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  Nude Vados, Chi Chi, Bulma, Vida DBZ Hentai

Submitter: [anonymous]
Type: Image (jpeg)
Category: Adult / Hentai
exhibition Date: 2018-06-06 18:24:23
Views: 948
Score: (not yet rated)
 

     
  Vados Sexy Girl Uncensored Dragon Ball Super Angel

Submitter: Luna
Type: Image (jpeg)
Category: Adult / Hentai
exhibition Date: 2018-06-06 18:40:44
Last Update: 2018-06-24 10:59:51
Views: 400
Score: (not yet rated)
 

     
  Penteract Projected

Submitter: [anonymous]
Type: Image (png)
Category: Objects
exhibition Date: 2018-05-06 14:43:25
Views: 1499
Score: 5.00 / 5.00 (Based on 1 votes.)
 

     
  Vados Nude - Dragon Ball Super Ecchi

Submitter: [anonymous]
Type: Image (jpg)
Category: Adult / Hentai
exhibition Date: 2018-06-06 18:16:19
Views: 260
Score: (not yet rated)
 

     
  Bulma Shower - Dragon Ball Z

Submitter: [anonymous]
Type: Image (jpg)
Category: Adult / Hentai
exhibition Date: 2016-09-01 17:03:58
Last Update: 2018-06-06 17:24:41
Views: 3460
Score: 5.00 / 5.00 (Based on 1 votes.)
 

     
  Lucy Nude Elfen Lied Coplay

Submitter: [anonymous]
Type: Image (jpg)
Category: Adult / Hentai
exhibition Date: 2016-09-01 20:39:00
Last Update: 2018-06-06 17:26:46
Views: 855
Score: (not yet rated)
 

     
  Android 18 Sexy Topless Nude Art

Submitter: [anonymous]
Type: Image (jpg)
Category: Adult / Hentai
exhibition Date: 2018-06-06 17:28:31
Views: 216
Score: (not yet rated)
 

     
  Vados Universe 10 Nude DBZ Angel Girl

Submitter: [anonymous]
Type: Image (jpg)
Category: Adult / Hentai
exhibition Date: 2018-06-06 17:34:49
Views: 245
Score: (not yet rated)
 

     
  Nude Shotgun Girl - Libertarian Angel

Submitter: [anonymous]
Type: Image (jpg)
Category: Adult / Hentai
exhibition Date: 2018-06-08 02:52:37
Views: 249
Score: 5.00 / 5.00 (Based on 1 votes.)
 

     
  Zangya DBZ Hentai Nude Girl Uncensored

Submitter: Luna
Type: Image (png)
Category: Adult / Hentai
exhibition Date: 2018-06-06 18:34:07
Last Update: 2018-06-06 18:34:20
Views: 217
Score: (not yet rated)
 
The universe is littered with the bones of those who dare to think otherwise.
-Zangya Dragon Ball Z: Bojack Unbound Movie Quote

Zangya (ザンギャ, Zangya) is one of Bojack's four Galaxy Soldiers in Dragon Ball Z: Bojack Unbound

     
  Lucy - Elfen Lied Cosplay

Submitter: [anonymous]
Type: Image (png)
Category: Adult / Hentai
exhibition Date: 2016-09-01 20:36:21
Last Update: 2018-06-06 17:24:22
Views: 580
Score: (not yet rated)
 

     
  Sexy Girl with Sniper Rifle

Submitter: [anonymous]
Type: Image (jpg)
Category: Adult / Hentai
exhibition Date: 2018-06-08 03:07:35
Views: 215
Score: (not yet rated)
 

     
  Asian Gun Girl Sexy & Naked

Submitter: Luna
Type: Image (jpg)
Category: Adult / Hentai
exhibition Date: 2018-06-08 15:35:51
Views: 201
Score: 5.00 / 5.00 (Based on 1 votes.)
 

