Assessing competence to refuse medical treatment

Mental Capacity Assessments for COVID-19 Patients: Emergency Admissions and the CARD Approach

The doctrine of consent (or informed consent, as it is called in North America) is built upon presumptions of mental capacity. Those presumptions must be tested according to legal rules that may be difficult to apply to COVID-19 patients during emergency presentations. We examine the principles of mental capacity and make recommendations on how to assess the capacity of COVID-19 patients to consent to emergency medical treatment. We term this the CARD approach (Comprehend, Appreciate, Reason, and Decide).

Australian and New Zealand clinical practice guidelines for the management of adult deliberate self-harm

BACKGROUND

The Royal Australian and New Zealand College of Psychiatrists is co-ordinating the development of clinical practice guidelines (CPGs) in psychiatry, funded under the National Mental Health Strategy (Australia) and the New Zealand Health Funding Authority.

METHOD

For these guidelines, the CPG Team for Deliberate Self-harm reviewed the treatment outcome literature (including meta-analyses) and consulted with practitioners and patients.

TREATMENT RECOMMENDATIONS

(i) Organization of general hospital services to provide: emergency department admission; a safe environment; integrated medical and psychiatric management; risk assessment; identification of psychiatric morbidity, and adequate follow-up. (ii) Detection and treatment of any psychiatric disorder. (iii) Dialectical behaviour therapy, psychoanalytically orientated partial hospitalization or home-based interpersonal therapy (for certain patients) to reduce repetition of deliberate self-harm (DSH).

CONCLUSION

Deliberate self-harm is common and is costly in terms of both individual distress and service provision. General hospitals are often the first point of clinical contact, but may not be appropriately organized to care for these patients. Evidence for the effectiveness of psychological treatments is based on single RCTs without replication. The three recommended psychological treatments are not widely available in Australia and New Zealand, and the interventions that are, such as cognitive behaviour therapy, problem solving and 'green cards' (an agreement guaranteeing access to services), do not reduce repetition of DSH. The effect of follow-up in psychiatric hospitals or in the community is poorly understood. We need to develop and evaluate interventions that will reduce repetition of both fatal and non-fatal deliberate self-harm and improve the person's functioning and quality of life.

Duty of care in the emergency department

This paper explores issues that relate to the management of deliberate self-harm in the emergency department (ED) from a New South Wales perspective. A scenario that is typical to the ED is presented to illustrate the dilemma that nurses face and the implications for clinical practice. Confusion and concern regarding the treatment and detention of this type of patient in the ED can often result in the inappropriate use of the Mental Health Act. It is preferable for clinicians to be aware of the treatment options they have under duty of care rather than relying on the unfounded reassurance provided by scheduling a patient under the Mental Health Act. Communication and negotiation skills are highlighted as attributes that clinicians must develop and enhance to effectively manage difficult presentations to the ED.