Successfully reported this slideshow.
We use your LinkedIn profile and activity data to personalize ads and to show you more relevant ads. You can change your ad preferences anytime.

Emergency Psychiatry

376 views

Published on

Emergency Psychiatry

Published in: Health & Medicine
  • Be the first to comment

  • Be the first to like this

Emergency Psychiatry

  1. 1. ED Psychiatry Dr Anne O’Sullivan Consultant Psychiatrist Clinical Lead SCGH Emergency Psychiatry Team (ED/MHOA)
  2. 2. Tricky concepts in ED Psych “Can my patient leave or do they have to stay?” •Duty of Care •Capacity/Competency •MHA 2014
  3. 3. “Daniel”
  4. 4. 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?
  5. 5. 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?
  6. 6. 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…
  7. 7. 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”
  8. 8. The Brain under Stress
  9. 9. Stress Response
  10. 10. The Brain under Stress
  11. 11. Amygdala Hijack
  12. 12. Amygdala Hijack
  13. 13. Tricky concepts in ED Psych “Can my patient leave or do they have to stay?” •Duty of Care •Capacity/Competency •MHA 2014
  14. 14. 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
  15. 15. 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.
  16. 16. Duty of Care cont … “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.
  17. 17. Duty of Care cont … “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.” Potentially incapable patients objecting to treatment: doctors’ powers and duties Kerri Eagle and Christopher J Ryan Med J Aust 2014; 200 (6): 352-354.
  18. 18. Duty of Care cont … • “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. Potentially incapable patients objecting to treatment: doctors’ powers and duties Kerri Eagle and Christopher J Ryan; Med J Aust 2014; 200 (6): 352-354.
  19. 19. Duty of Care cont … “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. Potentially incapable patients objecting to treatment: doctors’ powers and duties Kerri Eagle and Christopher J Ryan; Med J Aust 2014; 200 (6): 352-354.
  20. 20. So … A competent person has the right to refuse the treatment even if the decision is ‘not sensible, rational or well considered’
  21. 21. Duty of Care cont … • 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. Potentially incapable patients objecting to treatment: doctors’ powers and duties Kerri Eagle and Christopher J Ryan; Med J Aust 2014; 200 (6): 352-354.
  22. 22. Tricky concepts in ED Psych “Can my patient leave or do they have to stay?” •Duty of Care •Capacity/Competency •MHA 2014
  23. 23. 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)
  24. 24. 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
  25. 25. Assessing Capacity • Capacity is always presumed • Capacity is decision specific • Capacity can change over time  time specific
  26. 26. 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
  27. 27. 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?
  28. 28. Why is capacity so important in psychiatry?
  29. 29. Tricky concepts in ED Psych “Can my patient leave or do they have to stay?” •Duty of Care •Capacity/Competency •MHA 2014
  30. 30. 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
  31. 31. 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.
  32. 32. 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
  33. 33. 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 of another person; or 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?
  34. 34. 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
  35. 35. 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?
  36. 36. 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
  37. 37. 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.
  38. 38. Before a person is asked to make a treatment decision what must they 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.
  39. 39. ‘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”
  40. 40. 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)
  41. 41. 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.
  42. 42. 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.
  43. 43. 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‘
  44. 44. 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
  45. 45. MHA FORMS IN NON-AUTHORISED ED DEPT
  46. 46. 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.
  47. 47. 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
  48. 48. 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.
  49. 49. 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
  50. 50. What happene d to “Daniel” ??
  51. 51. 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.
  52. 52. “Amy”
  53. 53. “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?
  54. 54. 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.
  55. 55. Duty of Care cont … • 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. Potentially incapable patients objecting to treatment: doctors’ powers and duties Kerri Eagle and Christopher J Ryan; Med J Aust 2014; 200 (6): 352-354.
  56. 56. “Rache l”
  57. 57. “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?
  58. 58. 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?
  59. 59. Before a person is asked to make a treatment decision what must they 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.
  60. 60. 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)
  61. 61. “Nina”
  62. 62. “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?
  63. 63. 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 of another person; or 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?
  64. 64. CRITERIA FOR INVOLUNTARY TREATMENT ORDER – 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.
  65. 65. 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
  66. 66. “Jennife r”
  67. 67. 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.
  68. 68. 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.
  69. 69. 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?
  70. 70. Duty of Care cont … • “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. Potentially incapable patients objecting to treatment: doctors’ powers and duties Kerri Eagle and Christopher J Ryan; Med J Aust 2014; 200 (6): 352-354.
  71. 71. 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.
  72. 72. “McMurphy”
  73. 73. “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?
  74. 74. 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
  75. 75. “Ellen”
  76. 76. “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?
  77. 77. CRITERIA FOR INVOLUNTARY TREATMENT ORDER – 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.
  78. 78. 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
  79. 79. MHA FORMS IN NON-AUTHORISED ED DEPT
  80. 80. 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
  81. 81. • (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.

×