     
  Videl - DBZ Girl Fan Art

Submitter: [anonymous]
Type: Image (jpg)
Category:
exhibition Date: 2014-11-27 21:48:41
Views: 1335
Score: (not yet rated)
 

     
  Nyuu - Elfen Lied Nude Cosplay

Submitter: [anonymous]
Type: Image (jpg)
Category: Characters
exhibition Date: 2016-09-01 20:38:06
Last Update: 2016-09-01 20:38:12
Views: 504
Score: (not yet rated)
 

     
  Kefka Saiyan Naked Uncensored DBZ

Submitter: [anonymous]
Type: Image (jpeg)
Category: Adult / Hentai
exhibition Date: 2018-06-06 18:43:05
Views: 152
Score: (not yet rated)
 

     
  Horo - Spice and Wolf Nude Cosplay

Submitter: [anonymous]
Type: Image (jpg)
Category: Adult / Hentai
exhibition Date: 2016-09-03 17:30:59
Last Update: 2018-07-01 00:11:24
Views: 2932
Score: 5.00 / 5.00 (Based on 1 votes.)
 
Holo (ホロ Horo) is a female deity and the protagonist of the light novel, manga and anime series Spice & Wolf.

Character Background

Holo is a wolf harvest deity that was bound by promise to the town of Pasloe for several centuries, ensuring a bountiful harvest of wheat for the residents. As the villagers became more self-reliant with time, however, Holo was neglected. Feeling unneeded and that she had kept her promise long enough, she skipped town with a traveling merchant named Lawrence, by 'jumping' from the villagers' wheat to Lawrence's wheat in his wagon. She longs to return to Yoitsu, her snowy homeland, and makes a contract with Lawrence to accompany her there.

Appearance

Holo is perhaps best described in her own words:

"At certain times, Holo will appear in the village in the form of a pretty young woman, and she is always seen as a mid-adolescent. A lovely figure, she has long flowing hair as well as wolf ears and a beautiful dark brown tail with a splash of white at the end."

Holo has fangs for canine teeth. At the beginning of her transformation, all her teeth morph into fangs.

In her human form, Holo appears as a 15 year-old girl with long orange/brown hair and red eyes, although she still retains her wolf ears and tail. Due to her trademark ears and tail, Holo often has to wear a hooded robe or head scarf, and long voluminous skirts that hides her unusual features from people, which she dislikes as she adores her tail. Holo's true form is a giant brownish golden wolf. In her wolf form, her eyes stay red, but her sclera turn yellow, and her fur is the same color as her hair in human form. Her size is massive: a little bit bigger than an elephant. In her wolf form she is able to talk through a form of telepathy, and is capable of reaching unimaginable speeds. After forming a contract with Lawrence, Holo wears clothes and a simple hood she found in Lawrence's wagon.

The outfit she first wears is actually Lawrence's best clothes (collected over a period of ten years), consisting of a purple shirt with a black, fur-lined vest, a black skirt, black and white pants and a long beige hooded robe. The linings are bear fur, and were made with quality tailoring.

After the incidents in Pazzio, Holo purchases a pink shirt with purple trim on the bottom of it, black pants with matching cuff trim, a red silk sash, a light Blue/Cyan anklet on her right ankle, two high quality hooded robes, and cow leather traveling shoes. Lawrence later gets a deal on clothes for Holo that were once worn by a noble: a head scarf made of white rabbit fur trimmed in dark red, and a black collared short cape fastened with a walnut button and matching trim.

Holo is only able to change form by consuming a few wheat grains or drinking some fresh blood. (The English vocal script recorded that it was only human blood she could use, but that was not in the subtitle translation.)

Personality

Holo is smart and confident, though the latter is mostly seen around Lawrence (probably because he is the person she is most comfortable with). She is considered to be flirtatious and manipulative towards him, while often mocking his (supposed) thinking and negotiating skills. However, she seems to have a really deep fear of being alone, and having grown fond of Lawrence as her company, she nurtures a strong affection for him. She is also seen to feel uneasy about showing him her wolf form, but will do so in order to protect him, even if it means putting her life at risk. She is usually good-humored and talkative. She speaks in a formal manner that might be expected of people during her younger centuries, and rarely, if ever, uses contractions.

Holo is a massive alcoholic, often drinking when having the chance to do so and usually getting drunk because of it, though being somewhat able to sustain her wit. She is also somewhat of a glutton. She often convinces Lawrence (usually using her feminine charm) to buy her food, which is usually in large quantities and, at times, expensive. This might just be because she is really a massive wolf and needs the appropriate amount of nutrition. A perfect example of this was when she bought over 80 apples, her favorite food, with Lawrence's money without his permission (which was the beginning of a large and growing debt with Lawrence). She also appreciates how different human food is compared to foraging in the forest, especially how cooking changes it.

