Involuntary Detention & Treatment Flashcards
What is the mental health act and who is it for?
Who it applies to
Patients with a mental disorder who do not consent to an ‘informal’ (i.e. voluntary) admission or treatment.
In addition, non-capacitous patients are increasingly being treated under the MHA. These are patients who, although they are not refusing treatment, lack the capacity to consent meaningfully. Historically they would not have been sectioned, but it is increasingly felt that they should be, so as to enjoy the protections of the MHA.
Conditions of detention
The admission must be: (1) for a mental disorder of a sufficient degree and nature, which (2) requires inpatient treatment, and (3) which presents a risk to the patient or others. Risk to the patient can come from self-harm, self-neglect, or further decline in their illness.
Longer detentions (Sections 2 and 3) and compulsory treatment orders can be appealed against by the person being detained.
Which diseases are covered under the mental health act?
The patient must have a mental disorder, and the treatment must be for that condition.
Substance misuse is included, but not standalone acute intoxication.
Dementia is included, although such patients are more commonly detained using the deprivation of liberty safeguards of the Mental Capacity Act (MCA).
Delirium is included, although such patients would often just be treated in their best interests (under MCA), and detained with a short-term Section 5(2) if needed.
Which treatments are covered under the mental health act?
Sections 2 and 3 allow treatment, while treatment can be given under MCA for Section 4.
Physical symptoms can only be treated if they result from mental disorder e.g. in anorexia nervosa. Otherwise it may require the MCA.
ECT requires further authorisation, even under Sections 2 and 3.
Who does compulsory admission from the community apply to and which sections are relevant?
Outpatients, A&E patients, or any other individual in the community.
Relevant MHA sections
Section 2: 28 day admission for assessment and treatment. Non-renewable, but patient can be switched to a Section 3 if required.
Section 3: 6 month admission for treatment. Renewable for further 6 months then annually. If drugs given without consent, this needs to be reviewed at 3 months by a Second Opinion Appointed Doctor (SOAD), according to Section 58.
Section 4: 72 hour urgent admission when Section 2 cannot be arranged immediately. Requires only 1 doctor. Should be converted to Section 2 on admission. Treatment is given in line with the MCA.
Section 17: allows ward leave for patients detained under Section 2 or 3, agreed by the responsible clinician i.e. consultant psychiatrist.
People required
The application is made by an approved mental health professional (AMHP): a non-doctor, local authority-approved practitioner, usually a social worker or community psychiatric nurse (CPN). Rarely, the nearest relative can make the application instead of the AMPH.
It is done on the recommendation of two doctors who have seen the patient. One must be approved under Section 12 of the MHA, typically a consultant psychiatrist. Ideally, the other should know the patient previously e.g. GP.
Who does the short term detainment of in-patients apply to and which sections are relevant?
Who it applies to
Applies to those already admitted to a ward – i.e. not A&E – and are trying to leave hospital.
Relevant MHA sections Section 5(2): 72 hour detention by any doctor (F2 or above). Should be converted to a Section 2 within that time if required. Section 5(4): 6 hour detention by a nurse. If converted to a 5(2), the 6 hours are deducted from the 72 hours. These sections allow detention, while the Mental Capacity Act can justify treatment in their best interests.
Who does the compulsory treatment order apply to and why might this be done?
Done under Section 17 of MHA 1983 (Section 32 of MHA 2007).
For patients being discharged from a Section 3 who still require compulsory treatment in the community.
Made by the responsible clinician with the support of the AMPH.
Patients can be recalled to hospital if non-concordant.
Lasts for 6 months, then renewed a further 6 months then annually if required.
Which powers do police have under the mental health act for detaining people with mental illness?
Section 135
Allows police to enter a property for an MHA assessment, for someone at risk from self or others due to a mental illness.
Requires application to a magistrate by an AMPH.
Section 136
Detention by police for up to 72 hours. Should then be converted to Section 2 or 3 if required.
Designed to take people who need immediate care or control from a public place to a place of safety. Ideally a hospital, but can be a police station.
What is the mental capacity act and what are the five principles of mental capacity?
