The capacity to refuse psychiatric treatment: a guide to the law for clinicians and tribunal members

Implications of psychiatric diagnosis for Voluntary Assisted Dying in Victoria

Voluntary Assisted Dying is a process whereby terminally ill patients are provided a lethal dose of medication for them to voluntarily ingest to end their life. Victoria, Australia, implemented legislation permitting Voluntary Assisted Dying for terminally ill adult patients with a life expectancy less than 6 months. Ethical dilemmas arise when terminally ill patients with a comorbid mental illness attempt to access Voluntary Assisted Dying because of the complex relationship between psychiatric conditions and suicidal ideation. This paper seeks to investigate the most ethical approach for doctors to respond to such a request by discussing objections raised in other literature to patients with a comorbid psychiatric illness aiming to access Voluntary Assisted Dying in Victoria. To answer this question, objections to terminally ill patients with a comorbid psychiatric illness accessing Voluntary Assisted Dying were found through review of literature. Discussion of these objections centred around unpacking the two historical ethical justifications for Voluntary Assisted Dying: respect for autonomy and relief of suffering. Regarding autonomy, contention focused on competency to make autonomous decisions. Not all psychiatric patients lack competency to decide about Voluntary Assisted Dying, and there are comparable competency assessments used in psychiatry today. Considering suffering, objections related to the authenticity of the intolerable nature of a patient's suffering out of concerns that it has been influenced by their condition, and that the psychiatric illness may still be treatable. However, given suffering is subjective, its perception is not lessened if the source is psychological in nature. Furthermore, it is challenging to justify a position where a patient is forced to spend the last months of their life enduring suffering that has been historically refractory to multiple, genuine treatment efforts. Not all terminally ill patients with a comorbid psychiatric disorder will lack competency to choose Voluntary Assisted Dying, and many will have genuine suffering for which they are requesting Voluntary Assisted Dying. Multidisciplinary, holistic assessments for these patients are not mandated, but would be useful to address the issues, overcome barriers to access and determine that applicants are making an authentic request.

Insight and capacity to consent to electroconvulsive therapy

OBJECTIVE

To critically examine a recent decision of the Victorian Supreme Court that found that the Mental Health Tribunal and the Victorian Civil and Administrative Tribunal erred in the application of the capacity test in the Mental Health Act 2014 (Vic) and that compulsory electroconvulsive therapy would infringe upon the human rights of two patients who had no insight into their chronic schizophrenia.

CONCLUSIONS

After considering the concepts of insight and capacity to consent to treatment, the paper concludes that the decision in NJE and PBU v Mental Health Tribunal [2018] VSC 564 is problematic clinically.

An algorithm for managing adults who refuse medical treatment in New South Wales

OBJECTIVES

The assessment and management of a patient who refuses medical treatment requires clinical skill, and consideration of the relevant law and the patient's decision-making capacity. Psychiatrists are often asked to advise in these situations. We aimed to develop an algorithm describing the relevant legal pathways to assist clinicians, especially psychiatrists, working in New South Wales (NSW), Australia.

METHODS

We reviewed the academic literature on treatment refusal, relevant legislation, judicial rulings and NSW Health policy directives and guidelines. We consulted with clinicians and representatives of relevant tribunals.

RESULTS

We developed an algorithm for managing patients who refuse medical treatment in NSW. The algorithm emphases the evaluation of decision-making capacity and tracks separate pathways depending upon a person's status under the Mental Health Act 2007 (NSW).

CONCLUSIONS

The algorithm provides a clear decision tree for clinicians responding to a patient refusing medical treatment in NSW.

