Emergency Psychiatry

ED
Psychiatry
Dr Anne O’Sullivan
Consultant Psychiatrist
Clinical Lead
SCGH Emergency Psychiatry
Team
(ED/MHOA)

Tricky concepts in ED Psych
“Can my patient leave or do they have
to stay?”
•Duty of Care
•Capacity/Competency
•MHA 2014

Part 1- “Daniel”
It’s 2.30am on a Friday night. You are the Reg on duty.
A 19 yr old male is BIBP after neighbours called them. The
neighbour reported the pt was out in the middle of the
road screaming, “They’re going to get me,” and “Stop
talking to me.” He was all alone at the time.
In ED he is highly agitated, kicking out at staff and stating
he wants to die. Most of your team are occupied with a
trauma case and the nurse coordinator comes to you and
says you have to see this patient right now.
What are your initial thoughts and what do you want
to know ASAP?

Part 2 – “Daniel”
You’ve asked the PLN to look this patient up on PSOLIS
and there is no prior psychiatric history, nor is there
any past medical history.
Mum was on scene. She told police that he’s been
acting very strangely lately and he tried to attack her
tonight with a knife.
Mum’s ok, but police say she was distraught and
scared. The police have a number for his mum.
What are the things you want to know?

Part 3 – “Daniel”
The nurse then tells you that Daniel’s BAL is 0.12.
He’s extremely agitated with dilated pupils and tachy at
102 BPM.
Daniel is getting really angry because he wants to go
outside for a cigarette and keeps yelling, “You can’t
hold me here!”
The nurses keep asking you for your plan…

What are the main issues and concepts you need to
consider right now?
How do you decide what’s important?
How would you manage this patient?
What is a priority?
Are there any investigations you want to do?
“Daniel”

DUTY
OF
CARE
“Doctors have a duty to make the care of patients their
first concern and to practise medicine safely and
effectively. They must be ethical and trustworthy.”
A Code of Conduct for Doctors in Australia

Duty of Care cont …
• The principle of duty of care is that you have an
obligation to avoid acts or omissions, which could be
reasonably foreseen to injure of harm other people.
• This means that you must anticipate risks for your
clients and take care to prevent them coming to
harm.
• Remember that harm encompasses both physical and
emotional harm.

“Doctors owe a duty of care to their patients to
provide advice, care and treatment. The care
provided should be of a standard that would be
widely accepted by peer professional opinion
as competent professional practice.”
Potentially incapable patients objecting to treatment: doctors’ powers and duties
Kerri Eagle and Christopher J Ryan
Med J Aust 2014; 200 (6): 352-354.

“Doctors are also under a duty to provide
patients with information that any patient
would feel was relevant to the decision at
hand and any other information that the
doctor should have known would have been
important to that particular patient.”
Kerri Eagle and Christopher J Ryan
Med J Aust 2014; 200 (6): 352-354.

• “If there are no factors to suggest the patient lacks DMC or suffers from a
mental illness, or if there are such factors but there is no foreseeable risk of
serious harm to self or others, then the person should be given appropriate
advice, and his or her decision to leave should be respected.”
• If, on the other hand, there is:
• a known factor, such as a serious head injury, which may give rise to a lack
of DMC; or recent behaviour such as an overdose which might suggest the
presence of mental illness; or a decision to object to assessment or
treatment that, in the context, is so unusual or inappropriate as to lead a
reasonable person to suspect that the patient’s DMC may be impaired; and
• a foreseeable risk of serious harm to that person or others; and
• no less-restrictive way of clarifying the person’s capacity to refuse
assessment or prevent the risk;
• then, a clinician should detain a person for as long as necessary to
minimise the risk and/or until “regular and ordinary means” can be
resorted to.
Kerri Eagle and Christopher J Ryan; Med J Aust 2014; 200 (6): 352-354.

“If there are no factors to suggest the patient lacks DMC
(Decision Making Capacity) or suffers from a mental illness,
or
if there are such factors but there is no foreseeable risk of serious
harm to self or others, then the person should be given
appropriate advice, and his or her decision to leave should be
respected.