Though she is a deity Holo still suffers from the same faults as many humans do, For one Holo does experience jealousy toward other girls who talk to Lawrence. This is not shown better than with her and Lawrence meeting the lovely shepherd girl Nora Arendt. Holo was against hiring Nora as a bodyguard not only because they didn't really need one but also for the fact that Nora and Lawrence became close very quickly. Given that shepherds are enemies of wolves is factored in to Holo's initial dislike for Nora. Holo is a very proud "wolf" but does understand that she does not know everything; an example of this is when Lawrence explains why people get sick via the four humors.

Abilities

Holo is a wolf deity and because of this she has several supernatural abilities.

Transformation: Holo has the power to transform instantly into a massive wolf (bigger than an elephant) . In this form she can move at high speeds, much faster than any other known land-bound creature, due to her large size accompanying the appropriate musculature and stride. She also uses her huge jaws in order to defend herself and Lawrence. To activate this form, she must either consume wheat or fresh blood. She can also transform only part of herself, such as one limb, but this takes several moments and puts a strain on her. Clearly, she is not used to doing so and it requires quite a bit of concentration.
Heightened Sense of Smell: This ability can be used both in her wolf and human form. Like most canines, wolves have an excellent sense of smell and can pick up a particular scent from far distances far greater than humans. This allows Holo to be able to detect dangers such as wolves and other people much quicker than Lawrence.
Eternal Youth: Holo has lived for many centuries and is not visibly aged past 15 years old (at least in her human form). She credits her wisdom from the experiences her long life has given her. However she is not immortal, she explains that if the wheat she dwells in is destroyed, she would disappear.
Enhanced Hearing: Being a wolf Holo has great hearing. She is able to hear tiny sounds much farther away than humans, or from the other side of solid walls and floors. Her ears are so sensitive that she can hear the subtle differences in purity of coins by shaking them together. Holo's ears also have the ability to determine if a person is telling a lie or not. However she admits it's not 100% accurate.
Intense Howl: While she can howl perfectly well in human form, Holo can muster an extremely loud and powerful howl after taking a very deep breath. In an enclosed space, it can crack and disturb stonework. It was used in the underground tunnels of Pazzio to scare off a pack of tracking dogs. However, doing so is like intense, prolonged screaming that hurts the vocal cords, causing coughing and a sore throat.
Accelerated Crop Growth: Holo can cause nearby crops such as wheat or rye to grow and wither faster, if needed almost instantly. However since the crops need a great amount of nutrients from the ground that can only be replenished naturally, doing so puts great stress on the soil. Holo understands this cycle well, and when she first arrived in Pasloe, had warned that poor harvests were naturally inevitable for the fields to recover from several years of bountiful harvests.

Quotes

All quotes are from the English dub of the anime adaptation.

"I am not so grand, not as a god. I am Holo, and Holo is all that I am." (Season 1, Episode 1)

"I am Holo the Wise Wolf, and I am a very proud wolf." (Season 1, Episode 1)

“A trip is the most fun before one sets out on it. With dogs, the bark and not the bite is more frightening and women are almost always prettier when they are shrouded in mystery. I can never be as pretty as you imagine and I would never do something like that to you. Would it not be better to imagine?” (to Zheren, Season 1, Episode 2)

"Stupid potato!" (Season 1, Episode 2)

"Really? One true god did everything, and the humans are merely borrowing it? Nature is not a thing which can be created by someone." (Season 1, Episode 2)

“When a person lies, what is important is not the lie itself. No, it is their reason. Their why.” (to Lawrence, Season 1, Episode 2)

“If you only get upset when you are tricked, you will not go very far.” (to Lawrence, Season 1, Episode 3)

“All men are jealous idiots. And women are stupid too, to feel happy about it. It's true, there are idiots everywhere!” (to Lawrence, Season 1, Episode 3)

"I do not want to wake from my dream and discover that I am all alone. I am tired of being alone! I do not want to be cold! I do not want to be lonely!" (to Lawrence, Season 1, Episode 4)

“Loneliness is a disease that can lead to death. They might as well be the same thing.” (to Lawrence, Season 1, Episode 4)

“I am pretty, so human males have been known to fall for me. So it would be wise to remember I am too strong for a human. I am a wolf you know. I did warn them, 'Touch me and I will tear your thing off!' And can you believe, not one of them did.” (to Lawrence, Season 1, Episode 5)

“I need to have a drink, and I need one soon!” (to Lawrence Season 1, Episode 6)

