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Mental Health Presentations in ED

Mental Health Presentations in ED. AM O’Dwyer MD MRCPI MRCPsych Psychological Medicine Service. Mental Health in the ED. MSE Consent Capacity Mental Health Act UK legislation…. Mental State Examination Problematic Areas in ED Capacity…. Mental State Examination.

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Mental Health Presentations in ED

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  1. Mental Health Presentations in ED AM O’Dwyer MD MRCPI MRCPsych Psychological Medicine Service

  2. Mental Health in the ED • MSE • Consent • Capacity • Mental Health Act • UK legislation…

  3. Mental State Examination • Problematic Areas in ED • Capacity…

  4. Mental State Examination • Objective observation and assessment • Detail what you can see.. • Appearance; behaviour; dress; conduct; level of engagement… • Observe at all times..

  5. MSE • Appearance and Behaviour • Speech – tone rate and volume • Eye contact • Rapport /engagement • Affect – reactive; flattened/blunted • Mood • Thoughts • Perceptual • Cognitive • Insight

  6. Problems… • Short time to assess • Multiple demands • “Straight forward” cases… • “deliberate self harm/threatened DSH”… • 19 year old ; bridge • 16 year old ; note

  7. Careful/appropriate notes and observations crucial..

  8. Difficult assessments.. • Significant variations in the history • History varied throughout eg.. • Significant inconsistencies between history and observed behaviour/MSE for example… • History and collateral were not consistent • “knew couldn’t tell the truth or..” • X reported not always truthful/consistent in history..eg “….”

  9. Consider what you write: • “suicide attempt” • “suicidal” • “homicidal” • Use of questionnaires..sad people… • Risk??

  10. Describe what you see • Consider what you are writing • Drug screen • Collateral

  11. Medicine v Law • Ifs/but/not yet known • Possibly; maybe • Laws interpreted by different judges in different ways

  12. Clinical decisions influenced by: • Clinical need • Expressed wishes of the patients • Codes of practice (mental health act) • General medical council • Resources

  13. Common law • Statute laws – passed by Parliament – Acts • Judicial interpretation of statute laws • European law • Passed by the EU • European Convention on Human Rights • Compliance with ECHR determined by E Court HR

  14. “Common Law” • Judge-made law • “common sense under a wig” – Lord Donaldson • Called common law because common to all of the country • Body of law made up entirely of principles developed from individual cases on a case by case basis

  15. Bill –proposed - becomes Act with sections (paragraphs) • European Convention on Human Rights – articles (paragraphs) • Acts in the UK relating to mental health • Mental Health Act • Human Rights Act • Mental Capacity Act

  16. Examples of judge-made law • If a person is symptom free but only because on medication are they still suffering from the disorder? • Yes ..so long as it is necessary for a person to be under treatment for a disease or disability then that person must be held to be suffering from that disease ….s

  17. Can an informal mentally ill person who retains full decision making capacity be restrained? • In very limited circumstances… This power (common law power to restrain) is confined to imposing temporary restraint on a person who has run amok and is a manifest danger to himself or others… as obvious to a layman as a doctor…

  18. Cannot use common law if statutory alternative

  19. Human Rights Act 1998 • Incorporated the European Convention on Human Rights into UK law • In practice interchangeable • Articles: • 2 right to life • 3 prohibition of torture • 5 liberty and security • 6 fair trial • 8 respect for private and family life

  20. 3 categories of right • Absolute (3) • Limited – specific explicit circumstances eg 5 • Qualified – interference permitted in range of circumstances (8)

  21. Concept of proportionality • Any interference with convention right must be proportion to the intended aims • Eg amount of force/interference used depends on severity of threat

  22. Article 5 (liberty and security of person) • Everyone has right to liberty and security • Lawful detention/arrest/ • Informed promptly/understand • Brought promptly before judge • Entitled to take proceeding to decide on lawfulness of detention

  23. Article 8 – right to respect for private and family life • Confidentiality • Even minor interference with physical integrity ….if carried out against will..