So …
A competent person has the right to refuse
the treatment even if the decision is ‘not
sensible, rational or well considered’

• a known factor, such as a serious head injury, which may give rise to
a lack of DMC; or recent behaviour such as an overdose which might
suggest the presence of mental illness; or a decision to object to
assessment or treatment that, in the context, is so unusual or
inappropriate as to lead a reasonable person to suspect that the
patient’s DMC may be impaired; and
• no less-restrictive way of clarifying the person’s capacity to refuse
assessment or prevent the risk;
• then, a clinician should detain a person for as long as necessary
to minimise the risk and/or until “regular and ordinary means”
can be resorted to.

Capacity and Competence
• Capacity is a functional term that refers to the mental or
cognitive ability to understand the nature and effects of one’s
acts  clinical judgement
• Competence is a legal term that can be defined as being “duly
qualified: having sufficient, capacity, ability or authority” — in
clinical practice it requires health professionals to perform a
functional test of competence to examine the ability of the
particular patient to consent to the specific treatment being
offered
Capacity and competence are often used interchangeably
(LIFL)

What do we need to demonstrate
Legal standards of capacity?
FOUR important elements:
1. Able to communicate a choice
2. Understand the relevant information
3. Appreciate the medical consequences of the
situation
4. Able to reason about treatment choices

Assessing Capacity
• Capacity is always presumed
• Capacity is decision specific
• Capacity can change over time  time specific

Assessing Capacity cont
…
Capacity can be affected by anything
that alters mental status e.g.
• Stress/anxiety (amygdala hijack)
• Medication (sedation)
• Delirum
• Dementia
• Intoxication (D & A)
• Mental illness

Further considerations when
Assessing Capacity
Additional information always required
•Collateral from family, NOK, carers, GP etc
•Has patient discussed treatment options with
family in past i.e. living will/AHD
•Views of the family or carers on the treatment
•Is there a guardian?

Why is capacity so important
in psychiatry?

Assessing Capacity in
Psychiatry
• Evaluate the presence of a psychiatric
illness
• Is this currently influencing the
patients decision and judgement
• E.g. Auditory hallucinations telling them
not to have treatment because they
don’t deserve to live
• E.g. Highly depressed and suicidal
patient refusing treatment as they want
to go home to complete suicide

CRITERIA FOR INVOLUNTARY
TREATMENT – FORM 1A
A person is in need of an inpatient treatment order only if all of these
criteria are satisfied
• that the person has a mental illness for which the person is in need of
treatment;
• that, because of the mental illness, there is —
• (i) a significant risk to the health or safety of the person or to the safety
of another person; or
• (ii) a significant risk of serious harm to the person or to another person;
• that the person does not demonstrate the capacity required by
section 18 to make a treatment decision about the provision of the
treatment to himself or herself;
• that treatment in the community cannot reasonably be provided to
the person;
• There is no alternative that would be less restrictive to the person’s
freedom of choice and movement than making an inpatient treatment
order.

MHA 2014
• Criteria for Form 1A
• Establish or suspicion that the person has a mental illness for
which the person is in need of treatment.
• What is the definition of mental illness?
• A person has a mental illness if the person has a condition
that:
• is characterised by a disturbance of thought, mood, volition,
perception, orientation or memory; and
• significantly impairs (temporarily or permanently) the person’s
judgement or behaviour.
• What are the Internationally accepted standards a
decision must be made in accordance with?
• (ICD-10), Chapter 5, Mental and Behavioural disorders,
published by the WHO
• (DSM-5) published by the American Psychiatric Association

What are the questions I need to
ask in regard to the criteria for
Form 1A?
Do I suspect that the person has a mental illness requiring
treatment?
Do I suspect that because of that mental illness
there is a significant risk to the health or safety of the person or safety
there is a significant risk of serious harm to the person or another
person; or
a significant risk of the person suffering serious physical or mental
deterioration?
Do I suspect that the person is unable to demonstrate the capacity
to make informed decisions about treatment?
Do I suspect there is no less restrictive way for treatment to be
provided?