“I want you to please understand the scales of my heart will always be swaying back and fourth. But there is something you should know. I will never lean to one side or the other due to the weight of gold coins.” (to Witz, Season 1, Episode 6)

“Males burned with jealousy are too sweet to eat!” (to Lawrence, Season 1, Episode 6)

“I am Holo the Wise Wolf!” (to Lawrence, Season 1, Episode 7)

“I know it's difficult to look past my brilliant tail, brain and looks, but I also have excellent ears and eyes.” (to Lawrence, Season 1, Episode 7)
“When you are experienced you can become overly confident and such confidence can prove fatal. I thought you learned this lesson from Chloe.” (to Lawrence, Season 1, Episode 7)

“Stop pouting! You learned something valuable. Remember the lesson, not the disappointment.” (to Lawrence, Season 1, Episode 7)

“It appears that human males do not mind having several females around.” (to Lawrence, Season 1, Episode 8)

“Remember when I spoke of men being kind to women? Men should be measured by their kindness. However I am not your charity, and I have a tendency to consider things from only my perspective. A blink of an eye in my world is a lifetime in yours. A year or two is understandably precious to you. I forgot. I do not wish to waste your time.” Season 2 episode 1

“I believe I am drunk. I will put myself to bed before I say anything else I regret.” Season 2 episode 1

“Good grief! I believe you to be much cuter when you are panicking.” Season 2 episode 3

“Even if you have answers, you cannot always tell them to others. It is the way of the world.” Season 2 episode 3

“I am delicate, do not step on my feet!” Season 2 episode 3

“Pain makes one wise!' Season 2 episode 6

“For your information I am quite aware that you have been put through extraordinary distress after extraordinary distress since we began traveling together. However I do hope you'll remember that none of the trouble we experienced was my fault! The first for example, well I guess that was partially my fault.” Season 2 episode 7

“You are desperate for me to tease you. I still believe you to be adorable.” Season 2 episode 7

“Even when wolf packs are having a violent war over territory, the forest looks as calm as it always does from a distance.” Season 2 episode 8

“I am helping you because I believe in you with all my heart” Season 2 episode 10

“Men are onions. Many layers and all of them make you cry.” Season 2 episode 10

“I have no fear of watching you grow old while I remain young. I'll even watch you on your death bed. I am no stranger to death. But your heart is like that of an innocent child. It has always accepted everything about me, without hesitation. Because of that I am very afraid." Season 2 episode 11

“There is no better time to part, than when we wish for it never to end.” Season 2 episode 11

“Once you taste poison, you might as well finish the meal. If it comes to that you would make as fine a dish as any.” Season 2 episode 11

“I am going to drink so much that I vomit before I even start to feel drunk.” Season 2 episode 11

“I am Holo the Wise Wolf. I know that there are things in this world that I do not know and that makes me wise!” Season 2 episode 0

     
  Elfen Lied Cosplay - Lucy Naked

Submitter: [anonymous]
Type: Image (jpg)
Category: Characters
exhibition Date: 2016-09-01 21:28:11
Views: 383
Score: (not yet rated)
 

     
  Freedom Gun Girl Nude

Submitter: [anonymous]
Type: Image (jpg)
Category: Adult / Hentai
exhibition Date: 2018-06-08 15:28:12
Views: 140
Score: (not yet rated)
 
Sexy Nude Girl with Gun.

     
  Medb - Fate/Grand Order Naked Goddess Uncensored

Submitter: [anonymous]
Type: Image (jpg)
Category: Adult / Hentai
exhibition Date: 2018-06-07 02:23:00
Last Update: 2018-06-07 07:15:18
Views: 220
Score: (not yet rated)
 
The Eternal Lady Uncensored Fate Series

     
  Bulma in Pool Naked - Dragon Ball Z

Submitter: [anonymous]
Type: Image (png)
Category: Adult / Hentai
exhibition Date: 2014-09-06 13:44:38
Last Update: 2018-06-06 17:27:13
Views: 5292
Score: (not yet rated)
 

     
  Atalanta Fate/Grand Order Nude Girl Servent

Submitter: [anonymous]
Type: Image (jpg)
Category: Adult / Hentai
exhibition Date: 2018-06-07 20:43:03
Last Update: 2018-06-07 20:44:33
Views: 203
Score: (not yet rated)
 
Atalanta (/ˌætəˈlæntə/; Greek: Ἀταλάντη Atalantē) is a character in Greek mythology, a virgin huntress, unwilling to marry, and loved by the hero Meleager.

