Thursday, 3 March 2011

Case Based Discussion

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.


pj said...

It is an interesting one - I tend towards the view that once you're threatening people with detention then you ought to be carrying out a formal MHA assessment and detaining them under section because otherwise you are using the threat of section without the legal protection section offers.

But the converse view is also valid that offering informal admission but holding formal admission in reserve is offering a misleading non-choice.

I'm not sure what the answer is. I suppose ideally we should section everyone who we would formally admit if they declined informal admission - but that would see an enormous increase in the number of patients formally detained and create a lot of work - and also sour our relationship with a lot of patients who would have an unnecessary edge of coercion to their admission.

Gledwood said...

If I ever get threatened with sectioning I just hope they offer the informal option. I would be seriously pissed off otherwise. Worst I've ever been hit with is do I WANT to go in hospital and I later regretted turning them down. I mean it's fun going nuts in the kitchen on mania but after a while it gets tiring and I remember one day I just had to go to bed, still floridly manic, but acheing all over and totally nauseated from overdoing everything and not eating. I didn't even have a diagnosis then. I had syptoms of mental illness for 20 years until they found out what it actually was, which in retrospect seems truly pathetic on their part as it's not like I didn't ask for help.

lmm said...


I recently found your blog and have been reading back through your posts.

I wanted to tell you first of all how nice it is to get an insight into you and your job.

This post for me struck home. I'm a patient with an adult team and have spent time in hospital both informally and under section. I can see your point about how it could appear to be coercion/threatening a patient to give them the full picture, and indeed at times felt that, however on the whole I'd prefer to be able to make a choice having all the information. I find that I'm more frustrated when I'm sectioned and would have agreed to go in had I known that was where the conversation was going!

However I think as well that it depends on a lot of other factors - mental state at that moment, your relationship with the patient, and the patients' understanding of what is happening at that time too.