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PubMed1998

Issues of non-compliance in mental health.

This paper explores and questions the ideas and notions in respect of non-compliant behaviours. Traditionally, research into this area has focused on identifying individual characteristics from within the adult branch of nursing and within the confines of the medical model of compliance. Little research has investigated the phenomena of non-compliance within the specialty of mental health. It may be suggested that identifying characteristics in this setting is futile. There are many factors determining a client's compliance behaviours. These include gender, social class, race and socio-economic status. Those suffering from mental ill health are often the most vulnerable in society and it may be argued that as such are often coerced into accepting treatment with those who refuse frequently being labelled as non-conformist. The ability of the client to refuse treatment should be based upon informed consent, but is often dependent upon the social prejudice of the health care professional, their misuse of power to bring about compliance behaviours and their inability to act as an effective advocate. Finally, by eliciting information, shared negotiation, planning and improved communication health professionals may improve compliance behaviours based upon the client's needs and wishes.

Adult↗
PubMed2000

The nurses' power to detain informal psychiatric patients: a review of the statutory and common law provisions in England and Wales.

This paper explores the extent to which nurses can use statutory and common law provisions as lawful authority to detain informal psychiatric patients. The power of a nurse to detain informal psychiatric patients received statutory recognition for the first time in the Mental Health Act (1983). Section 5(4) of this Act, the 'Nurses Holding Power', provides for nurses of the 'prescribed class' to detain informal psychiatric patients for up to 6 hours. Further statutory authority that may be invoked with respect to the detention of patients is laid out in the Criminal Law Act (1967) and the Police and Criminal Evidence Act (1984). These statutes set out the circumstances whereby a nurse can use reasonable force to detain a patient. One of the most confusing areas in law is the extent to which common law powers can be used by nurses to detain or restrain informal psychiatric patients, including those who lack mental capacity. The detention of those patients who lack the mental capacity to express an informed desire to leave hospital has caused uncertainty and difficulties for nurses caring for them. These difficulties relate to whether it is lawful to detain and give treatment to informal patients who lack the capacity to express a choice. The principles derived from the case law are discussed in relation to detention, clinical practice and patients rights.

Commitment of Persons with Psychiatric Disorders↗
PubMed1998

Informing patients and relatives about do-not-resuscitate decisions. Attitudes of cardiologists and nurses in Sweden.

OBJECTIVES: To survey the attitudes of Swedish cardiologists and nurses regarding information given to patients and relatives concerning do-not-resuscitate (DNR) status. METHOD: Questionnaire. SETTING: Nationwide, 2 years after the publication of a proposal of guidelines on DNR. SUBJECTS: 10% random sample of members of the Swedish Cardiac Society, 104 physicians and 196 nurses. Response rate 73%. RESULTS: According to most Swedish cardiologists and cardiac nurses, patients and relatives should be honestly informed about a patient's DNR status if they ask for information. Almost all (97%) answered that the relatives of a noncompetent patient should be informed when they ask and (67%) believe that the relatives should be informed even if they do not ask. Most of the respondents (61%) stated that the patient, if mentally competent, should be informed about the DNR status first and decide if the information should be passed on to relatives. Only 12% of the respondents were of the opinion that if the relatives asked for this information to be withheld from the patient, this should be respected even if the patient asked for information, and 45% believed it should be respected if the patient did not ask. With reference to the latter, many (31%) were uncertain. The cardiologists and cardiac nurses expressed almost identical opinions in the matter of informing patients and relatives about DNR status. CONCLUSIONS: Current guidelines recommend honest answers to questions and that priority should be given to the autonomy of the patient. However the guidelines do not offer any assistance when no questions are asked. In such cases, there may be an ethical conflict between two requirements: respect for the person and do not harm. Many health care professionals believe that the information could, in some cases, harm the patient. This conflict can hardly be solved by referring to more basic ethical values. More training in informing patients and relatives about delicate matters is probably required, together with more knowledge about the wishes of very ill patients.

Attitude of Health Personnel↗
PubMed1998

'We're doing it already ...': adult protection in mental health services.

This paper explores the implementation of generic adult protection policies in mental health services, both in terms of conceptual issues about the nature and thresholds of abuse which are identified and/or tolerated within different settings, and in relation to existing structures for working on risk assessment, such as the Care Programme Approach and Supervised Discharge. The paper asks if resistance from mental health workers to new adult protection procedures reflects a reality that they have 'been doing it already' or whether there is a deeper resistance to acknowledgement of abuse issues in the lives of service users, and to the burden which such knowledge places on workers who are already stretched to the limit.