According to the Bibliotheca of pseudo-Apollodorus, Atalanta was the daughter of Iasus, son of Lycurgus, and Clymene, daughter of Minyas. She is also mentioned as the daughter of Mainalos or Schoeneus, according to (Hyginus), of a Boeotian (according to Hesiod), or of an Arcadian princess (according to the Bibliotheca). The Bibliotheca is the only source which gives an account of Atalanta’s birth and upbringing. King Iasus wanted a son; when Atalanta was born, he left her on a mountaintop to die. Some stories say that a she-bear suckled and cared for Atalanta until hunters found and raised her, and she learned to fight and hunt as a bear would. She was later reunited with her father.

Having grown up in the wilderness, Atalanta became a fierce hunter and was always happy. She took an oath of virginity to the goddess Artemis.

     
  Christie Monteiro - Tekken Girl Ecchi Topless Nude

Submitter: [anonymous]
Type: Image (jpg)
Category: Adult / Hentai
exhibition Date: 2018-06-06 17:37:40
Views: 193
Score: (not yet rated)
 

     
  Vados Naked Dragon Ball Super Girl Uncensored

Submitter: [anonymous]
Type: Image (jpg)
Category: Adult / Hentai
exhibition Date: 2018-06-06 18:26:25
Views: 229
Score: (not yet rated)
 

     
  Taking Aim - Nude Sexy Gun Girls

Submitter: [anonymous]
Type: Image (jpg)
Category: Adult / Hentai
exhibition Date: 2018-06-08 09:58:30
Views: 157
Score: 5.00 / 5.00 (Based on 1 votes.)
 

     
  Asuka Langley Calender Ecchi Nude Eva Girl

Submitter: [anonymous]
Type: Image (jpg)
Category: Adult / Hentai
exhibition Date: 2014-09-06 14:08:04
Last Update: 2018-06-06 17:25:22
Views: 1178
Score: (not yet rated)
 

     
  Super Saiyan Goku Powering Up - DBZ

Submitter: [anonymous]
Type: Image (jpg)
Category: Anime
exhibition Date: 2016-09-03 17:38:51
Views: 859
Score: (not yet rated)
 

     
  Rin Tohsaka Topless - Fate/Stay Night

Submitter: [anonymous]
Type: Image (jpg)
Category: Adult / Hentai
exhibition Date: 2016-06-18 11:20:40
Last Update: 2018-06-06 17:57:05
Views: 699
Score: (not yet rated)
 

     
  Naked Anime Girls Lucy Asuna Bulma Uncensored

Submitter: [anonymous]
Type: Image (png)
Category: Adult / Hentai
exhibition Date: 2018-06-06 23:23:57
Views: 137
Score: (not yet rated)
 

     
  Cleopatra - Fate/Grand Order Uncensored Girls

Submitter: [anonymous]
Type: Image (jpg)
Category: Anime
exhibition Date: 2018-06-08 05:06:51
Last Update: 2018-06-08 05:20:22
Views: 119
Score: (not yet rated)
 

     
  Genesis vs Sephiroth - FF7 Crisis Core

Submitter: [anonymous]
Type: Image (jpg)
Category:
exhibition Date: 2014-07-06 09:56:28
Views: 1279
Score: (not yet rated)
 

     
  Frieza Powering Up (1st Form) Animated GIF

Submitter: [anonymous]
Type: Image (gif)
Category:
exhibition Date: 2015-12-10 07:14:34
Views: 816
Score: (not yet rated)
 

     
  Sephiroth Kills Aerith

Submitter: [anonymous]
Type: Image (jpg)
Category:
exhibition Date: 2014-08-01 11:16:05
Views: 735
Score: (not yet rated)
 

     
  Sephiroth Stabbing Cloud - FFVII Advent Children

Submitter: [anonymous]
Type: Image (png)
Category: Movies / Television
exhibition Date: 2017-04-22 12:47:40
Views: 734
Score: (not yet rated)
 

     
  Paintball Gun Girls Sexy

Submitter: [anonymous]
Type: Image (jpg)
Category: Adult / Hentai
exhibition Date: 2018-06-08 05:47:21
Views: 93
Score: (not yet rated)
 

     
  DBZ Beach Babes - Chi-Chi, Bulma, Android 18

Submitter: [anonymous]
Type: Image (jpg)
Category: Adult / Hentai
exhibition Date: 2014-09-06 13:46:15
Last Update: 2018-06-30 21:22:20
Views: 4084
Score: 5.00 / 5.00 (Based on 1 votes.)
 