Changes in Cognition and Decision Making Capacity Following Brain Tumour Resection: Illustrated with Two Cases

Changes in cognition, behaviour and emotion frequently occur in patients with primary and secondary brain tumours. This impacts the ability to make considered decisions, especially following surgical resection, which is often overlooked in the management of patients. Moreover, the impact of cognitive deficits on decision making ability affects activities of daily living and functional independence. The assessment process to ascertain decision making capacity remains a matter of debate. One avenue for evaluating a patient’s ability to make informed decisions in the context of brain tumour resection is neuropsychological assessment. This involves the assessment of a wide range of cognitive abilities on standard measurement tools, providing a robust approach to ascertaining capacity. Evidence has shown that a comprehensive and tailored neuropsychological assessment has greater sensitivity than brief cognitive screening tools to detect subtle and/or specific cognitive deficits in brain tumours. It is the precise nature and severity of any cognitive deficits that determines any implications for decision making capacity. This paper focuses on cognitive deficits and decision making capacity following surgical resection of both benign and malignant, and primary and secondary brain tumours in adult patients, and the implications for patients’ ability to consent to future medical treatment and make decisions related to everyday activities.

Understanding advocacy practice in mental health: a multidimensional scalogram analysis of case records

BACKGROUND

Few studies have examined mental health consumers' motives for seeking advocacy assistance.

AIMS

This study aimed to identify factors that influenced mental health consumers' use of advocacy services.

METHODS

The analysis was based on 60 case records that were sourced from a community advocacy service. Each record was dichotomously coded across 11 variables to generate a series of categorical data profiles. The data set was then analysed using multidimensional scalogram analysis to reveal key relationships between subsets of variables.

RESULTS

The results indicated that mental health consumers commonly reported a sense of fear, which motivated them to contact the advocacy service in the hope that advocates could intervene on their behalf through effective communication with health professionals. Advocates often undertook such intervention either through attending meetings between the consumer and health professionals or contacting health professionals outside of meetings, which was typically successful in terms of achieving mental health consumers' desired outcome. The resolution of most concerns suggests that they were often legitimate and not the result of a lack of insight or illness symptoms.

CONCLUSION

Health professionals might consider exploring how they respond when consumers or carers raise concerns about the delivery of mental health care.

The recovery of factors associated with decision-making capacity in individuals with psychosis

BACKGROUND

There is limited data on the recovery of factors associated with decisional capacity in patients with psychosis.

AIMS

To study the relationship between changes in mental capacity, symptoms and global functioning using structured measures during treatment for psychosis.

METHOD

Fifty-six patients with psychosis were assessed for capacity to consent to treatment on admission and at 6 and 12 weeks following treatment. The MacArthur Competence Assessment Tool - Treatment, the Positive and Negative Symptom Scale and the Global Assessment of Functioning Scale were used to measure mental capacities, symptom severity and global functioning respectively. Treating consultants rated capacity to consent, masked to these measures.

RESULTS

Greater impairments on all measures were found in patients assessed as lacking capacity. These improved with treatment over 12 weeks with significant effect sizes (0.5 to 0.6). Stronger correlations between mental capacities, positive symptoms (-0.47) and global functioning (0.56) were noted in the first 6 weeks.

CONCLUSIONS

Impairments in capacity in acute stages of psychosis are related to symptom severity and functional impairment. They improve during treatment, particularly in the first 6 weeks.

DECLARATION OF INTEREST

None.

COPYRIGHT AND USAGE

© The Royal College of Psychiatrists 2017. This is an open access article distributed under the terms of the Creative Commons Non-Commercial, No Derivatives (CC BY-NC-ND) license.

The impact on clinical practice of the 2015 reforms to the New South Wales Mental Health Act

OBJECTIVES

The Mental Health Act 2007 (NSW) ( MHA) was recently reformed in light of the recovery movement and the United Nations Convention on the Rights of Persons with Disabilities. We analyse the changes and describe the impact that these reforms should have upon clinical practice.

CONCLUSIONS

The principles of care and treatment added to the MHA place a strong onus on clinicians to monitor patients' decision-making capacity, institute a supported decision-making model and obtain consent to any treatment proposed. Patients competently refusing treatment should only be subject to involuntary treatment in extraordinary circumstances. Even when patients incompetently refuse treatment, clinicians must make every effort reasonably practicable to tailor management plans to take account of any views and preferences expressed by them or made known via friends, family or advance statements.

