1 detention rights where do we stand? dr. tristan mcgeorge registrar dr. andy mcclelland specialist...
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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?
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