Adult↗
PubMed1999

Oral ivermectin in the treatment of scabies.

One hundred and twenty scabietic patients attending the outpatient clinic of the Department of Dermatology, Mansoura University Hospital, voluntarily participated in this uncontrolled, open label study to evaluate ivermectin 20 microg/kg as a scabietic after they had given their consent. The scabietic subjects included in this study were otherwise healthy, mentally competent, aged more than 18 years, and used no topical antiscabietic treatment in the week before ivermectin treatment, or during the 4-week study period. Patients were also required to show clinical evidence of scabies, and the microscopically demonstrated presence of Sarcoptes scabiei, their eggs, or their fecal pellets (scybala). A thorough history was taken, and a physical examination was conducted that included measurement of the pulse, blood pressure, temperature, and weight. For each participant, the distribution of scabies lesions was plotted on a body diagram, and the severity of disease was recorded as mild (10 or fewer lesions), moderate (11-49 lesions), or severe (50 or more lesions). Skin scrapings were examined for mites, eggs, or scybala. Urinalysis, stool analysis, a complete blood count, prothrombin time, and serum chemistry studies (serum creatinine, alanine aminotransferase (ALT), and total bilirubin) were performed before treatment, and 2 and 4 weeks after the drug was given. Ivermectin was administered as scored 6-mg tablets with water, and the dose was designed to provide 200 micrograms/kg (ivermectin was provided by Delta Pharma, Tenth of Ramadan City, Egypt). The patients were instructed to have recently worn clothing, sheets, and towels washed in a hot cycle the day after treatment. The patients were interviewed 3 days after treatment about any symptoms or subjective evidence of adverse reactions. Follow-up examinations were carried out 2 and 4 weeks after intake of ivermectin, and all examination procedures and laboratory investigations were repeated. Cure criteria included absence of nocturnal itching as well as dermatologic evidence of scabies, and negative skin scraping. Patients showing evidence of active scabies or having new lesions during the follow-up visits were given a second dose of ivermectin. All members of the household and immediate family were treated with either topical 5% permethrin cream or 1% gamma benzene hexachloride to reduce the chance of reinfestation.

Administration, Oral↗
PubMed2002

Advanced 'prescribing' of nurses' emergency holding powers under New Zealand mental health legislation.

Since the mid-19th century doctors have exercised almost exclusive control in health professionals' decisions concerning compulsory assessment and treatment of the mentally ill. This control has the potential to compromise the legitimate professional practice of other mental health professionals. A new approach to mental health legislation has seen the involvement of a range of health professionals in legislated mental health roles, including the power of registered nurses to detain patients in hospital under Section 111 of the New Zealand Mental Health (Compulsory Assessment and Treatment) Act (1992). Under this Section a nurse who believes that a voluntary patient meets the legal criteria of the Act can independently detain the patient for a period of up to 6 hours, pending further assessment by a medical practitioner. However, anecdotal evidence and a clinical audit undertaken by the authors suggest some doctors 'prescribe' Section 111 at the time of admission. This practice instructs nurses to initiate Section 111 if particular voluntary patients choose to leave hospital. This study outlines practice issues resulting from 'prescribing' Section 111; provides a legal critique of medical practitioners' involvement in this practice; and makes recommendations for guidelines toward a more constructive use of Section 111.

Attitude of Health Personnel↗
PubMed1999

Assessment of patient capacity to consent to treatment.