When should capacity be
assessed?
• Just because a person has a
mental illness it does not mean
they lack capacity.
• The vast majority of mental
health patients have capacity to
provide informed consent to
proposed treatment
• The person is making decisions very
different from their usual decisions:
e.g. spending money due to mania.
• Conflicts with their usual
preferences: e.g. refusing contact
with relatives because the person is
experiencing depression.
• The person is making decisions now
which puts the person or others at
significant risk of harm
• If the person is confused about
matters which they easily
understood in the past

What are the 5 criteria for
determining capacity in MHA 2014?
a) understand the things that are required
under s.19 to be communicated to the
person about the treatment; and
b) understand matters involved in making
the treatment decision; and
c) understand the effect of the treatment
decision; and
d) weigh up the factors referred to in
paragraphs (a), (b) and (c) for the purpose
of making the treatment decision; and
e) communicate the treatment decision in
some way.
Can you tell
me?
Can you paraphrase
it?
Do you believe it? Can
you appreciate the
consequences?
How did you decide?
Can you
weigh up risks/benefits?

MHA 2014 & informed
consent
• Consent is given freely and voluntarily
• Consent is either given by the patient or the
person who is authorised by law to make the
decision on the patient’s behalf
• A person has the capacity to make a treatment
decision
• Explanation of proposed treatment must be
given
• Sufficient time for consideration

Before a person is asked to make a
treatment decision what must they
be provided with?
• Sufficient information to enable the person to make a balanced
judgement about the treatment to the extent of what a reasonable
person would expect.
• Identifying and explaining any alternative treatments about which there
is insufficient knowledge to justify it being recommended or to enable its
effects to be predicted reliably.
• Warning the person of any risks inherent in the treatment.
• Sufficient time to consider the matters involved in the treatment
decision
• A reasonable opportunity to discuss those matters with the health
professional who is proposing the provision of the treatment.
• A reasonable opportunity to obtain any other advice or assistance in
relation to the treatment decision that the person wishes.

be provided with?
• In summary
• A person must understand the
advice given.
• Understanding can be impaired
by intoxication, a head injury,
delirium, intellectual disability,
dementia, experiencing mental
illness which interferes with
capacity to comprehend.

‘Sliding Scale’ approach
• More complicated decisions
may require more cognitive
power to meet the threshold
of understanding and
weighing.
• ‘greater’ or ‘better’
capacity?
• The stringency of test
depends on the seriousness
of the likely consequences of
patients’ decision
Shulman 2007
“The more serious the decision, the
greater the capacity required”

What should we do if our
patient lacks capacity?
• Identify and treat the cause of the incompetence
• Infection, hypoxia, uremia, sedation
• Treat underlying psychiatric/medical illness
• Provide more intensive education
• Introduce trusted confidant or adviser to the consent process
• If incompetent -> substitute decision maker
• Advanced Health Directive /surrogate decision maker
• Family members: spouse, adult children, parents, sibilngs and
other relatives
• In emergency, provide appropriate care under the
presumption that a reasonable person would have consented
to such treatment
• If any doubt, provide support necessary to preserve
life and then refer the decision to tribunal (SAT or MHRB)

Guardianship &
Administration Act
Urgent treatment
Treatment is regarded as urgent if it is needed to save a person's life or prevent
the person from suffering significant pain or distress.
Where a person requires urgent treatment and it is not practicable for the health
professional to determine whether an Advance Health Directive has been made
or
to obtain a treatment decision from anybody in the hierarchy
the health professional may provide the necessary treatment.

Guardianship & Administration
Act cont …
Urgent treatment following attempted
suicide
In cases where a person is in need of urgent
treatment that the health professional
believes is the result of attempted suicide,
the health professional may administer
the necessary treatment even:
if the person has made an Advance
Health Directive in which consent for
the required treatment is withheld.
And/Or
the person's guardian, enduring
guardian or person with authority to
make a decision withholds consent.

