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DETENTION RIGHTSWhere do we stand?

Dr. Tristan McGEORGE Dr. Tristan McGEORGE RegistrarRegistrar

Dr. Andy McCLELLAND Dr. Andy McCLELLAND SpecialistSpecialist

Department of Emergency MedicineDepartment of Emergency Medicine

Peter Le CREN Peter Le CREN A+ Legal AdvisorA+ Legal Advisor

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DETENTION RIGHTSWhere do we stand?

INTRODUCTIONINTRODUCTION

CASES x 2CASES x 2

MEDICO-LEGAL FRAMEWORKMEDICO-LEGAL FRAMEWORK

THE ROLE OF THE LEGAL ADVISORTHE ROLE OF THE LEGAL ADVISOR

THE ROLE OF LIAISON PSYCHIATRYTHE ROLE OF LIAISON PSYCHIATRY

DISCUSSIONDISCUSSION

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What is important?

Patient competencePatient competenceDecision-making capacityDecision-making capacity

Right to refuse medical Right to refuse medical treatment treatment

DetentionDetention

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Case 1. Mr. CD 45 year old male arrived by ambulance45 year old male arrived by ambulance HISTORY: HISTORY:

‘‘Assault, thrown through plate glass Assault, thrown through plate glass window’ window’

‘‘~2000 ml blood loss’~2000 ml blood loss’ Patient aggressive attitude, would not Patient aggressive attitude, would not

answer questionsanswer questions

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Case 1. Mr. CD ASSESSMENT:ASSESSMENT:

GCS = 15 GCS = 15 A B C = normalA B C = normal Lacerations anterior NECK x 2Lacerations anterior NECK x 2 Mental stateMental state

‘‘Appropriate speech’ ‘orientated’ Appropriate speech’ ‘orientated’ religiose ideationreligiose ideation

Refuses surgical treatmentRefuses surgical treatment

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Case 1. Mr. CD

PAST HISTORY:PAST HISTORY: Paranoid schizophreniaParanoid schizophrenia ItinerantItinerant MedicationMedication

Respiridone - noncompliantRespiridone - noncompliant ‘‘Hepatitis C positive’Hepatitis C positive’

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Case 1. Mr. CD A+ legal advisor consultedA+ legal advisor consulted Assessed by psychiatric liaison nurse Assessed by psychiatric liaison nurse

Collateral history of recent deterioration Collateral history of recent deterioration in mental state:in mental state:Hallucinations, verbal direction from Hallucinations, verbal direction from

God, inappropriate behaviourGod, inappropriate behaviour Section 8 mental health actSection 8 mental health act initiated by initiated by

the Homeless Outreach Treatment Teamthe Homeless Outreach Treatment Team

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Case 1. Mr. CD

After discussion with patientAfter discussion with patient Agreed to limited interventionAgreed to limited intervention Collapsed in ED shower / further blood Collapsed in ED shower / further blood

loss - ‘seizure’, rx iv fluidsloss - ‘seizure’, rx iv fluids Transfer to O.T.Transfer to O.T.

Seizure in preop. room; Hb = 53Seizure in preop. room; Hb = 53 RBC transfusion total 8 unitsRBC transfusion total 8 units Operation: lacerations repairedOperation: lacerations repaired

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Case 1. Mr. CD

PROGRESS:PROGRESS: Admitted post-op to surgical wardAdmitted post-op to surgical ward

Psychiatry consult: Psychiatry consult: Detained under section 8 MHA1992Detained under section 8 MHA1992 Further detention section10(2)bFurther detention section10(2)b

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Case 1. Mr. CD

PROGRESS:PROGRESS: Medical registrar consult re. ‘seizure’ Medical registrar consult re. ‘seizure’

advised CT Scan Head - postponedadvised CT Scan Head - postponed Transfer to Connolly UnitTransfer to Connolly Unit Discharged 2 days laterDischarged 2 days later

no acute psychosisno acute psychosis refused voluntary admissionrefused voluntary admission

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Case 2. Mrs. AB

77 year old woman77 year old woman HISTORY: HISTORY:

intentional overdose ~12 hours intentional overdose ~12 hours earlierearlierWarfarin 5 mg x 10Warfarin 5 mg x 10Digoxin 0.0625 mg x 10Digoxin 0.0625 mg x 10Zopiclone 7.5 mg x 10Zopiclone 7.5 mg x 10

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Case 2. Mrs. AB

HISTORY:HISTORY: patient phoned a pharmaceutical patient phoned a pharmaceutical

companycompany company phoned ambulancecompany phoned ambulance ambulance phoned GPambulance phoned GP and brought patient to EDand brought patient to ED

