Lecture 12 - concordance and legislation Flashcards
when is legislation used in mental health ?
RISK / HARM – patient is risk to themselves OR risk to wider society Detained under Mental Health or Criminal Justice legislation.
Lack of Capacity or Consent treatment according to Adults With Incapacity legislation
describe the mental health legislation
When and how people can be treated if they have a mental disorder
When people can be treated or taken into hospital against their will
What people’s rights are, and the safeguards which ensure that these rights are protected
3 main types: Emergency Detention, Short Term Detention and Compulsory Detention
what are the mental health act detention types?
Emergency Detention- allows a person to be held in hospital for up to 72 hours while their condition is assessed by a doctor – must be a Mental Health Officer (MHO). Treatment is NOT allowed without consent unless it is an emergency or the person is being treated under a different law (e.g AWI)
Short term detention - allows a person to be detained in hospital for up to 28 days for assessment and/or treatment. It can only take place if recommended by a psychiatrist (a RMO, Responsible Medical Officer) AND a mental health officer (MHO). Treatment can be given without consent, if deemed in the patient’s best interests- only for the psych disorder not physical meds
A Compulsory Treatment Order (CTO) allows a person to be treated for their mental illness either in hospital or in the community- provided certain conditions are met.
The CTO can last up to six months. It can be extended for a further six months and then for periods of 12 months at a time.
Medical treatment can be given on a CTO – conditions might be attached e.g supervised consumption of antidepressant in a named community pharmacy, administration of injectable antipsychotic at a depot clinic (GP surgery).
outline the mental health act consent to medication.
Medication can be given without consent in the first two months of a detention (start of compulsory treatment) with or without the patients consent.
After 2 months- a second opinion must be sought (Designated Medical Practitioner- DMP as authorised by the MWC) as to the suitability of treatment- DMP can only give an opinion on the specific medical treatment and not give an opinion as to the diagnosis or general treatment.
Consent must be:
* Given freely, without duress or coercion;
* Given by someone who is legally capable (or competent) of consenting
* Specific and cover the intervention or procedure to be performed;
* Informed (the person understands what is involved)
* Enduring (for treatment given over a period of time).
how is MHA consent to treatment documented?
The Consent to Treatment must be documented on the relevant paperwork known as T2 and T3 Forms/certificates.
T2 Form -patient CONSENTS to taking all the named (prescribed) psychotropic medication listed on the form and Kardex- Patient MUST co-sign within 7 days.
T3 From- patient does not consent BUT the 2nd opinion doctor (DMP) signs on their behalf that the treatment is appropriate.
Both forms have an ‘until date’- recommended not to exceed 3 years
what is medication concordance affected by?
Illness: lack of motivation, delusions, paranoia, insight
lack of belief in the medication (situational/social needs)
Clinical effect i.e delayed onset / ‘numbing’ of other emotions
Fear that it is addictive or habit forming
Need to implement ‘lifestyle changes’ i.e diet, reduce intake of alcohol etc
Side effects (mainly physical/sexual- can be stigmatising in themselves)
Attitudes of family/friends/professionals
what are questions to ask the patient about their medication in regard to keeping up with concordance?
Do you know what the medication is for?
Do you know of the name or what you have been prescribed? (branded VS generic)
How often have you to take the medication?
Have you started taking it/ when you start to take it.. Expect the following effects (not always side effects!)
D you have any concerns about taking the medicine
Do you know what to do if you miss any doses/forget to take it?
Do you have any issues taking/swallowing the medicine?
Are you taking any OTC meds/supplements?
Have you been given any advice abut diet or physical activity
Do you have any questions or is there anything you want me to go over again?
what does installment dispensing allow to achieve?
Can form part of the requirements for the CTO-usually only psychotropic drugs e.g antidepressant or antipsychotic.
Can allow better compliance for chaotic patients i.e routine and engagement.
Convenience for patient esp if also OST.
Assurance patient is receiving dose
Comm Pharm is front line to note if patients relapses (from non attendance)
what is the MH (C & T Act) Safe Guarded Treatments?
Part 16 - Treatments with special safeguards i.e MUST have a 2nd opinion even if patient consents
artificial feeding / nutrition (NG Tube)
medication to reduce sex drive eg anti androgenic (sex crimes)
Electroconvulsive therapy (ECT)
Other invasive treatments that act directly on the brain e.g vagal stimulation
how are the adults of incapacity defined as incapable?
incapable of :
acting or
making decisions or
communicating decisions or
understanding decisions or
retaining the memory of decisions
by reason of mental disorder or of inability to communicate because of physical disability or neurological impairment- i.e not caused by psychiatric disorder which can be treated on its own
what is the awic treatment guideline?
If the need is immediate treatment to save life, staff will act immediately
.
If the doctor thinks the patient cannot consent, a “section 47” certificate must be completed.
This allows the doctor and other staff to give treatment but it cannot be ‘forced’.
A welfare attorney or guardian may have the power to give consent (or refuse consent) the doctor should consult the attorney or guardian before treatment, if they refuse consent, the doctor can ask the MWC to appoint an independent doctor to give their opinion.
what are AWIC advance statements?
Written statement setting out how ‘they (the patient) wish to be treated, or wish not to be treated, for a mental disorder should their ability to make decisions about treatment for their mental disorder become significantly impaired as a result of that mental disorder.”
There is set criteria under which an advance statement can be made, how it should be witnessed and what should happen when it is overridden. (makes the presumption that an individual who writes an advance statement will have experience of the treatment).
NOT the same as “living wills” or “advance directives” = no formal legislative basis in Scotland and are often used in respect of treatment for physical conditions or end of life care.
what is the capacity assessment the doctor carries out ?
Where doctor thinks the patient is unable to give consent- an assessment as to capacity to consent.
Factors to consider:
Is capable of making and communicating their choice
Understands the nature of what is being asked and why
Has memory abilities that allow the retention of information
Has knowledge of the risks and benefits involved
Is aware that such information is of personal relevance to them
Is aware of any alternatives
Is aware of their right to refuse, how to refuse, as well as the consequences of refusal
Has ever expressed their wishes relevant to the issue when greater capacity existed
Is expressing views consistent with their previously preferred moral, cultural, family, and experiential background
Is not under undue influence from a relative / carer / third party
what is covert medication treatment?
“Covert medication is the administration of any medical treatment in a disguised form.
This usually involves disguising medication by administering it in food and drink.
As a result the person is unknowingly taking medication.
This is likely to be due to a refusal to take medication when it is offered, but where treatment is necessary for the person’s physical or mental health”. (Mental Welfare Commission).
Only where patient lacks capacity to make decision to accept that medication
Essential mediation only- Any benefit of has to be balanced against the risk of its use.
The decision must be a multidisciplinary discussion which includes all practitioners directly or indirectly involved in covert medication, and never without the expert guidance of a Pharmacist.
Documented outcomes of effect- Kept under regular review
Care pathway completed by prescriber
If the person has a welfare proxy (welfare attorney or guardian), that person must be consulted unless impracticable. (Treatment cannot proceed if that person objects.)