     
  Cooler vs Frieza - DBZ Fanart

Submitter: [anonymous]
Type: Image (jpg)
Category:
exhibition Date: 2014-08-26 15:55:25
Views: 2069
Score: 5.00 / 5.00 (Based on 1 votes.)
 

     
  Momo - To Love-Ru Darkness

Submitter: [anonymous]
Type: Image (png)
Category: Adult / Hentai
exhibition Date: 2016-09-01 17:06:36
Last Update: 2018-06-06 17:25:07
Views: 1012
Score: (not yet rated)
 

     
  Sakura Matou & Rider in Fate/Hollow Ataraxia

Submitter: [anonymous]
Type: Image (jpg)
Category:
exhibition Date: 2014-11-27 21:58:44
Views: 600
Score: (not yet rated)
 

     
  Harem Hentai Yuri Girls

Submitter: [anonymous]
Type: Image (jpg)
Category: Adult / Hentai
exhibition Date: 2018-06-06 22:33:11
Views: 228
Score: (not yet rated)
 

     
  Frankenstein Berserker - Fate/Grand Order Nude Gir

Submitter: [anonymous]
Type: Image (jpg)
Category: Adult / Hentai
exhibition Date: 2018-06-08 02:32:37
Views: 169
Score: (not yet rated)
 

     
  Vados Universe 10 Ecchi Nude Dragon Ball Girl

Submitter: [anonymous]
Type: Image (png)
Category: Adult / Hentai
exhibition Date: 2018-06-06 17:32:03
Last Update: 2018-06-06 17:32:36
Views: 151
Score: (not yet rated)
 

     
  Girl Soldiers

Submitter: [anonymous]
Type: Image (jpg)
Category: Adult / Hentai
exhibition Date: 2018-06-08 02:47:48
Views: 91
Score: (not yet rated)
 

     
  Annual Regulatory Requirements, Current Practice

Submitter: [anonymous]
Type: Literature (txt)
Category: Guides / Tutorials - Health / Medical
exhibition Date: 2017-02-26 07:34:31
Last Update: 2017-02-26 08:04:43
Views: 967
Score: 5.00 / 5.00 (Based on 1 votes.)
 