Guardianship &
Administration ActNon-urgent treatment
•If a person in need of non-urgent treatment has made an Advance Health
Directive (AHD) and the directive covers the treatment required, the health
professional will need to proceed in accordance with the directive.
•Some circumstances where the AHD may be considered invalid, in which case
the health professional may not follow the directive.
•If for some reason the AHD is invalid, or if a person has not made an AHD, the
legislation sets out the order of people who the health professional will need to
obtain a treatment decision from 
'the hierarchy of treatment decision-makers‘

MHA Forms?
• 51 forms in total!
But for ED:
• Form 1A –Referral to a
psychiatrist (72 hrs)
• Form 3A – Detention
order (24 hrs)
• Form 4A – transport
order

MHA FORMS IN NON-AUTHORISED ED
DEPT

MHA Forms
Form 1A – Referral to a psychiatrist – NOT an
involuntary patient at this stage
Form 3A – Detention order
authorises staff to detain the person
under a duty of care the use of reasonable force by
staff or others such as security staff.
Always least restrictive means and only use force
when no other safe options to control the situation.
Duty of care must be justified.

Form 3A Detention Order
•A medical practitioner or AMHP and not necessarily the
practitioner who made the Referral Order can authorise
detention (Form 3A) for up to 24 hours if satisfied that the
person needs to be detained to enable the person to be taken to
the authorised hospital or other place.
•Until there are amendments minimal physical force cannot
be used under the Act but is allowable under Duty of Care
•Need for detention – any behaviour or condition in a patient
that could put them at risk i.e. unwilling to be transported, if they
have self-harmed and want to leave

Form 3A Detention Order
• Can only be made after Form 1A
• E.g. Patient may have anorexia but not under Form1A & wants
to leave ED may do so and no power under the Act to detain
them.
• However, if they are under a Form1A and they have some
physical injury that would place them at risk if they left ED, or
they were suicidal then they may be detained under the Act
with a Form 3A
• In most cases detention will be used because of the referred
persons mental illness an the risk to their own or another's
health or safety.

What do we do in ED?
“Understanding that ED’s are operating under Duty of
Care principle as often extreme and difficult
circumstances”
(WA Office of the Chief Psychiatrist)
If does not fulfil MHA criteria &
If emergency medical treatment required
 Emergency treatment under Duty of Care or
 Guardianship and Administration Act , section 110ZI or
110ZIA

What
happene
d to
“Daniel”
??

Part 4 - “Daniel”  Mum
Mum says that ‘Daniel’ has been acting “really strangely lately”.
He’s been locking himself in his room, barely eating, has lost a lot
of weight and not showering. He refuses to sit in the lounge room
and watch “The Voice” with her – it used to be their favourite
show to watch together. She’s not sure, but she thinks he been
talking with someone when he’s in his room, but when she’s gone
in to there to check, the computer is off and he’s alone. He was
studying engineering at UWA – he was past dux of his school – but
last semester he failed, and the last 2 weeks of semester he didn’t
go to uni or attend his exams. He’s stopped seeing his friends,
stating “They don’t know the real me.” She doesn’t know what’s
going on with him, but she’s really worried because he’s started
to talk about how great life after death must be. Her brother
committed suicide many years ago after spending time in a
‘mental institution’.
Mum then starts to cry and pleads for you to help her son.

“Amy”
• 28 yr with 4 gram OD of Quetiapine.♀
• Was found with a handwritten note to say she
intended to suicide
• Has an AHD found at the scene that states she is
withholding consent for treatment and to allow her
to die.
• Her husband cannot be contacted.
• What do you do?

“Rachel”
• 32yr with BAL 0.342 and found by her roommate♀
(GCS 9) with obvious recent lacerations to her arms +
lac to her head
• No ID, eventually get her name (PLN recognises her)
• PSOLIS gives hx of frequent presentations for DSH -
mainly “Intoxicidal” with 1 x ICU OD admit since her
divorce
• She wants to leave and is becoming extremely
agitated/aggressive
• What do you do?

be provided with?
• In summary
• A person must understand the advice given.
• Understanding can be impaired by
intoxication, a head injury, delirium,
intellectual disability, dementia, experiencing
mental illness which interferes with capacity
to comprehend.

