Need-for-treatment criteria for involuntary civil commitment: impact in practice

Case report: are clinicians obligated to medically treat a suicide attempt in a patient with a prognosis of weeks?

BACKGROUND

There is broad ethical and professional consensus that preventing a patient from initiating or successfully completing a suicide attempt is a core physician obligation and justifies the use of aggressive interventions such as emergency detention and mechanical ventilation. This case examines the acute medical care of an individual with a progressive brain tumor after an apparent suicide attempt.

RESULTS

In guiding the care of this patient, we found that the patient's prognosis of days to weeks made the ethical rationale of implementing aggressive medical interventions to treat the sequelae of his suicide attempt less compelling.

Compulsory community mental health treatment: literature review

Following their introduction in the United States in the 1970s various forms of compulsory treatment in the community have been introduced internationally. Compulsory treatment in the community involves a statutory framework that mandates enforceable treatment in a community setting. Such frameworks can be categorized as preventative, least restrictive, or as having both preventative and least restrictive features. Research falls into two categories; descriptive, naturalistic studies and controlled and uncontrolled comparative studies. The research has produced equivocal results, and presents numerous methodological challenges. Where programmes have demonstrated improved outcomes debate continues as to whether these outcomes are associated with legal compulsion or enhanced service provision. Service user, family and clinician perspectives demonstrate a divergence of views within and across groups, with clinicians more strongly in support than service users. The issue of compulsory community treatment is an important one for nurses, who are often at the forefront of clinical service provision, in some cases in statutory roles. Critical reflection on the issue of compulsory community treatment requires understanding of the limitations of empirical investigations and of the various ethical and social policy issues involved. There is a need for further research into compulsory community treatment and possible alternatives.

A competency-based approach to managing violence with involuntary outpatient treatment

Involuntary outpatient treatment is one of the most controversial areas in public psychiatry. There are cogent arguments and strong emotions both for and against the use of it. Yet there is violent behavior towards others by individuals with mental illness who reside in the community that is not managed well even when recognized as highly likely. For individuals already in the community mental health system, the ability to keep them in treatment, even against their will, is necessary in some instances to decrease the likelihood of them engaging in outwardly directed violent behavior.

Reasons for admission and their implications for the nature of acute inpatient psychiatric nursing

The purpose of acute inpatient psychiatric care, and nurses' role within that, are in need of clarification and restatement in order to provide a framework for practice, education, research and development. Inpatient psychiatry has suffered from a paucity of research in recent years. In addition, being a complex system, involving multiple professions with differing ideologies, means that widely accepted succinct descriptions of its purpose are hard to achieve. Yet such a framework is essential to support positive attitudes to patients and for good staff-management relationships. Using an oblique strategy, this paper defines the function of acute inpatient psychiatry, and the role of psychiatric nurses, via a structured examination of the literature on reasons for admission to acute inpatient psychiatric wards. Seven such reasons were discovered and are described: dangerousness, assessment, medical treatment, severe mental disorder, self-care deficits, respite for carers, and respite for the patient. Acute inpatient psychiatric nurses are therefore: providing safety for the patient and others; collecting and communicating information about patients, giving and monitoring treatment; tolerating and managing disturbed behaviour; providing personal care; and managing an environment where patients can comfortably stay. The implications for psychiatric nursing are discussed.

Use of the Mental Health Act criteria in the decision-making process for compulsory admissions: a study of psychiatrists in South London

This study investigates the decision-making process for admitting patients compulsorily under the Mental Health Act 1983 of England and Wales. We used three case-vignettes describing different clinical situations: 1) a man with depression and psychotic symptoms; 2) a woman with a possible first episode of psychosis; and 3) a man with a history of substance abuse and bipolar disorder. The vignettes were administered to a group of psychiatrists working at the Bethlem Royal and Maudsley Hospitals in South London. The psychiatrists were asked to rate 11 factors from the most to the least important in their decision to admit the individual compulsorily. Three factors resembled the criteria considered in the Mental Health Act 1983 for compulsory admission: current mental state; severity of the disease; and dangerousness to self or others. Three were other clinical features of the patient: diagnosis; psychiatric history; and likely response of the mental state to the medical treatment. The remaining five were sociodemographic features of the patient: age and gender; owning a home; occupational status; and social support available. The psychiatrists were not given the option that the patient would accept a voluntary admission to hospital. We obtained responses from 42 psychiatrists (25 males and 17 females). The most important factor for deciding to detain a patient compulsorily was perceived dangerousness to self and others. The current mental state of the patient and the severity of the illness were the next two important factors. Our results confirm that the criteria recommended by the Mental Health Act 1983 of England and Wales were applied consistently in three different hypothetical situations. The need for protection of the patient or others may take precedence over the current mental state of the patient or the severity of the illness, a finding that warrants further investigation in view of the current debate on the responsibility of psychiatrists in deciding to detain subjects affected by personality disorder.

Criteria for involuntary hospitalisation

OBJECTIVE

The aim of this paper is to provide an overview of the ethical bases of compulsory commitment legislation.

METHOD

The ethical principles of beneficence and autonomy are examined and used to identify criteria for the commitment of mentally ill patients.

RESULTS

Two aspects of beneficence, medical paternalism and social paternalism, are discussed. It is argued that social paternalism is insufficient ethically to warrant involuntary admission, and that the basis for compulsory hospitalisation is medical paternalism.

CONCLUSION

The central role of autonomy in medical ethics suggests a patient should have a diminished capacity for autonomous decision-making and a potential to benefit from hospitalisation, as well as a risk of harm to self (including self-neglect) to warrant committal. In specific circumstances, the risk of harm to others may also justify committal. These ethical principles may be at odds with public attitudes.