1
Express and Informed Consent
(See also Voluntary Admissions and Emergency Treatment Orders)
Competence to Consent
Q. Who is eligible to consent or refuse to consent to their own treatment?
Minors cannot make their own inpatient mental health treatment decisions; this is the
responsibility of their parent or guardian. Neither can persons with a court appointed
guardian or who have a health care surrogate or proxy currently making decisions for
them. Only adults who are consistently able to make well-reasoned, willful and knowing
decisions about their own mental health or medical care can consent, refuse consent, or
revoke consent to their own treatment.
Q. If a person arrives at a receiving facility for an involuntary examination is
cooperative and willing to take medications, is this sufficient to document
“express and informed consent”?
No. "Cooperative and willing" are helpful descrip
tors, but more important is competence
of the person to make such decisions. This is defined in the law as being able to make
well-reasoned, willful and knowing decisions about one's mental health and medical
care. Without competence, as defined here, no amount of cooperation or willingness is
sufficient. The standard under the Baker Act requires more than “implied consent”
because the person may have taken the medications prior to admission and/or is not
currently refusing the medications. “Med compliance” is a behavior, but doesn’t
necessarily reflect competence.
Q. Is it true that a non-psychiatrist physician, during the involuntary examination,
can determine competency? I think the answer is yes, but just need verification.
You are correct. A non-psychiatric physician can determine competency to consent to
treatment. No professional other than a physician can do so. Whether on voluntary or
involuntary status, the physician must certify that the person is able to make well-
reasoned, willful and knowing decisions about his/her health and mental health care –
the definition of competence to consent – before permitting the individual to consent to
treatment. All voluntary patients must be certified as “competent” within 24 hours of
admission and any persons on involuntary st
atus who are refusing examination but
allowed to consent to their own treatment must also be certified.
It’s important that the documentation in the cl
inical record reflects that the individual
maintains this competence as long as treatment is provided. If at any time the individual
displays statements or behaviors that suggest he/she isn’t any longer able to make such
well reasoned decisions, treatment can’t be continued except when imminent danger
has been documented (ETO) or a legally authorized substitute decision-maker is
designated to provide consent.
2
Q. Recently we had a question come up about a patient being able to sign legal
documents brought in by the family. The patient was not deemed incompetent by
our doctor, but was not here voluntarily either. Can the patient is able to sign
legally binding documents while inpatient in a mental health hospital or CSU?
It’s unclear what kind of legal documents are involved. Just because a person hasn't
been adjudicated incapacitated by a court, doesn't mean he/she is competent for various
purposes.
If the patient is on voluntary or involuntary status and has been allowed to provide
consent to his/her own treatment, a physi
cian would have had to document the person's
competence to provide express and informed
consent on a sustained basis (not just
some "window of lucidity"). This medical statement means that the person is able to
make well-reasoned, willful and knowing medical and mental health decisions.
If the person's clinical record has notes from nurses, social workers or other personnel
that reflect the person's judgment or insight was impaired at the, the legitimacy of any
consent would be questionable, even for treatment not to mention other legal
documents. One would question how the person would meet the acuity criteria for
inpatient psychiatric care and yet be able to pass the high threshold of competence to do
so.
If a person was being held involuntarily because of "refusal" instead of "unable to
determine the exam/placement was needed", it may be possible to overcome with
sufficient documentation a presumption of incapacity.
The person could later challenge any document signed at such a time and place due to
diminished capacity or perceived coercion, whether the documents are Advance
Directives, quit claim deeds, a will, powers of attorney, or any other legal document.
Q. If a person is admitted on involuntary examination status and the box on the
BA-52 form is checked 'refusing voluntary exam' – can the patient be capable of
providing consent to their psychotropic medications and treatments as long as
the staff notes that they appeared to be consistently able to make well-reasoned,
willful and knowing decisions about their treatment?
Yes. A person may refuse admission but may be competent to consent or refuse
consent to treatment.
Q. Can a person on involuntary status still be competent to consent or refuse
consent to their own treatment?
YES. The issue of competence to consent is considered separately from the placement
issue. If the person meets the criteria for involuntary examination or involuntary
placement but is capable of making well-reasoned, willful, and knowing decisions about
their medical or mental health, he or she may continue to consent, withhold consent, or
refuse consent to treatment.
3
A person on involuntary status may or may not be competent to consent to his or her
own treatment. If the person who initiated the involuntary examination noted on the form
that the person was unable to determine the exam was necessary, as opposed to
refusing the exam, the person must be presumed to be incompetent to consent to
treatment until determined by a physician to have such capacity.
Q. Does a physician need to complete Certification of Person’s Competence to
Provide Express and Informed Consent (Form #3104) if the patient is to be
discharged from involuntary status and our facility within 24 hours of admission,
or can s/he complete the 3111 only?
The Certification of Competence is used as follows:

If the person arrives on voluntary status and is released in less than 24 hours,
the 3104 form doesn’t need to be completed.

If the person arrives on either voluntary or involuntary status and consents
to/receives psychotropic medications, the 3104 form must be used even if the
person is released within 24 hours.

If the person arrives on involuntary status and is subsequently released either
within or outside the 24 hour window and regardless of whether the person has
been medicated, the 3111 or it’s equivalent must be completed.
Q. Does competency to consent to treatment have to be documented by a
physician before consent can be sought and treatment administered?
NO. Chapter 65E-5.170(1), FAC requires that as soon as possible, but in no event
longer than 24 hours from entering a designated receiving facility on a voluntary or
involuntary basis, each person shall be examined by the admitting physician to
determine the person's ability to provide express and informed consent to admission and
treatment.
This doesn't require that the examination or completion of the form be done prior to
administering psychotropic medications. However, the law is very clear that the person
must be able to provide express and inform
ed consent for any treatment rendered, after
full disclosure of all the legally required information.
With regard to adults on
voluntary
status, one can presume the person is competent to
consent to medications and other treatment prio
r to being certified by a physician as long
as staff notes that the person appears to be able to consistently make well-reasoned,
willful, and knowing decisions about his/her medical and mental health treatment.
However, at any time the person displays statements or behaviors that would lead one
to believe that he or she is not able to make well-reasoned, willful and knowing
decisions, the treatment must be discontinued until informed consent can be obtained
from a legally authorized person, unless an emergency treatment order is issued
because of imminent danger.
If a person is admitted on
involuntary
status and the block on the BA-52 form indicates
the person was unable to determine a voluntary examination was needed is checked, a
facility would have to presume the person is incompetent to consent to medications.