Comparative analysis of the integument transcriptomes of the black dilute mutant and the wild-type silkworm Bombyx mori

The insect cuticle is a critical protective shell that is composed predominantly of chitin and various cuticular proteins and pigments. Indeed, insects often change their surface pigment patterns in response to selective pressures, such as threats from predators, sexual selection and environmental changes. However, the molecular mechanisms underlying the construction of the epidermis and its pigmentation patterns are not fully understood. Among Lepidoptera, the silkworm is a favorable model for color pattern research. The black dilute (bd) mutant of silkworm is the result of a spontaneous mutation; the larval body color is notably melanized. We performed integument transcriptome sequencing of the wild-type strain Dazao and the mutant strains +/bd and bd/bd. In these experiments, during an early stage of the fourth molt, a stage at which approximately 51% of genes were expressed genome wide (RPKM ≥1) in each strain. A total of 254 novel transcripts were characterized using Cuffcompare and BLAST analyses. Comparison of the transcriptome data revealed 28 differentially expressed genes (DEGs) that may contribute to bd larval melanism, including 15 cuticular protein genes that were remarkably highly expressed in the bd/bd mutant. We suggest that these significantly up-regulated cuticular proteins may promote melanism in silkworm larvae.

Application and implications of Mental Health Act 2007 (NSW) certificate use in acute generalist settings

Objective This retrospective study aimed to explore the appropriate application and implications of Mental Health Act 2007 (NSW) (MHA) certificate use in a metropolitan generalist hospital in New South Wales. Methods A de-identified MHA certificate review was undertaken within acute generalist medical and surgical specialties between June 2012 and May 2013. To assess differences, data were separated into two categories according to whether certificates were completed by psychiatry trainees or generalist medical officers. Analysis of indications for detention was also undertaken and qualitatively matched against legislative criteria. Results A total of 43 MHA certificates were included in the review, which highlighted missing elements in most certificates. Differences were found when professional consensus by the researchers was used to match documentation to legislative criteria. The researchers disagreed with nine of the 16 indications (mental illness/mental disorder) by the generalist medical officers and only one indication by a psychiatry trainee. Six of the certificates appeared to be related to lack of capacity and need for treatment of medical conditions, thus more related to Guardianship Act 1987 (NSW) applications. Conclusion This study highlights inconsistencies in legislative knowledge and requirements between professional groups. Education and training opportunities have been identified to ensure greater consistency in application of the MHA, preservation of patient rights and avoidance of stigma. MHA use in this setting should be exercised with caution and by appropriately trained individuals. What is known about the topic? The MHA and its state and territory counterparts provide for the treatment, care and support of people who have a mental illness and the protection of a person’s rights therein. Despite not being intended for application in generalist facilities, mental health legislation is widely used in generalist facilities and certificates are completed by generalist health professionals with limited training in this area of practice. What does this paper add? This study adds to the limited body of knowledge in relation to MHA detention in acute generalist facilities. Disparate preparation of medical officers in the use of this legislation has been identified, which has potential wider implications for patients beyond immediate care. What are the implications for practitioners? Inadequate attention to correct completion of MHA certificates and associated documentation could potentially invalidate detention, leaving healthcare professionals and institutions open to litigious claims that restrictive or coercive practices subsequent to the certificate’s completion were technically unlawful. Further, detention under the MHA, albeit temporarily, has potential human rights issues attached and wrongful detention could lead to longstanding issues relating to stigma.

Assessing and managing suicidal patients in the emergency department

OBJECTIVE

The objective of this article is to set out consensus guidelines for the assessment and management of "suicidal patients" in the emergency department.

CONCLUSIONS

Clinicians should be respectful and reassuring. They should review old notes, conduct a full history and examination, and talk to friends, family and any practitioners already involved in the patient's care. Management should be guided, where possible, by the patient's preferences, not by notions of risk. Every negotiated management plan and its rationale should be carefully documented.