What should we do if our
patient lacks capacity?
• Identify and treat the cause of the incompetence
• Infection, hypoxia, uremia, sedation
• Treat underlying psychiatric/medical illness
• Provide more intensive education
• Introduce trusted confidant or adviser to the consent process
• If incompetent -> substitute decision maker
• Advanced Health Directive /surrogate decision maker
• Family members: spouse, adult children, parents, sibilngs and
other relatives
• In emergency, provide appropriate care under the
presumption that a reasonable person would have consented
to such treatment
• If any doubt, provide support necessary to preserve
life and then refer the decision to tribunal (SAT or
MHRB)

“Nina”
• 22yr BIBP and SJA after violent altercation with her mother.♀
• Mum stated Nina suddenly attacked her because, “The voices
told her I was evil and must be stopped.” Reports Nina has
been acting “weird” lately – talking to someone in her room
(was alone), states people are out to hurt her and trying to
“trick her”. Been under a lot of pressure lately at her dance
school.
• Mum has a hx of depression
• No known PSOLIS hx
• Nina refuses to stay – states she needs to get to rehearsal and
says, “You are ruining my career by keeping me here. You're all
trying to ruin me”.
• What do you do?

What are the questions I need to ask
in regard to the criteria for Form 1A?
Do I suspect that the person has a mental illness requiring
treatment?
Do I suspect that because of that mental illness
there is a significant risk to the health or safety of the person or safety
there is a significant risk of serious harm to the person or another
person; or
a significant risk of the person suffering serious physical or mental
deterioration?
Do I suspect that the person is unable to demonstrate the capacity
to make informed decisions about treatment?
Do I suspect there is no less restrictive way for treatment to be
provided?

TREATMENT ORDER – FORM 1A
treatment;
• that the person does not demonstrate the capacity required by
section 18 to make a treatment decision about the provision of the
treatment to himself or herself;
the person;
order.

Part 1- “Jennifer”
• A 29 yr old woman is brought in by her husband after he found in
her half naked in their garden trying to pee on a pregnancy stick.
• He said she been missing earlier that day, and for the last 2 days
had been behaving really oddly. She had barely been sleeping and
was writing furiously on post-it notes and placing them all over
the house.
• He said she was off work for the last 2 weeks because she had
sore eyes and couldn’t look at the computer screen at work. She
had her eyes lasered 6 months prior. Her ophthalmologist had
recently given her steroid drops for her eyes.
• Her husband said she’s normally “really fit” and had just
completed the HBF 12km fun run the week before and is “never
sick”.
• They have no kids, are from the UK, and been in Australia for 2
yrs.

Part 2 – “Jennifer”
• When you see Jennifer she’s very pleasant, but has a far away look
in her eyes.
• She tells you that she’s figured out the role of the universe and
evolution and believes that she is now pregnant and about to
deliver her baby.
• She also tells you her eyes are dry and burning. She’s sitting up in
bed writing lists of “Things to Do”, and tells you she can
communicate telepathically with her husband.
• She then states that she thinks she killed him and that she is going
to die. She then starts hyperventilating and screaming that’s she’s
going into labour. She then spreads her legs as though she is
delivering a baby.
• It is noted she is afebrile, but having episodes of tachycardia, then
complaining of feeling “dizzy and sick”
• The nurse tells you she had bradycardia (40 bpm) on the 1st
ECG, but
now you can’t find it. The repeat ECG was normal.

What other history do you want to know?
What are your main concerns now?
What is a priority?
What investigations do you want to do?

• “If there are no factors to suggest the patient lacks DMC or suffers from a
mental illness, or if there are such factors but there is no foreseeable risk of
serious harm to self or others, then the person should be given appropriate
advice, and his or her decision to leave should be respected.”
• a known factor, such as a serious head injury, which may give rise to a lack of
DMC; or recent behaviour such as an overdose which might suggest the
presence of mental illness; or a decision to object to assessment or treatment
that, in the context, is so unusual or inappropriate as to lead a reasonable
person to suspect that the patient’s DMC may be impaired; and
• no less-restrictive way of clarifying the person’s capacity to refuse assessment
or prevent the risk;
• then, a clinician should detain a person for as long as
necessary to minimise the risk and/or until “regular and
ordinary means” can be resorted to.