OBJECTIVE: To compare results of a specific capacity assessment administered by the treating clinician, and a Standardized Mini-Mental Status Examination (SMMSE), with the results of expert assessments of patient capacity to consent to treatment. DESIGN: Cross-sectional study with independent comparison to expert capacity assessments. SETTING: Inpatient medical wards at an academic secondary and tertiary referral hospital. PARTICIPANTS: One hundred consecutive inpatients facing a decision about a major medical treatment or an invasive medical procedure. Participants either were refusing treatment, or were accepting treatment but were not clearly capable according to the treating clinician. MEASUREMENTS AND MAIN RESULTS: The treating clinician (medical resident or student) conducted a specific capacity assessment on each participant, using a decisional aid called the Aid to Capacity Evaluation. A specific capacity assessment is a semistructured evaluation of the participant's ability to understand relevant information and appreciate reasonably foreseeable consequences with regard to the specific treatment decision. Participants also received a SMMSE administered by a research nurse. Participants then had two independent expert assessments of capacity. If the two expert assessments disagreed, then an independent adjudication panel resolved the disagreement after reviewing videotapes of both expert assessments. Using the two expert assessments and the adjudication panel as the reference standard, we calculated areas under the receiver-operating characteristic curves and likelihood ratios. The areas under the receiver-operating characteristic curves were 0.90 for specific capacity assessment by treating clinician and 0.93 for SMMSE score (2p =.48). For the treating clinician's specific capacity assessment, likelihood ratios for detecting incapacity were as follows: definitely incapable, 20 (95% confidence interval [CI] 3. 6, 120); probably incapable, 6.1 (95% CI 2.6, 15); probably capable, 0.39 (95% CI 0.18, 0.81); and definitely capable, 0.05 (95% CI 0.01, 0.29). For the SMMSE, a score of 0 to 16 had a likelihood ratio of 15 (95% CI 5.3, 44), a score of 17 to 23 had a likelihood ratio of 0. 68 (95% CI 0.35, 1.2), and a score of 24 to 30 had a likelihood ratio of 0.05 (95% CI 0.01, 0.26). CONCLUSIONS: Specific capacity assessments by the treating clinician and SMMSE scores agree closely with results of expert assessments of capacity. Clinicians can use these practical, flexible, and evaluated measures as the initial step in the assessment of patient capacity to consent to treatment.

Aged↗
PubMed2002

[A symptom oriented approach to evaluate legal capacity under account of the term will].

After summarising the legal requirements of contractual capacity, an attempt is made to define the term will with psychiatric conceptualisations. Possible restrictions of a free declaration of will are outlined. Symptoms, which possibly influence cognitive preconditions of will and personal values, are taken into account. Our considerations are supposed to improve orientation in this complex field and to contribute to the communication between psychiatric expert and the court. However, the analysis of each individual case remains essential.

Dementia↗
PubMed2002

[Informing psychiatric patients about medication - results of a query].

PURPOSE: Physicians are obliged to inform all patients about the purpose and risks of therapeutic procedures, also drug treatment. However, although there may be some severe difficulties in informing psychiatric patients only very few data concerning this topic are available as yet. Thus, the aim of this query was to evaluate the patients' opinion of the information about medication. METHODS: In this investigation 255 psychiatric inpatients were asked to complete a questionnaire. RESULTS: 42 % of the patients complained about no or insufficient information of the expected effects of the prescribed medication and 62 % about no or insufficient information of side-effects. An association was found between the willingness to take the medication for a long time and insight in their psychic condition, but not with satisfying informing. CONCLUSION: This query showed the need of a more precise and satisfying information on medication and the need to develop strategies for a better information about side-effects.

Adult↗
PubMed1994

Informed refusal: the patient's influence on long-term treatment.

Outpatient studies in private practices revealed that psychiatric treatments often do not meet therapeutic standards. One possible explanation for this is that the autonomous patient substantially participates in therapeutic decision-making. Basic preconditions for the therapeutic decision-making are the patient's right of self-determination, the doctor's duty to inform, and a risk-benefit assessment on the part of patient and doctor. However, ethical and possibly also legal problems may result if the physician has to be responsible for a treatment decision which was influenced by the autonomous patient, but which is less effective and less safe than the treatment he recommends to the patient. Two outpatient examples will be given where doctor and patient come to different risk-benefit assessments. Emerging ethical problems will be discussed.

Altruism↗
PubMed1977

Autonomy for burned patients when survival is unprecedented.

Altered states of consciousness often exclude the seriously burned patient from decision making in his own case. During the first few hours of hospitalization, however, even the most severely burned patient is usually alert and mentally competent. When burns are so severe that survival is unprecedented, we use an aggressive approach to decision making to preserve patient autonomy. While still lucid, and with sufficient information, the patient is asked if he wishes to choose between a full therapeutic regimen or ordinary care, reassured that with either choice, the burn team will provide the constant presence of human caring and full use of its professional skills. This approach has not changed the mortality rate of such patients, but has increased both the self-determination that they exercise and the empathy that they receive.

Aged↗