Information

In March 1998, the Advisory Commission on Consumer Protection and Quality in the Health Care Industry issued its final report, which included the Consumer Bill of Rights and Responsibilities. The Commission was appointed by President Bill Clinton, and co-chaired by Donna Shalala, Secretary of the Department of Health and Human Services.

The purpose of the Bill of Rights is:

To build up consumer confidence in the health care system, by making it easy for consumers to be involved in their own health care.
To strongly support the importance of a good health care provider and that of a good provider-patient relationship.
To emphasize and support the importance of the consumers' role in making sure they have rights and responsibilities with regard to health improvement.

The Consumer Bill of Rights was developed by the federal government. This has been used by many health plans, including the federal-government-sponsored health plans.

Consumer Bill of Rights

I. Information Disclosure

You have the right to receive accurate information you can understand about your health, treatments, health plan, providers, and health care facilities. If you speak another language, have a physical or mental disability, or just do not understand something, you will be helped so you can make informed health care decisions.

II. Choice of Providers and Plans

You have the right to choose your provider, within your health plan.

III. Access to Emergency Services

If you have severe pain, an injury, or sudden illness and you are concerned that you could be seriously ill, hurt, or could die, you have the right to get emergency services whenever and wherever needed, to be seen by a doctor and get services, even if you do not ask your health plan first, and you will not be charged a penalty.

IV. Participation in Treatment Decisions

You have the right to know all your treatment options, even if they are not covered by your health plan, and make decisions about your care. Parents, guardians, family members, or others that you choose can represent you if you cannot make your own decisions.

V. Respect and Nondiscrimination

You have the right to considerate, respectful care, and to not be discriminated against by your doctors, other health care providers, or health plan representatives.

VI. Confidentiality of Health Information

You have the right to talk in private with providers and to have your health care information protected. You also have the right to review and copy your own medical record and ask your doctor to make corrections to your record if it is not accurate or complete, or if it has information that does not relate to your health care.

VII. Complaints and Appeals

You have the right to a fair, fast, and objective review of any complaint you have against your health plan, doctors, hospitals, or other health care personnel. This includes complaints about wait times, hours available, health care facilities, and the conduct of health care personnel.

Consumer Responsibilities

In addition to listing consumer rights for health care, the Advisory Commission on Consumer Protection and Quality in the Health Care Industry also listed the responsibilities of consumers. These are ways the consumer can work together with health care providers to get the best quality health outcome.

Do your best to get well and stay healthy with habits such as exercising, not smoking, and eating a nutritious diet.
Give your providers the information they need, and clearly communicate what you want and need.
Be involved in making health care decisions with your health care providers.
Work with providers to develop and carry out the treatment plans you choose.
Use the health plan's internal complaint and appeal process to address concerns that may arise.
Avoid knowingly spreading disease.
Recognize the risks and limits of medical science, and know that providers are human and can make mistakes.
Be aware of a provider's need to fairly provide care to other people and the community.
Learn about your health plan's coverage and options (when available), including covered benefits, limits, services that are not covered, rules regarding information use, and how to appeal coverage decisions.
Show respect for other people and health workers.
Make a good-faith effort to pay your health care bills.
Follow procedures outlined by your health plans and providers.
Report wrongdoing and fraud to the right resources or legal authorities.

For more information, visit the Office for Civil Rights - HIPAA website -- www.hhs.gov/ocr/hipaa.
References

Centers for Medicare and Medicaid Services. The Center for Consumer Information and Insurance Oversight. Patient's Bill of Rights. Available at: www.cms.gov/CCIIO/Programs-and-Initiatives/Health-Insurance-Market-Reforms/Patients-Bill-of-Rights.html. Accessed October 13, 2015.
Review Date: 8/14/2015
Reviewed By: Linda J. Vorvick, MD, Medical Director and Director of Didactic Curriculum, MEDEX Northwest Division of Physician Assistant Studies, Department of Family Medicine, UW Medicine, School of Medicine, University of Washington. Also reviewed by David Zieve, MD, MHA, Isla Ogilvie, PhD, and the A.D.A.M. Editorial team

     
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