JISC UPDATE December 2010
The month kicked off with a fabulous discussion about the legal framework
for medical treatment of a self-harming patient:
Respondent 1: Assuming lack of capacity (e.g. citing ambivalence and the OD
itself) you would treat under MCA (proportionate restraint, best interest,
principle of necessity) and consider using MHA to actually detain on a
medical ward for further assessment of possible mental disorder. Current
MHA doesn’t actually allow treatment of a physical disorder (OD) even
though it may be due to a mental disorder, although ‘legal opinion’ (but not
case law) suggests that it should.
Respondent 2: Agreed with above, until Louis Appleby’s letter to the RCPsych
(http://www.rcpsych.ac.uk/rollofhonour/rcpsychnews/january2010/applebyl
etter.aspx) stating the opinion that the MHA could be used in such
circumstances. However, as it is time consuming to complete a section, I
think the MCA would come into play first.
Respondent 3: I thought there was case law about treating a physical
disorder due to a mental disorder (B v Croydon Health Authority) under
Section 63 as an ancillary act if the self-harm can be categorised as the
consequence or symptom of a patient's mental disorder [Jones 11th edition,
Page 327].
Respondent 4: We had a case recently where the ED staff felt the patient had
capacity to refuse treatment after paracetamol overdose (as per
Wooltorton) and we were going to use MHA. And they recommended the
following:
David AS, Hotopf M, Moran P, et al. Mentally disordered or lacking capacity?
Lessons for managment of serious deliberate self harm. BMJ 2010; 341:
c4489.
MCA vs MHA.
Wollerton case.pdf
Antipodean respondent 5: recommended:
Ryan CJ, Callaghan S. Legal and ethical aspects of refusing medical treatment
after a suicide attempt: the Wooltorton case in the Australian context.
Medical Journal of Australia 2010; 193: 239-242.
Respondent 6 who speaks for all of us! : ‘I always think I'm on top of this
topic, until it's discussed, and then I end up feeling utterly confused’.
Respondent 7: The first part of Appleby’s letter confirms that treatment for
physical consequences of self harm can be treated under the MHA.
But the second part of the letter states "...it is possible for someone to meet
the criteria for detention under the Act even though they retain the mental
capacity to take decisions about their treatment. So the need for detention
under the Act is certainly one possibility to consider in the case of a patient
who has seriously self-harmed as a result of mental disorder, even though
they have the capacity to refuse treatment for their injuries (or have refused
it by means of an advance decision). In that respect, they are no different
from any other suicidal or self-harming patient."
So, we are being told that life-threatening self harm is not treatable under the
MHA if the patient has capacity to refuse treatment? If they have a severe
enough mental illness to warrant detention, and which itself has led to
severe self harm, under what circumstances are they likely to have capacity
to refuse treatment? One would have to postulate that the suicidal act and
the mental illness are independent events, the treatment of one having
nothing to do with the other.
Respondent 8: I note that usually the MCA is the first step on the algorithm,
because it is usually the most pragmatic. But still, what a mess.
A real Pandora’s box, this. The legal opinion I mentioned was from Lord
Justice Hoffman:
“It would seem strange to me if a hospital could, without the patient's
consent, give him treatment directed to alleviating a psychopathic disorder
showing itself in suicidal tendencies, but not without such consent be able to
treat the consequences of a suicide attempt."
B v Croydon Health Authority (1995) that Louis Appleby refers to in his letter
actually relates to force-feeding, not the treatment of an OD.
If I was asked for an opinion, I’d go for MCA to treat ± MHA to admit.
Respondent 9 is a new JISC member: and helpfully writes –
1) DSH/OD/other physical problems as a direct consequence of mental
illness:
Possibility A: Capacity to accept/refuse physical treatment absent
 Treat physical health under MCA and
 Treat Mental health under MHA, if criteria met.
Possibility B: Capacity to accept/refuse physical treatment present
Option 1
- Physical treatment accepted - go ahead informally.
- Treat mental health under MHA, if criteria met.
Option 2
- physical treatment refused: MCA is not applicable here as capacity is
present. So treat Physical health under MHA (as suggested by example of
forced feeding in B v Croydon health authority AND Prof Appleby's letter
referring to code of practice).
But what if person does not meet criteria for detention under MHA?
2) DSH/OD/other physical problems present with but NOT a direct
consequence of mental illness:
Everything stays same except the fact that in possibility B option 2: Neither
MCA nor MHA applicable for treatment of physical health.