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Case 2. Mrs. AB

PAST HISTORY:PAST HISTORY: Vertigo = peripheral and central Vertigo = peripheral and central Depression and anxietyDepression and anxiety Mitral valve replacementMitral valve replacement Chronic atrial fibrillationChronic atrial fibrillation Poor vision: glaucoma, cataract opPoor vision: glaucoma, cataract op

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Case 2. Mrs. AB

ASSESSMENT: ASSESSMENT: GCS = 15 GCS = 15 A B C = normalA B C = normal ECG = 65/minute sinus rhythm, LVHECG = 65/minute sinus rhythm, LVH accepted basic investigationsaccepted basic investigations willing to stay but refusing treatmentwilling to stay but refusing treatment life-threatening overdoselife-threatening overdose

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Case 2. Mrs. AB

‘‘suicide letter’suicide letter’ ‘‘Advance Directive’ July 2000Advance Directive’ July 2000 Voluntary Euthanasia SocietyVoluntary Euthanasia Society

member 3 yearsmember 3 years Deterioration in ‘quality of life’Deterioration in ‘quality of life’

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Case 2. Mrs. AB

A+ Legal Advisor consulted A+ Legal Advisor consulted assess competencyassess competency consider past wishesconsider past wishes inform patientinform patient

Liaison Psychiatrist consultationLiaison Psychiatrist consultation competent to refuse treatmentcompetent to refuse treatment

Daughter presentDaughter present

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Case 2. Mrs. AB

INVESTIGATIONSINVESTIGATIONS

INR = 5.8 on arrivalINR = 5.8 on arrival

>10 the next morning>10 the next morning

DIGOXIN = 2.1DIGOXIN = 2.1

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Case 2. Mrs. AB

PROGRESSPROGRESS Admitted to medical wardAdmitted to medical ward

No complicationsNo complications

Discharged on day 5 to rest homeDischarged on day 5 to rest home

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The meaning of detention

Legal definitionLegal definition In practiceIn practice

Deprivation of liberty by physical Deprivation of liberty by physical meansmeans

Induce to stay by threats or Induce to stay by threats or assertion of authorityassertion of authority

Reasonable conclusion that they Reasonable conclusion that they are not free to goare not free to go

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Necessity

Requirements for psychiatric Requirements for psychiatric detentiondetention Actually mentally disorderedActually mentally disordered Situation of imminent danger or perilSituation of imminent danger or peril Necessary in the circumstancesNecessary in the circumstances

S.62 MHA 1992 –Urgent TreatmentS.62 MHA 1992 –Urgent Treatment

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A Legal Framework

Emergency SituationsEmergency Situations Crimes Act 1961Crimes Act 1961 NecessityNecessity

The Mental Health (CAT) Act 1992The Mental Health (CAT) Act 1992

The Bill of Rights Act 1990The Bill of Rights Act 1990

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Context

Right to refuse medical treatment Right to refuse medical treatment (S.11 Bill of Rights Act)(S.11 Bill of Rights Act)

Treatment only with informed consentTreatment only with informed consent(Right 7(1) Code of Patient Rights)(Right 7(1) Code of Patient Rights)

Assault; false imprisonmentAssault; false imprisonment

Doctrine of urgent necessityDoctrine of urgent necessity

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Is the patient competent?Is the patient competent? PartialPartial

Is the patient mentally disordered?Is the patient mentally disordered?Mental HealthMental Health (Compulsory Assessment (Compulsory Assessment

and Treatment) Act 1992and Treatment) Act 1992

S.8 ApplicationS.8 Application S.38 Duly Authorized OfficerS.38 Duly Authorized Officer S.110 Medical PractitionerS.110 Medical Practitioner S.111 NurseS.111 Nurse

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Patient not competent?Patient not competent?Right 7(4) Code of Patient RightsRight 7(4) Code of Patient Rights

Advance directive?Advance directive? Legal representative?Legal representative? Best interests?Best interests? Consumer’s view?Consumer’s view? Other suitable persons?Other suitable persons?

IITREATTREAT

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S.41 Crimes Act 1961S.41 Crimes Act 1961““ Everyone is justified in using Everyone is justified in using such force as may be reasonably such force as may be reasonably necessary in order to prevent the necessary in order to prevent the commission of suicide, or the commission of suicide, or the commission of an offence which commission of an offence which would be likely to cause immediate would be likely to cause immediate and serious injury to the person or and serious injury to the person or property of anyone…”property of anyone…”

S.48S.48

Self Defence or Defence of othersSelf Defence or Defence of others

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ADVICE Offer optionsOffer options

Fully inform patientFully inform patient

Spread riskSpread risk

Minimum interventionMinimum intervention

Documentation – ‘refusal to treat’Documentation – ‘refusal to treat’

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The role of Liaison PsychiatryThe role of Liaison Psychiatry

The role of the Legal AdvisorThe role of the Legal Advisor

What if they don’t phone back?What if they don’t phone back?