  24. Capacity /Consent • Competent patient absolute right to refuse to consent to medical treatment • For any reason • Rational or irrational • Or for no reason at all • Even if death

  25. If go ahead without consent • Civil wrong of trespass • Criminal offence of assault • Prosecuted by police • Sued by patient

  26. Right to decide • Regardless of wisdom or consequences of decision • Decision does not have to be justified to anyone • Fact that intervention is well meaning or therapeutic makes no difference

  27. Open and honest • Illness • Treatment • Risks and benefits • Explain in way can understand • No duress • Information – correct and complete

  28. MCA Principles • Presumption of capacity • Right to make own decisions • Right to make unwise decisions • Anything done without capacity best interests • Least restrictive of their rights and freedom of action

  29. Decision making capacity • Relate to the decision to be made at the time of assessment • Decision and time specific • Cannot describe person as lacking capacity • Lacks capacity at this time and in relation to this decision

  30. Decision making capacity • Lack capacity if unable to understand the information relevant to the decision • Retain the information • Use or weigh information as part of making the decision • Communicate the decision

  31. Information relevant: • About reasonably forseeable consequences of • Deciding one way or another • Failing to make the decision

  32. Consent to medical treatment (UK) • Capacity – act under Common law • Mental illness – capacity - MHA • Lack capacity – Mental Capacity Act • Advance refusals • Lasting powers of attorney • Deputies appointed by court of protection

  33. Decision making capacity • Capacity – ability to make decision • Cannot lack capacity unless have an impairment of or disturbance in functioning of mind or brain • Not an all or nothing phenomenon

  34. Real life: • Temporary factors – temporary impaired capacity • Confusion • Unconsciousness • Fatigue • Shock • Pain • Drugs • REDUCED CAPACITY

  35. Whether at that time the capacity reduced below level needed in the case of a refusal of that importance • Some involve risk to life/irreparable damage • Others not • Degree of incapacity required to deem lacking capacity may depend, in part, on the complexity of the decision and the seriousness of the outcome

  36. Mental Capacity Act 2005UK • Act may authorize medical treatment • If (>16) lack capacity to make decision • Also empowers adults to make provision for the future

  37. If patient incapable of making decision, consider.. 1. Have made Advance Statement? 2. Have given another adult lasting power of attorney? 3. Has Court of protection appointed deputy to make decision?

  38. Advance Statement?: • If request for treatment (as always) clinician will consider but not bound by it • If refusal of treatment, clinician bound by it

  39. Advance Statement/decision • Must closely mirror current circumstances • Does not have to be in writing unless withdrawal of life support • If yes, must be witnessed and signed /written

  40. Advance decision • Invalid if : • Capacity to refuse consent to it • Withdrew decision when had capacity to do so • Lasting power of attorney (created after advance decision made) • Reasonable grounds believing circumstances exisit not anticipated at the time of the decision • Advance decisions are about medical treatment not about going to home…

  41. Lasting power of attorney • Can consent or refuse treatment as if patient • Excludes decisions re life sustaining treatment unless specifically excluded • Attorneys power does not come into effect until donor has lost capacity • Differs from finance – where both make decision until donor loses capacity..

  42. Usually none of these apply • Decide whether will regain capacity • Encourage to participate • Take into account • Past;present wishes • Beliefs and values if known • Carers • Independent mental capacity advocate

  43. Deprivation of Liberty safeguard • Vascular dementia/ Korsakoff/alcohol related amnesia • Insulin dependent diabetes • Admitted to hospital informally • Deprived of liberty • DoLs under MCA vs MHA • MHA first; if not appropriate then MCA

  44. Lord Donaldson: • Patient’s interest consists of right to self-determination • Even if damages health/premature death • Society – all life is sacred and should be preserved • In the ultimate the right of the individual is paramount • .. If doubt…resolved in favour of the preservation of life for if the individual is to override the public interest he must do so in clear terms..

  45. Summary • Capacity – for consent • Criteria – • Information • Use it/weight it up • Communicate decision • Be sensible! • Document reasons • Consult a colleague

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