(Though it is unlikely to be a common occurrence because if somebody is
refusing treatment of physical health problems - it is more likely to be a
result/manifestation of mental illness and in that case can be treated under
MHA)
Respondent 10: presents 2 more scenarios:
3) DSH/OD/other physical problem, treatment refused and capacity retained
(whether or not person has a mental illness)
If capacity is truly retained, then we really shouldn't be treating people
because a person should be allowed to make a with-capacity decision to end
his or her own life. Classically the Jehovah's Witness who refuses a blood
transfusion, which almost everyone will agree is a decision that should be
accepted, as long as we are clear that it is definitely (or fairly definitely) a
decision made with capacity. (This includes advanced directives to refuse
treatment).
Outside the JW situation one can imagine a situation where a person with a
terminal illness and with the support of their family and with clear
documentation of their choice and with no doubt about their capacity at the
time of their choice presented to ED with a suicide attempt gone wrong,
where one should probably respect the person's decision to decline
treatment.
Cases like this are incredibly rare; where capacity is retained but the person
nonetheless has a mental illness, that is not interfering with their capacity
(defined in a sense that means that the person was making a considered and
sustained decision that life was not worth living not clouded by their mental
illness - i.e. defined more tightly than a typical legal definition).
The coroner felt that Wooltorton was such a case, but I suspect it was not. It
would be very hard to know whether Ms W had true capacity at the time she
wrote her note (not that the coroner thought that relevant) and it is almost
certainly the case Ms W was intoxicated secondary to the ethylene glycol
within a short period after its ingestion, likely robbing her of capacity.
The other scenario worthy of consideration is:
4) DSH/OD/other physical problem, treatment refused and we are just not
sure what we should be doing.
In Australia the courts have been clear that they are very happy to hear these
cases urgently, and can make decision under parens patriae powers. Those
powers are no longer open to English courts but they can make declarations
about what they think would be the legal course of action.
There was a case discussion about using modafinil in chronic fatigue
syndrome? All organic causes ruled out (including sleep telemetry). Patient
was intolerant to antidepressants (low in mood- mainly fed up due to
frustration with the fatigue, which seemed to come first), and despite
psychological interventions by CFS/ME specialist nurse, was getting no better
with ++ functional impairment and associated distress.
A London based Liaison psychiatrist with some expertise in this area said
there was no evidence base to support use of modafanil and it is not
recommended by NICE for this reason (listed in the guidance under the
heading "Strategies that should not be used for CFS/ME"). NICE cites blood
tests that should be done & a suggestion is to manage individual symptoms
(pain, insomnia etc) to try and optimise any modifiable contributory factors.
March 2nd – March 4th 2011, Glasgow: The joint programme for the annual
residential meetings for Faculty of Liaison Psychiatry and Faculty of
Psychotherapy. The academic programme for the Faculty of Liaison
Psychiatry starts on Wednesday the 2nd March 2011. Both the faculties have
organized a joint day on the topic of Medically Unexplained symptoms on 3rd
March 2011. Both the faculties have a separate programme for 4th March
2011.
Advance notice of a meeting of the North West, N Wales and Mersey
Liaison Psychiatry Special Interest Group on Friday 18th February 2011 at the
Rawnsley Building, Manchester Royal Infirmary. The theme of the day is
the likely impact of the new commissioning framework on Liaison
Psychiatry, and what opportunities these could offer in terms of
improving the provision of health care within a bio-psychosocial
framework. Dr Alan Nye, Clinical Adviser Elective Care Department of
Health, Associate Medical Director NHS Direct and Director Pennine MSK
Partnership Ltd (an NHS ICATS organisation, which has contracted a
Psychological Medicine Service from us at Oldham) will be speaking.
There was grateful feedback from a clinician who presented a patient with
functional dysphonia. After 2/52 on 5mg aripiprazole he is significantly
better with a clear fluent voice and he has made his first telephone call in
2yrs. He says improvement was first noticed by others about 1/52 after
starting treatment. I didn't sell it to him as 'the answer', and with no
response to 5mg tds diazepam I think it is less likely that the mechanism of
action is anxiolytic or placebo. Interestingly his abnormal gulping breathing
pattern has not completely abated and physiotherapists are still helping him
with breathing.. My hypothesis is that this was a secondary response to try to
force speech despite motor dysfunction.
An eighty four year old lady with a florid catatonic presentation admitted
under the care of elderly medicine. There was no fever or haemodynamic
instability. She did have auditory, visual (she is registered blind) and
olfactory hallucinations and thought we were from the devil. Fortunately she
responded to treatment with Lorazepam. Currently there is no hypertonia,
hallucination, delusion, confusion or evidence of a dementing illness and she
is euthymic. She has no past psychiatric history but is registered blind and
is hypertensive. After investigation we could not determine any particular
cause of this presentation.
My understanding is that for a significant minority the catatonia can be
idiopathic particularly in elderly women. My questions are:
1. What are the more obvious causes or differentials?
2. In the absence of any obvious reason how long should Lorazepam be
continued?
Jackie Gordon
Worthing