in the regulations that the ‘prescriber’ has the responsibility to gain informed consent. It is not required by law that the patients or their representative sign the form, so this might be rejected by some groups. We can recommend it as a best practice.

One recommendation the coalition discussed was whether to recommend two different antipsychotic medication forms: one that would require the signature of the patient and the other that would not require a signature.

Hollingsworth called this suggestion “ludicrous.” She told me, “No one is going to get a signature if it's not required.”  

I asked a few questions of Tony Chicotel, a staff attorney of California Advocates for Nursing Home Reform and the moderator for the group considering the proposal. He did not respond last week. I’ll let you know if I receive some answers.

Many of you have family members or friends in skilled-nursing facilities or have written about patient care in those settings. What do you think? Send me a note at askantidote [at] or via Twitter @wheisel.

Photo by K. Kendall via Flickr.


Picture of <span class="username">Guest (not verified)</span>

Hi William, I am a stakeholder with this group.... I formed FATE over 30 years ago because my aunt was also medicated with antipsychotics without my family's knowledge and she died as a result.... I know Marian Hollingsworth very well as she has been a FATE client for several years. I also know Tony Chicotel of CANHR. FATE works for the preventions of elder abuse and we have served over 4,500 patients and families all over the country and have clients in every state. I would certainly like to talk with you about your article on this very important issue of patient rights.... Please feel free to call my office at (916)481-8558 and go to our web site at to see the work we do. thank you for your interest in this issue..
Carole Herman/President
Foundation Aiding The Elderly (FATE)
Sacramento, CA

Picture of <span class="username">Guest (not verified)</span>

Thanks for this informative article on antipsychotics in nursing homes. Nursing homes do not have enough staff so many times this is what is used instead.

Picture of <span class="username">Guest (not verified)</span>

Hi Bill,
Thanks for calling attention to this enduring problem of the inappropriate prescribing of antipsychotic medications in the elderly who reside in California nursing homes and the debate about consent. It's an issue I wrote about in January 2012 for the Bay Citizen that appeared in the New York Times. (see: California Advocates for Nursing Home Reform, for which Tony Chicotel is an attorney, spearheaded a campaign to stop this problem of inappropriate prescribing of these medications in nursing homes.

Picture of <span class="username">Guest (not verified)</span>

This law would legalize doctors lying. Giving or withholding consent is a sacred right of accepting responsibility for your decision. Either give the doctor power of attorney to make these decisions, or else say the doctor can override the patient to make these decisions. Defining the law as the doctor giving consent for the patient is a disgusting perversion of reality. It would legally turn the patient from a person into an object with no authority of consent.

This is one step away from doctors being able to consent people for medical experiments.

Picture of <span class="username">Guest (not verified)</span>

There is a skilled nursing facility in San Diego County called Mission Hills Healthcare. CNAs working there have reported NUMEROUS Times to Dept of health and human services that the patients there are in serious danger of being HARMED and NOBODY HAS investigated. Yes, Mission Hills Healthcare in San Diego County, has about 48 patients, many whom are VULNERABLE and can't speak, who are being NEGLECTED and ABUSED daily due to insufficient staffing patterns within Mission Hills. Mission Hills Healthcare hires only ONE LVN for every 48 patients. And too few CNAs. As such, CNAs who work here have reported that many dementia patients have been left unattended and "fallen" and received "injuries" but the owner of the home, Peter HIggins, doesn't want anyone working for him to call 911, so it all goes UNREPORTED. Patients at Mission Hills Healthcare are being ABUSED and NEGLECTED. Nurses who work there are overwhelmed by patient load. The level of staffing and patient care is substandard and is contributing to DEATHS of vulnerable patients and nobody with a brain is investigating this stuff. Where is San Diego Adult Protective Services? Or Department of Health and Human Services? Why aren't there PRO active and acute responsive strategies in place to catch these BAD and dangerous skilled nursing facilities?

Picture of <span class="username">Guest (not verified)</span>

Peter Higgins. Works in San Diego County. Runs home contracted by Veterans Administration.

Facility called Mission Hills. Higgins appointed a Mexican American CNA with a known drinking and drug problem on the job as a "social worker." This CNA has no training being a social worker.

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