“McMurphy”
• 39yr with known Hx of paranoid schizophrenia.♂
• Lives in supported accommodation and on clozapine
• Has injury to left hand after punching a wall 3/7 ago
• MH Case worker brought him in after he refused to see GP
• Red, swollen, painful over 4th
and 5th
metacarpals, can’t make a
fist, laceration over 5th
metacarpal
• Says “I thought the guy in the other room was watching me
through the wall. I wanted him to piss off. He's always
watching me.”
• When asked about his hand –”Yeah it hurts. I think I need to fix
it.”
• What do you do?

“Ellen”
• 19yr referred in from GP with concerns she needs♀
“admission”.
• Hx of anorexia since age 15yrs
• Known to WAEDOCS team
• BMI <15
• HR 120 with postural drop >20 beats/min
• Lying BP 95/60; standing 75/50
• ECG – non-specific ST changes
• BSL 2.4
• Refusing any treatment including bloods and fluids.
• Very distressed and wants to leave. Parent's present but not
helpful. Seem to be making things worse.
• What do you do?

TREATMENT ORDER – FORM 1A
treatment;
• that the person does not demonstrate the capacity required by section
18 to make a treatment decision about the provision of the treatment
to himself or herself;
the person;
order.

MHA FORMS IN NON-AUTHORISED ED DEPT

Form 9B –
Emergency Non- Psychiatric
Treatment
• Medical treatment in Involuntary patients  Must
already be under a Form 6A or Form 6B
• Provided to a patient without consent under a duty of
care where consent is not able to be provided by
alterative decision maker – ie guardian or parent
• Urgent treatment –
• Save a patients life
• Prevent serious damage to the patients health
• Prevent the patient from suffering or continuing to suffer
significant pain or distress

• (2009). Hunter and New England Area Health service v A. Hunter, NSWSC. 761.
• Appelbaum , P. S. (2007). "Assessment of Patients' Competence to Consent to Treatment." New England Journal of
Medicine 357(18): 1834-1840.
• Commission, M. H. (2014). Mental Health Act 2014. 5. W. A. Legislation. 024 of 2014: 17-20.
• Emergency psychiatry. Hillard, R.; and Zitek, B. 2008 McGraw-Hill
• Emergency Care Institute NSW: Mental Health for Emergency Departments 2016
• Grisso, T. and P. S. Appelbaum (1995). "The MacArthur Treatment Competence Study. III: Abilities of patients to
consent to psychiatric and medical treatments." Law Hum Behav 19(2): 149-174.
• Kenneth I. Shulman , M. D., F.R.C.P.C. ,, et al. (2007). "Assessment of Testamentary Capacity and Vulnerability to
Undue Influence." American Journal of Psychiatry 164(5): 722-727.
• Kim, S. Y., et al. (2002). "Current state of research on decision-making competence of cognitively impaired elderly
persons." Am J Geriatr Psychiatry 10(2): 151-165.
• Marson, D. C., et al. (1997). "Consistency of Physician Judgments of Capacity to Consent in Mild Alzheimer's Disease."
Journal of the American Geriatrics Society 45(4): 453-457.
• Owen, G. S., et al. (2013). "Decision-making capacity for treatment in psychiatric and medical in-patients: cross-
sectional, comparative study." The British Journal of Psychiatry 203(6): 461-467.
• Oxford Handbook of Psychiatry, 2nd
edition
• Raymont, V., et al. (2004). "Prevalence of mental incapacity in medical inpatients and associated risk factors: cross-
sectional study." The Lancet 364(9443): 1421-1427.
• Ryan, C., et al. (2015). "The capacity to refuse psychiatric treatment: A guide to the law for clinicians and tribunal
members." Australian & New Zealand Journal of Psychiatry 49(4): 324-333.
• Vollmann, J., et al. (2003). "Competence of mentally ill patients: a comparative empirical study." Psychol Med 33(8):
1463-1471.
• White-Bateman, S. R., et al. (2007). "Consent for intravenous thrombolysis in acute stroke: review and future
directions." Arch Neurol 64(6): 785-792.

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