We tell patients the truth. How much is valid consent, how much is coercion?
This is a theme that case based discussion threw up with my colleagues and me. I was pleased, I'd not expected case based discussion to be at all useful. On exploring, with a peer group, how a Consultant managed random in-patient episodes, reviewing the notes and talking it through, a significant difference in approach emerged.
One school of thought was that patients deserve the truth, patients need an honest account of what professional advice a Consultant is offering. More, patients also need to know the consequences of their choice, if it's to be making a considered and valid decision, so patients need to be aware of outcomes from choices. Consultants in this camp will tell patients something along the lines, "We're both agreeing that you're not as well as we'd both wish, we're seeing you're behaving in a way that's unhelpful to you and those you care about, we know being in hospital is helpful for you and over a few weeks has worked every time before, I strongly believe you need to be in hospital, now."
The patient declines the offer of support within an in-patient unit and then is told, "If you're not wishing to come in informally, I'll need to look at a Mental Health Act assessment and admission under section 2."
It was strongly argued that not to tell the patient this was unfair, since valid consent and joint guidance from the BMA and Law Society in 2004 requires that the patient needed to know the consequences of not accepting the proposed treatment.
The other school of thought was that patients deserve the truth and an honest account but this related to the immediate issue. Whether their choices could then perhaps lead to discharge or perhaps to compulsory admission or maybe to consideration of a depot or whatever is a future consideration and shouldn't excessively influence the decision in the here and now.
It was suggested you'd have the same identical conversation but if after you recommended hospital admission your patient declines, you'd walk away and discuss it with the MDT and an AMHP rather than suggest compulsory denention.
It was strongly argued that as well as essentially making a threat, however tactfully delivered, it was inappropriate to offer informal admission then in the same breath say that if you don't come informally, formal admission will be sought, because there's then undue pressure. The same joint guidance from the BMA and Law Society in 2004 reequire that valid consent is made with "free choice" to curtailing choice to "do this, or I'll make it happen" is a less than free choice.
Mostly the argumements and points of view expressed by the Consultants weren't medicolegal or clinical, but essentially were ethical.
Is it better to be totally honest and let patients know the consequences of their decisions? Is it better to offer the choice and then if patients choose to decline, to then approach the MDT/AMHP to discount informal admission and revisit options?
I was firmly in the second camp, I've never to my recollection said to a patient that I'm offering informal admission and if it's declined I'm coming back with pink papers, an AMHP, a GP and an ambulance (with or without police, to convey) since that to my mind could be perceived as somewhat coercive. The argument was that I'd then be admitting people under a section of the MHA 1983 more often than they otherwise needed to be. I typically have just a couple of section 2 admissions a year, I've only made recommendations and managed my patients under section 3 twice in my career to date, so my use of both section 2 and section 3 is lower than colleagues within my peer group.
Different points of view, with different Consultants giving different answers. Usually you ask half a dozen Consultant Psychiatrists a question and you get half a dozen different answers. Unusually we had agreement with just 2 camps and recognition that the opposing camp had valid views but maintaining strong views that their camp was the best way to practice.
I was surprised by how useful the case based discussion was. I'd expected a tedious hour. The open exploration of implications of different approaches to practice, reflection on how we worked and discussion of alternate view points was stimulating and genuinely useful.
A pleasant surprise.