Transcript DETENTION RIGHTS Where do we stand?

DETENTION RIGHTS
Where do we stand?
Dr. Tristan McGEORGE
Dr. Andy McCLELLAND
Registrar
Specialist
Department of Emergency Medicine
Peter Le CREN A+ Legal Advisor
1
DETENTION RIGHTS
Where do we stand?
INTRODUCTION
CASES x 2
MEDICO-LEGAL FRAMEWORK
THE ROLE OF THE LEGAL ADVISOR
THE ROLE OF LIAISON PSYCHIATRY
DISCUSSION
2
What is important?
 Patient
competence
 Decision-making capacity
 Right
to refuse medical
treatment
 Detention
3
Case 1. Mr. CD


45 year old male arrived by ambulance
HISTORY:
 ‘Assault, thrown through plate glass
window’
 ‘~2000 ml blood loss’
 Patient aggressive attitude, would not
answer questions
4
Case 1. Mr. CD

ASSESSMENT:
 GCS = 15
 A B C = normal
 Lacerations anterior NECK x 2
 Mental state
 ‘Appropriate speech’ ‘orientated’
religiose ideation
 Refuses surgical treatment
5
Case 1. Mr. CD

PAST HISTORY:
 Paranoid schizophrenia
 Itinerant
 Medication
 Respiridone - noncompliant
 ‘Hepatitis C positive’
6
Case 1. Mr. CD


A+ legal advisor consulted
Assessed by psychiatric liaison nurse
 Collateral history of recent deterioration
in mental state:
 Hallucinations, verbal direction from
God, inappropriate behaviour
 Section 8 mental health act initiated by
the Homeless Outreach Treatment Team
7
Case 1. Mr. CD
After discussion with patient
 Agreed to limited intervention
 Collapsed in ED shower / further
blood loss - ‘seizure’, rx iv fluids
 Transfer to O.T.
 Seizure in preop. room; Hb = 53
 RBC transfusion total 8 units
 Operation: lacerations repaired
8
Case 1. Mr. CD
PROGRESS:
 Admitted post-op to surgical ward

Psychiatry consult:
 Detained under section 8 MHA1992
 Further detention section10(2)b
9
Case 1. Mr. CD
PROGRESS:
 Medical registrar consult re. ‘seizure’
advised CT Scan Head - postponed
 Transfer to Connolly Unit
 Discharged 2 days later
 no acute psychosis
 refused voluntary admission
10
Case 2. Mrs. AB
77 year old woman
 HISTORY:
 intentional overdose ~12 hours
earlier
 Warfarin 5 mg x 10
 Digoxin 0.0625 mg x 10
 Zopiclone 7.5 mg x 10

11
Case 2. Mrs. AB
HISTORY:
 patient phoned a pharmaceutical
company
 company phoned ambulance
 ambulance phoned GP
 and brought patient to ED
12
Case 2. Mrs. AB
PAST HISTORY:
 Vertigo = peripheral and central
 Depression and anxiety
 Mitral valve replacement
 Chronic atrial fibrillation
 Poor vision: glaucoma, cataract op
13
Case 2. Mrs. AB
ASSESSMENT:
 GCS = 15
 A B C = normal
 ECG = 65/minute sinus rhythm, LVH
 accepted basic investigations
 willing to stay but refusing treatment
 life-threatening overdose
14
Case 2. Mrs. AB
‘suicide letter’
 ‘Advance Directive’ July 2000
 Voluntary Euthanasia Society
 member 3 years
 Deterioration in ‘quality of life’

15
Case 2. Mrs. AB
A+ Legal Advisor consulted
 assess competency
 consider past wishes
 inform patient
 Liaison Psychiatrist consultation
 competent to refuse treatment
 Daughter present

16
Case 2. Mrs. AB
INVESTIGATIONS

INR = 5.8 on arrival
>10 the next morning

DIGOXIN = 2.1
17
Case 2. Mrs. AB
PROGRESS
 Admitted to medical ward

No complications

Discharged on day 5 to rest home
18
The meaning of detention
Legal definition
 In practice
 Deprivation of liberty by physical
means
 Induce to stay by threats or
assertion of authority
 Reasonable conclusion that they
are not free to go

19
Necessity

Requirements for psychiatric
detention
Actually mentally disordered
 Situation of imminent danger or peril
 Necessary in the circumstances


S.62 MHA 1992 –Urgent Treatment
20
A Legal Framework

Emergency Situations
 Crimes Act 1961
 Necessity

The Mental Health (CAT) Act 1992

The Bill of Rights Act 1990
21
Context

Right to refuse medical treatment
(S.11 Bill of Rights Act)

Treatment only with informed consent
(Right 7(1) Code of Patient Rights)

Assault; false imprisonment

Doctrine of urgent necessity
22

Is the patient competent?
 Partial

Is the patient mentally disordered?
Mental Health (Compulsory Assessment
and Treatment) Act 1992
S.8 Application
 S.38 Duly Authorized Officer
 S.110 Medical Practitioner
 S.111 Nurse

23

Patient not competent?
Right 7(4) Code of Patient Rights





Advance directive?
Legal representative?
Best interests?
Consumer’s view?
Other suitable persons?
I
TREAT
24

S.41 Crimes Act 1961
“ Everyone is justified in using such
force as may be reasonably
necessary in order to prevent the
commission of suicide, or the
commission of an offence which
would be likely to cause immediate
and serious injury to the person or
property of anyone…”

S.48
Self Defence or Defence of others
25
ADVICE

Offer options

Fully inform patient

Spread risk

Minimum intervention

Documentation – ‘refusal to treat’
26
 The
role of Liaison Psychiatry
 The
role of the Legal Advisor
 What
if they don’t phone back?
27