Mental Capacity Act 2005 (MCA)
Outlines the principles of mental capacity and people’s ability to consent for treatment in England and Wales.
5 principles
People are assumed to have capacity.
Health professionals should support decision making as much as possible by providing information.
Decisions should be made in the patient’s best interests. This doesn’t mean giving them what you think is the most effective treatment, but what you think they would decide if they had capacity.
Use the least restrictive method possible for treating them.
Respect unwise decisions: they are not evidence of lack of capacity.
Who does the mental capacity act apply to?
Patients aged 16 and older whose capacity to accept or refuse treatment is unclear.
For patients with a mental illness, it only applies if they also lack capacity. It is not usually relevant, since Sections 2 and 3 allow treatment, but it may apply in acute situations such as a Sections 4, 5(2), or 5(4), or when an informally admitted patient becomes non-concordant and needs emergency treatment.
How is capacity assessed?
If you believe an individual has an impairment of their mental function, proceed to assess.
Capacity is the ability to understand, retain, weigh, and convey ideas about treatment.
Document your assessment.
Capacity should be assessed by the treating doctor.
It is decision-specific – referring to a specific treatment decision – and time-specific – as capacity may change at a later date.
What does the mental capacity act allow?
Treatment can be given if it is in the patient’s best interests but they lack capacity.
Restraint can be used to give treatment in exceptional circumstances, when the lack of treatment would cause serious harm. This also allows, for example, carers to forcefully present incapacitous people from crossing the road.
The MCA includes the deprivation of liberty safeguards (DoLS), which are the other way – in addition to the MHA – whereby a patient can be detained. In general, DoLS are used for patients receiving longer term care e.g. dementia patients, especially in care homes.
How can threatening behaviour from patients be managed?
First try de-escalation. One staff member should be in charge, and pay careful attention to what has upset/angered the patient.
If unsuccessful, rapid tranquillisation, physical intervention and seclusion should be considered.
Rapid tranquilisation: offer PO first, then IM if refused. If it is simply a behavioural disturbance, use PO or IM lorazepam. If psychosis is present, combine with haloperidol.
The use of tranquillisation should be discussed with and explained to the patient at the earliest opportunity possible after the event.
What is advanced care planning and what does it allow?
Overview:
Advance care planning allows individuals to make decisions in advance about the care they would like in the event of them lacking capacity.
The criteria around ADRT and LPA are outlined in the MCA 2005, but the advance statement is less formal.
Advance statement
Verbal or written statement of their broad wishes about what they would like done.
No formal criteria. Could be a conversation or scribbled on a piece of paper. However, professional advice can help ensure it’s useful and appropriate.
Not legally binding on doctors, but should be taken into account.
What is an advanced decision to refuse treatment?
Advance decision to refuse treatment (ADRT)
Verbal or written statement of decisions about wanting to refuse treatment.
In general, no formal criteria. Could be a conversation or scribbled on a piece of paper. However, professional advice can help ensure it’s useful and appropriate. The exception is if it is an advance decision to refuse life-sustaining treatment, which must be written, signed, witnessed, and contain the words “even if life is at risk”.
Legally binding if it is valid and applicable to a given case.
What is lasting power of attorney and how is it implemented?
Key features:
Nomination of another individual(s) – a ‘donee’ – to make decisions on your behalf, in your best interests, if/when you lack capacity.
2 separate forms: LPA for health and welfare, and an LPA for property and financial issues. At least one person must be named for each (can be the same).
Must be registered with the Office of the Public Guardian (OPG).
If an individual says they have LPA for health and welfare, seek confirmation (sensitively): see the stamped document or phone the OPG.
Can be overridden by an ADRT, unless the LPA document specifically says to the contrary.
If you feel that the donee is not making decisions in the patient’s best interests, you can contact the OPG or Court of Protection to potentially overrule.
If there is ever any doubt about the veracity of LPA status, or whether they are acting in the patient’s best interests, treat according to the following principles – in order of importance – until more information is available:
Preserve life, even if dignity is violated.
Prevent deterioration.
Control pain.
Preserve dignity.
